employee total rewards guide 2020 - reston total rewards gui… · recognizing and rewarding...
TRANSCRIPT
Employee Total Rewards Guide
2020
Compensation Recognition amp Rewards
See page 3
Wellness Program amp Benefits
See page 5
Training amp Career Development
See page 22
WorkLife Balance See page 21
Total Rewards
Contact your Human Resources team at 703-435-7990 or hrrestonorg with any questions or concerns about your Total Rewards Package
Reston Association is committed to providing a comprehensive Total Rewards Package
The goal of Restonrsquos Total Rewards Package is to create value for employees
by striving to meet their professional goals and personal needs
Reston Association Core Values Service bull Collaboration bull Stewardship bull Innovation bull Leadership
2
Compensation
Base Pay Reston Association strives to be competitive with wages within our industry and within our community We believe in an equitable balanced total pay program that offers competitive pay RA hires employees within the minimum of market pay range or RArsquos salary grade range whichever is greater for the job with variations based on job-related skills education ability experience and the current job market RArsquos salary ranges and job descriptions are available to view in CommonHumRes
Annual Performance Reviews amp Merit Increases Performance reviews are scheduled annually A merit increase may be applied to your base pay in conjunction with your performance review You and your supervisor should also review your job description at this time and inform HR if any updates are necessary
Recognition amp Rewards
Kudos Notes Take a minute to recognize a co-worker for something positive by writing them a Kudos Note There is never a reason too small There is a Kudos board at CSF and WNEC (Nature House) and there are three Kudos boards at Headquarters There will be periodic Kudos Note drawings throughout the year
Reston Employee Awards Program (REAP) The purpose of REAP is to recognize and reward employees for going above and beyond in performing their responsibilities and service to the organization Nominations for REAP awards are reviewed by the REAP Committee on a monthly basis Employees can receive an individual or group REAP award
3
Recognition amp Rewards
Reston Association recognizes and rewards employees for going above and beyond in performing their responsibilities and service to the organization and to all that Reston encompasses Employees can be recognized and rewarded by their peers by receiving an Achievement award or a Recognition award
Achievement Recognizing and rewarding employees for achieving a sustainable impact Award criteria includes bull Progressive for RA and RArsquos goals bull Innovative bull Sustained Excellence bull Saves RA timemoneyother resources
Recognition Recognizing and rewarding employees for a moment of excellence Award criteria includes bull A moment of excellence performed under challenging or uncommon circumstances bull A single event of outstanding service that goes beyond onersquos core job responsibilities and that demonstrates
an employeersquos willingness to take initiative in assisting internal andor external customers
Service Awards Reston Association provides awards for reaching years of service milestones Awards are given in December of the year in which you reach one of the following service milestones 5 years bull 10 years bull 15 years bull 20 years bull 25 years bull 30 years bull 35 years
Employee of the Year Every year Reston Association selects an Employee of the Year The purpose of the Employee of the Year award is to honor those who have invested their time and taken initiative to make significant contributions to the organization and community over the course of the year with consideration given to past achievements and contributions The Employee of the Year receives one paid day off certificate a $500 bonus and dedication of a tree in Reston
4
Benefits ndash RArsquos Wellness Program
Reston Association is committed to providing a culture that promotes healthy living through education and resources RArsquos Wellness Program works to achieve this commitment through its goals
To help employees reduce lifestyle risk factors and become better health care consumers
To raise employee awareness about the importance of preventative health care and overall wellness including financial and mental
To provide employees a work environment that supports positive health and fitness practices
Every year at RArsquos annual wellness and benefits fair in November you will be given a Passport to Wellness where you earn stamps for individual and group activities Benefits of participating in the Wellness Program include
Wellness screenings and flu shots at the Benefits Fair in November Quarterly Brown Bag presentations related to wellness and workplace topics Activities events and team challenges such as the YMCA Corporate Challenge car
free days blood drives water-only challenges smoothie days and more Earn stamps for participation in individual and group activities Redeem your stamps
for prizes including the grand prize
5
Benefits ndash PlanContact Information
Enrollment in the majority of these benefits must be done within 30 days of hire during open enrollment or within 30 days of a qualifying life change event Open enrollment occurs annually from mid-November to mid-December
Benefits elected during open enrollment will take effect January 1
The employee their spouse or domestic partner (regardless of sex) and their children under age 26 are eligible to enroll in benefits
Insurance Benefits
Health Insurance Provider Name Kaiser Permanente group 3007-4 (HMO Select) 3007-6 (POS) 3007-10 (HRA-DHMO) Provider Contact Member Services 301-468-6000 Provider Web Address wwwkporg
Dental Insurance Provider Name MetLife group 5469528 Provider Contact Member Services 800-ASK-4MET Provider Web Address httpsmybenefitsmetlifecom
Supplemental Vision Insurance ndash two options 1Provider Name VSP group 30017163
Provider Contact Member Services 800-877-7195 Provider Web Address wwwvspcom
2Provider Name SpecteraUHC group GA9N9747BW Provider Contact Member Services 800-839-3242 Provider Web Address wwwmyuhccom
Flexible Spending Accounts (FSA) amp Dependent Care Accounts (DCA) Contact Optum Health Provider Contact Member Services 800-243-5543 Provider Web Address httpssecureoptumhealthfinancialcom
LifeADampD Short-term Disability (STD) amp Long-term Disability (LTD) Insurance Provider Name Sun Life group 211628 Provider Contact Member Services 800-247-6875 Provider Web Address wwwsunlifecomus
Savings Benefits 401(k) Retirement Savings Plan (pre-tax and Roth)
Provider Name Ascensus Broker Contact Mark Ivcevich 301-326-1521 markqp-consultingcom Web Address httpsmyaccountascensuscomrplink
529 College Savings Plan Contact Human Resources
6
Medical Premium Costs per Paycheck for Employees Hired Prior to 1-1-2019
The amount of your paycheck cost difference will be dependent on the type of coverage you choose
for 2020 (see last column on the table below)
Rates are effective January 1 2020
HRA-HMO
Signature
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $50725 $3512
Employee + 1 $101444 $8193
Employee + Family $147096 $12408
HMO Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $58173 $4027
Employee + 1 $116340 $9397
Employee + Family $168696 $14229
POS Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $85966 $5951
Employee + 1 $171932 $13887
Employee + Family $249293 $21028
NOTE The Health Insurance Premium Bank is still available to those who qualify Request for
assistance must be made annually by December 15th or within 30 days of a qualifying event
7
Medical Premium Costs per Paycheck for Employees Hired After 1-1-2019
The amount of your paycheck cost difference will be dependent on the type of coverage you choose
for 2020 (see last column on the table below)
Rates are effective January 1 2020
HRA-HMO
Signature
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $50725 $4682
Employee + 1 $101444 $10535
Employee + Family $147096 $15802
HMO Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $58173 5370
Employee + 1 $116340 $12081
Employee + Family $168696 $18122
POS Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $85966 $7935
Employee + 1 $171932 $17854
Employee + Family $249293 $26781
NOTE The Health Insurance Premium Bank is still available to those who qualify Request for
assistance must be made annually by December 12th or within 30 days of a qualifying event
8
Dental amp Vision Premium Costs per Paycheck
The following rates represent your monthly Dental and Vision premiums effective January 1 2020
MetLife Dental Per Paycheck
FULL-TIME Cost
Per Paycheck
PART-TIME Cost
Employee $000
Contact HR for cost Employee + 1 $000
Employee + Family $000
VSP Vision Per Paycheck Cost
Employee $513
Employee + Adult $864
Employee + Child $882
Employee + Family $1423
SpecteraUHC Vision Per Paycheck Cost
Employee $415
Employee + Adult $843
Employee + Child $883
Employee + Family $1116
9
Health Insurance ndash Option 1
DHMO HRA Signature In Network You Pay Out-of-Network You Pay
Deductible Coinsurance Out-of-Pocket
$750 Individual$1500 Family (RA funds) 9010
$3000 Individual $6000 Family
(less than regular HMO)
NA
Primary Care and Specialist Office Visit $15 PCP$25 Specialist NO COVERAGE
Emergency Room Visits $75 per visit (waived
if admitted) NO COVERAGE
Hospital ndash Inpatient Stay 10 after deductible NO COVERAGE
Home Health Care 10 after deductible NO COVERAGE
Outpatient Facility Services 10 after deductible NO COVERAGE
X-Ray and Laboratory Services 10 after deductible NO COVERAGE
Specialty Imaging (CTMRIPET scan) 10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $15 PCP$25 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $30 Participating $50 Plan $45 Participating $65
$20$30$45
Kaiser Permanente D-HMO HRA Signature (Facilities Only) With the Signature Network members receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Medical centers offer convenient services including primary care specialty care laboratory radiology and pharmacy at most locations and in some locations optical Signature members also have access to more than 40 hospitals in the region
10
Health Insurance ndash Option 2
Kaiser Permanente HMO Select (Facilities amp Contracted Providers Only) With the Select Network members may receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Building on the Signature physician network the Select network adds access to more than 15000 contracted community physicians in private practice Select members also have access to more than 40 hospitals in the region
HMO Select In-Network You Pay Out-of-Network
You Pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
NA
Primary Care and Specialist Office Visit $30 PCP$40 Specialist NO COVERAGE
Emergency Room Visits $100 per visit
(waived if admitted) NO COVERAGE
Hospital ndash Inpatient Stay $250 per admission NO COVERAGE
Home Health Care No charge NO COVERAGE
Outpatient Facility Services $100 NO COVERAGE
X-Ray and Laboratory Services No charge NO COVERAGE
Specialty Imaging (CTMRIPET scan) $50 per test NO COVERAGE
Chiropractic amp Acupuncture Services $40 copay
20 visits per contract year NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$15 copay-group therapy $30 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $30 PCP$40 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
11
Kaiser Permanente POS Select (Facilities amp Contracted Providers with an Out of Network Option) Members can use in-plan benefits by using a Kaiser facility or a contracted primary care physician Your chosen PCP will provide care and coordinate referrals and hospital admissions Members also have the freedom to choose any other licensed provider outside the provider network however you will be responsible for deductibles and coinsurance above the health planrsquos payment
POS Select In-Network You Pay Out-of-Network
you pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
$300 Individual $600 Family
8020 $3000 Individual
$6000 Family
Primary Care and Specialist Office Visit $15 PCP$30 Specialist 20 of UCR
Emergency Room Visits $75 per visit (waived if
admitted) $75 per visit
(waived if admitted)
Hospital ndash Inpatient Stay $250 per admission 20 of UCR
Home Health Care No charge 20 of UCR
Outpatient Facility Services $50 20 of UCR
X-Ray and Laboratory Services No charge 20 of UCR
Specialty Imaging (CTMRIPET scan) No charge 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
20 of UCR
Vision (Children Only) $15 PCP$30 Specialist per visit 20 of UCR
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
Health Insurance ndash Option 3
12
Dental Insurance
MetLife Dental PPO The Dental PPO plan is 100 Employer Paid for all tiers and provides comprehensive coverage with a nationwide PPO network This gives members access to more in-network dentists making it easier for them to reduce out-of-pocket costs for covered procedures and treatments Dental procedure frequencies Preventative care covers an exam and cleaning (once every 6 months) Fluoride treatment (two per benefit period under age 19 only) Full mouth X-ray (once every 60 months) Bitewing X-ray (once every 12 months age 14 and over once every 12 months under age 14)
PPO Dental Plan Features In-Network Out-of-Network
Type A Preventive Care Services (oral exams cleanings x-rays sealants)
100 of Fee Schedule 100 of Usual amp Customary
Charge
Type B Basic Restorative Dental Services (fillings simple extractions space maintainers)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type B Major Surgical Dental Services (Endodontics amp Periodontics)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type C Major Restorative Dental Services (bridges crowns dentures implants)
50 of Fee Schedule 50 of Usual amp Customary
Charge
Orthodontia (under age 19 only)
Lifetime maximum - $1000 50 of allowed benefit
Calendar Year Deductible Applies to Type B amp C services only
$25 Single $75 Family
Calendar Year Maximum Per Person $1500 combined maxper calendar year
Prior to receiving dental services it is recommended that you first obtain a pre-determination of benefits from your dentist so you know exactly how much your dental insurance will cover Spouses domestic partners and dependent children to age 26 (regardless of student status) are eligible
13
Vision Insurance ndash Option 1
Vision Plan through VSP (Voluntary) VSP is the largest private provider vision carrier in the country VSP contracts with Costcoreg Optical Eye Care Centers of America Inctrade which includes popular stores like EyeMasters VisionWorld and Hour Eyes and other quality retail chains When you visit a VSP participating provider your benefits include routine vision exams lenses and preferred pricing on all patient options Frequency Eye Exam 12 monthsLenses 12 monthsFrames 24 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $45
Eyeglass Lenses (standard) Single Bifocal Trifocal
Covered in Full Covered in Full Covered in Full
Plan pays up to $30 Plan pays up to $50 Plan pays up to $65
Frames $130 allowance then 20 off remaining balance
Plan pays up to $70
Necessary Contact Lenses Covered in Full Plan pays up to $210
Elective Contact Lenses $130 allowance Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $60
copay Not Available
Spouses domestic partners and dependent children to age 19 (or to age 25 if FT student) are eligible
14
Vision Insurance ndash Option 2
Vision Plan through Spectera UHC (Voluntary)
UHC offers you one of the largest vision care networks in the industry Their network includes convenient retail locations including My Eye Dr and Hour Eyes Best of all ndash when you receive care from a participating provider you receive the greatest benefits and money-saving discounts
Frequency Eye Exam 12 monthsLenses 12 monthsFrames 12 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $40
Eyeglass Lenses (standard) Single Bifocal Trifocal
$25 copay $25 copay $25 copay
Plan pays up to $40 Plan pays up to $60 Plan pays up to $80
Frames $2500 copay $130 retail frame
allowance 30 discount above allowance
Plan pays up to $45
Necessary Contact Lenses $25 copay Plan pays up to $210
Elective Contact Lenses
$25 copay from the ldquoCovered contact lens
selectionrdquo All others- $105
allowance
Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $25
copay Not Available
Spouses and dependent children to age 26 are eligible
15
Pre-tax FSA amp DCA
Flexible Spending Account (FSA) through Optum Health The Flexible Spending Account provides employees a means to reduce their taxes by the amount of their out of pocket health-related expenses (subject to eligibility) This tax free savings program allows employees to submit receipts for reimbursement for medical dental vision care prescription drug co-payments and other expenses not covered by our insurance In 2020 employees may contribute up to $2750 per year toward their FSA Employees have until March 14 2020 to use the money in their FSA or else they lose it (This contribution amount could change based on IRS guideline updates)
Dependent Care Spending Account (DCA) through Optum Health The Dependent Care Spending Account provides employees a means to reduce their taxes by the amount of their child care costs to a licensed provider up to $5000 annually
Health Insurance Premium Bank
Reston Association has established a program to help regular full-time and regular part-time employees pay their portion of the health insurance premium This program is only available to employees who are enrolled in or plan to enroll in the Kaiser Permanente HMO health insurance plans offered by the Reston Association Employees are eligible to apply to the Health Insurance Premium Bank if their adjusted gross household incomes are less than or equal to $60000 Requests for assistance must be made annually or at any time there is a qualifying event and submitted to Human Resources with necessary documentation by December 12th of each year To apply complete a request form (available in CommonHumResBenefits) and submit to HR with a copy of your most recent tax return showing adjusted gross household income This threshold is subject to change
16
Life and ADampD Insurance
Basic LifeADampD Insurance Reston Association provides 100 employer paid Life and ADampD Insurance through Sun Life to employees working 25 or more hours per week Coverage becomes effective the first of the month following six months of service
Benefit 2x Annual Earnings to a maximum of $200000 Age reduction Benefit reduced to 65 at age 65 and to 50 at age 70
Optional LifeADampD Insurance for Employee Spouse and Dependent Children
Optional Life Insurance for the employee spouse and dependent children is available at the employeersquos cost Optional Life is not available for domestic partners
Employee Benefit Increments of $10000 to a maximum of the lesser of $300000 or 3x your Basic Annual Earnings
Spouse Benefit Increments of $5000 to a maximum of $150000 Dependent Child Benefit Increments of $1000 to a maximum of $10000
Your amount of Dependent Spouse and Dependent Child Optional Life Insurance cannot exceed 50 of your amount of Optional Life Insurance Initial eligibility period will require evidence of insurability
STD amp LTD Insurance
Short Term and Long Term Disability Reston Association provides eligible employees with short and long-term disability income benefits through Sun Life In the event you become disabled from a non work-related injury or sickness disability income benefits are provided as a source of income These benefits are 100 employer paid
Benefit Short-Term Disability Long-Term Disability
Income Replacement -Eligible Employees -Executives
60 60
Elimination Period - Accidental Injury - Sickness
29 days 90 days
Benefit Period 9 weeks maximum To Social Security
normal retirement age
Benefit Maximum -Eligible Employees -Executives
$1000 per week $6000 per month $8000 per month 17
At a cost of $19month you can enroll in the Legal Resources benefit As a Legal Resources Member you have immediate and ongoing access to comprehensive legal coverage services and expertise that will easily save you money mdash and could save you a whole lot more Covered legal services include
Legal Advice and Consultation Tenant Dispute with Landlord District Court Representation for Civil Action Review of a Financial Contract or Lease Purchase sale or refinance of primary home Traffic Court Representation (includes 1st DUI) Will Preparation Uncontested Divorce Representation Defense of Child in Court (misdemeanor)
Legal Resources
Employee Assistance Program (EAP)
Reston Association offers a free confidential Employee Assistance Program (EAP) to all employees and their eligible dependents Through RArsquos EAP provider Lytle EAP Partners you and your immediate family members have immediate access on your date of hire to confidential professional counseling and referral services for help with anything that affects you or your dependentsrsquo well-being You can reach an EAP counselor by dialing 1-800-327-7272 24 hours a day or you may visit their website at wwwLytleEAPcom (password is reston) for more information Visit wwwLytleEAPcom for web-based legal financial worklife resources There are also work-related resources available online for managers Note Since EAP services are provided as a benefit only RA makes no representation concerning quality of care
18
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Reston Association is committed to providing a comprehensive Total Rewards Package
The goal of Restonrsquos Total Rewards Package is to create value for employees
by striving to meet their professional goals and personal needs
Reston Association Core Values Service bull Collaboration bull Stewardship bull Innovation bull Leadership
2
Compensation
Base Pay Reston Association strives to be competitive with wages within our industry and within our community We believe in an equitable balanced total pay program that offers competitive pay RA hires employees within the minimum of market pay range or RArsquos salary grade range whichever is greater for the job with variations based on job-related skills education ability experience and the current job market RArsquos salary ranges and job descriptions are available to view in CommonHumRes
Annual Performance Reviews amp Merit Increases Performance reviews are scheduled annually A merit increase may be applied to your base pay in conjunction with your performance review You and your supervisor should also review your job description at this time and inform HR if any updates are necessary
Recognition amp Rewards
Kudos Notes Take a minute to recognize a co-worker for something positive by writing them a Kudos Note There is never a reason too small There is a Kudos board at CSF and WNEC (Nature House) and there are three Kudos boards at Headquarters There will be periodic Kudos Note drawings throughout the year
Reston Employee Awards Program (REAP) The purpose of REAP is to recognize and reward employees for going above and beyond in performing their responsibilities and service to the organization Nominations for REAP awards are reviewed by the REAP Committee on a monthly basis Employees can receive an individual or group REAP award
3
Recognition amp Rewards
Reston Association recognizes and rewards employees for going above and beyond in performing their responsibilities and service to the organization and to all that Reston encompasses Employees can be recognized and rewarded by their peers by receiving an Achievement award or a Recognition award
Achievement Recognizing and rewarding employees for achieving a sustainable impact Award criteria includes bull Progressive for RA and RArsquos goals bull Innovative bull Sustained Excellence bull Saves RA timemoneyother resources
Recognition Recognizing and rewarding employees for a moment of excellence Award criteria includes bull A moment of excellence performed under challenging or uncommon circumstances bull A single event of outstanding service that goes beyond onersquos core job responsibilities and that demonstrates
an employeersquos willingness to take initiative in assisting internal andor external customers
Service Awards Reston Association provides awards for reaching years of service milestones Awards are given in December of the year in which you reach one of the following service milestones 5 years bull 10 years bull 15 years bull 20 years bull 25 years bull 30 years bull 35 years
Employee of the Year Every year Reston Association selects an Employee of the Year The purpose of the Employee of the Year award is to honor those who have invested their time and taken initiative to make significant contributions to the organization and community over the course of the year with consideration given to past achievements and contributions The Employee of the Year receives one paid day off certificate a $500 bonus and dedication of a tree in Reston
4
Benefits ndash RArsquos Wellness Program
Reston Association is committed to providing a culture that promotes healthy living through education and resources RArsquos Wellness Program works to achieve this commitment through its goals
To help employees reduce lifestyle risk factors and become better health care consumers
To raise employee awareness about the importance of preventative health care and overall wellness including financial and mental
To provide employees a work environment that supports positive health and fitness practices
Every year at RArsquos annual wellness and benefits fair in November you will be given a Passport to Wellness where you earn stamps for individual and group activities Benefits of participating in the Wellness Program include
Wellness screenings and flu shots at the Benefits Fair in November Quarterly Brown Bag presentations related to wellness and workplace topics Activities events and team challenges such as the YMCA Corporate Challenge car
free days blood drives water-only challenges smoothie days and more Earn stamps for participation in individual and group activities Redeem your stamps
for prizes including the grand prize
5
Benefits ndash PlanContact Information
Enrollment in the majority of these benefits must be done within 30 days of hire during open enrollment or within 30 days of a qualifying life change event Open enrollment occurs annually from mid-November to mid-December
Benefits elected during open enrollment will take effect January 1
The employee their spouse or domestic partner (regardless of sex) and their children under age 26 are eligible to enroll in benefits
Insurance Benefits
Health Insurance Provider Name Kaiser Permanente group 3007-4 (HMO Select) 3007-6 (POS) 3007-10 (HRA-DHMO) Provider Contact Member Services 301-468-6000 Provider Web Address wwwkporg
Dental Insurance Provider Name MetLife group 5469528 Provider Contact Member Services 800-ASK-4MET Provider Web Address httpsmybenefitsmetlifecom
Supplemental Vision Insurance ndash two options 1Provider Name VSP group 30017163
Provider Contact Member Services 800-877-7195 Provider Web Address wwwvspcom
2Provider Name SpecteraUHC group GA9N9747BW Provider Contact Member Services 800-839-3242 Provider Web Address wwwmyuhccom
Flexible Spending Accounts (FSA) amp Dependent Care Accounts (DCA) Contact Optum Health Provider Contact Member Services 800-243-5543 Provider Web Address httpssecureoptumhealthfinancialcom
LifeADampD Short-term Disability (STD) amp Long-term Disability (LTD) Insurance Provider Name Sun Life group 211628 Provider Contact Member Services 800-247-6875 Provider Web Address wwwsunlifecomus
Savings Benefits 401(k) Retirement Savings Plan (pre-tax and Roth)
Provider Name Ascensus Broker Contact Mark Ivcevich 301-326-1521 markqp-consultingcom Web Address httpsmyaccountascensuscomrplink
529 College Savings Plan Contact Human Resources
6
Medical Premium Costs per Paycheck for Employees Hired Prior to 1-1-2019
The amount of your paycheck cost difference will be dependent on the type of coverage you choose
for 2020 (see last column on the table below)
Rates are effective January 1 2020
HRA-HMO
Signature
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $50725 $3512
Employee + 1 $101444 $8193
Employee + Family $147096 $12408
HMO Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $58173 $4027
Employee + 1 $116340 $9397
Employee + Family $168696 $14229
POS Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $85966 $5951
Employee + 1 $171932 $13887
Employee + Family $249293 $21028
NOTE The Health Insurance Premium Bank is still available to those who qualify Request for
assistance must be made annually by December 15th or within 30 days of a qualifying event
7
Medical Premium Costs per Paycheck for Employees Hired After 1-1-2019
The amount of your paycheck cost difference will be dependent on the type of coverage you choose
for 2020 (see last column on the table below)
Rates are effective January 1 2020
HRA-HMO
Signature
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $50725 $4682
Employee + 1 $101444 $10535
Employee + Family $147096 $15802
HMO Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $58173 5370
Employee + 1 $116340 $12081
Employee + Family $168696 $18122
POS Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $85966 $7935
Employee + 1 $171932 $17854
Employee + Family $249293 $26781
NOTE The Health Insurance Premium Bank is still available to those who qualify Request for
assistance must be made annually by December 12th or within 30 days of a qualifying event
8
Dental amp Vision Premium Costs per Paycheck
The following rates represent your monthly Dental and Vision premiums effective January 1 2020
MetLife Dental Per Paycheck
FULL-TIME Cost
Per Paycheck
PART-TIME Cost
Employee $000
Contact HR for cost Employee + 1 $000
Employee + Family $000
VSP Vision Per Paycheck Cost
Employee $513
Employee + Adult $864
Employee + Child $882
Employee + Family $1423
SpecteraUHC Vision Per Paycheck Cost
Employee $415
Employee + Adult $843
Employee + Child $883
Employee + Family $1116
9
Health Insurance ndash Option 1
DHMO HRA Signature In Network You Pay Out-of-Network You Pay
Deductible Coinsurance Out-of-Pocket
$750 Individual$1500 Family (RA funds) 9010
$3000 Individual $6000 Family
(less than regular HMO)
NA
Primary Care and Specialist Office Visit $15 PCP$25 Specialist NO COVERAGE
Emergency Room Visits $75 per visit (waived
if admitted) NO COVERAGE
Hospital ndash Inpatient Stay 10 after deductible NO COVERAGE
Home Health Care 10 after deductible NO COVERAGE
Outpatient Facility Services 10 after deductible NO COVERAGE
X-Ray and Laboratory Services 10 after deductible NO COVERAGE
Specialty Imaging (CTMRIPET scan) 10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $15 PCP$25 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $30 Participating $50 Plan $45 Participating $65
$20$30$45
Kaiser Permanente D-HMO HRA Signature (Facilities Only) With the Signature Network members receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Medical centers offer convenient services including primary care specialty care laboratory radiology and pharmacy at most locations and in some locations optical Signature members also have access to more than 40 hospitals in the region
10
Health Insurance ndash Option 2
Kaiser Permanente HMO Select (Facilities amp Contracted Providers Only) With the Select Network members may receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Building on the Signature physician network the Select network adds access to more than 15000 contracted community physicians in private practice Select members also have access to more than 40 hospitals in the region
HMO Select In-Network You Pay Out-of-Network
You Pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
NA
Primary Care and Specialist Office Visit $30 PCP$40 Specialist NO COVERAGE
Emergency Room Visits $100 per visit
(waived if admitted) NO COVERAGE
Hospital ndash Inpatient Stay $250 per admission NO COVERAGE
Home Health Care No charge NO COVERAGE
Outpatient Facility Services $100 NO COVERAGE
X-Ray and Laboratory Services No charge NO COVERAGE
Specialty Imaging (CTMRIPET scan) $50 per test NO COVERAGE
Chiropractic amp Acupuncture Services $40 copay
20 visits per contract year NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$15 copay-group therapy $30 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $30 PCP$40 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
11
Kaiser Permanente POS Select (Facilities amp Contracted Providers with an Out of Network Option) Members can use in-plan benefits by using a Kaiser facility or a contracted primary care physician Your chosen PCP will provide care and coordinate referrals and hospital admissions Members also have the freedom to choose any other licensed provider outside the provider network however you will be responsible for deductibles and coinsurance above the health planrsquos payment
POS Select In-Network You Pay Out-of-Network
you pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
$300 Individual $600 Family
8020 $3000 Individual
$6000 Family
Primary Care and Specialist Office Visit $15 PCP$30 Specialist 20 of UCR
Emergency Room Visits $75 per visit (waived if
admitted) $75 per visit
(waived if admitted)
Hospital ndash Inpatient Stay $250 per admission 20 of UCR
Home Health Care No charge 20 of UCR
Outpatient Facility Services $50 20 of UCR
X-Ray and Laboratory Services No charge 20 of UCR
Specialty Imaging (CTMRIPET scan) No charge 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
20 of UCR
Vision (Children Only) $15 PCP$30 Specialist per visit 20 of UCR
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
Health Insurance ndash Option 3
12
Dental Insurance
MetLife Dental PPO The Dental PPO plan is 100 Employer Paid for all tiers and provides comprehensive coverage with a nationwide PPO network This gives members access to more in-network dentists making it easier for them to reduce out-of-pocket costs for covered procedures and treatments Dental procedure frequencies Preventative care covers an exam and cleaning (once every 6 months) Fluoride treatment (two per benefit period under age 19 only) Full mouth X-ray (once every 60 months) Bitewing X-ray (once every 12 months age 14 and over once every 12 months under age 14)
PPO Dental Plan Features In-Network Out-of-Network
Type A Preventive Care Services (oral exams cleanings x-rays sealants)
100 of Fee Schedule 100 of Usual amp Customary
Charge
Type B Basic Restorative Dental Services (fillings simple extractions space maintainers)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type B Major Surgical Dental Services (Endodontics amp Periodontics)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type C Major Restorative Dental Services (bridges crowns dentures implants)
50 of Fee Schedule 50 of Usual amp Customary
Charge
Orthodontia (under age 19 only)
Lifetime maximum - $1000 50 of allowed benefit
Calendar Year Deductible Applies to Type B amp C services only
$25 Single $75 Family
Calendar Year Maximum Per Person $1500 combined maxper calendar year
Prior to receiving dental services it is recommended that you first obtain a pre-determination of benefits from your dentist so you know exactly how much your dental insurance will cover Spouses domestic partners and dependent children to age 26 (regardless of student status) are eligible
13
Vision Insurance ndash Option 1
Vision Plan through VSP (Voluntary) VSP is the largest private provider vision carrier in the country VSP contracts with Costcoreg Optical Eye Care Centers of America Inctrade which includes popular stores like EyeMasters VisionWorld and Hour Eyes and other quality retail chains When you visit a VSP participating provider your benefits include routine vision exams lenses and preferred pricing on all patient options Frequency Eye Exam 12 monthsLenses 12 monthsFrames 24 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $45
Eyeglass Lenses (standard) Single Bifocal Trifocal
Covered in Full Covered in Full Covered in Full
Plan pays up to $30 Plan pays up to $50 Plan pays up to $65
Frames $130 allowance then 20 off remaining balance
Plan pays up to $70
Necessary Contact Lenses Covered in Full Plan pays up to $210
Elective Contact Lenses $130 allowance Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $60
copay Not Available
Spouses domestic partners and dependent children to age 19 (or to age 25 if FT student) are eligible
14
Vision Insurance ndash Option 2
Vision Plan through Spectera UHC (Voluntary)
UHC offers you one of the largest vision care networks in the industry Their network includes convenient retail locations including My Eye Dr and Hour Eyes Best of all ndash when you receive care from a participating provider you receive the greatest benefits and money-saving discounts
Frequency Eye Exam 12 monthsLenses 12 monthsFrames 12 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $40
Eyeglass Lenses (standard) Single Bifocal Trifocal
$25 copay $25 copay $25 copay
Plan pays up to $40 Plan pays up to $60 Plan pays up to $80
Frames $2500 copay $130 retail frame
allowance 30 discount above allowance
Plan pays up to $45
Necessary Contact Lenses $25 copay Plan pays up to $210
Elective Contact Lenses
$25 copay from the ldquoCovered contact lens
selectionrdquo All others- $105
allowance
Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $25
copay Not Available
Spouses and dependent children to age 26 are eligible
15
Pre-tax FSA amp DCA
Flexible Spending Account (FSA) through Optum Health The Flexible Spending Account provides employees a means to reduce their taxes by the amount of their out of pocket health-related expenses (subject to eligibility) This tax free savings program allows employees to submit receipts for reimbursement for medical dental vision care prescription drug co-payments and other expenses not covered by our insurance In 2020 employees may contribute up to $2750 per year toward their FSA Employees have until March 14 2020 to use the money in their FSA or else they lose it (This contribution amount could change based on IRS guideline updates)
Dependent Care Spending Account (DCA) through Optum Health The Dependent Care Spending Account provides employees a means to reduce their taxes by the amount of their child care costs to a licensed provider up to $5000 annually
Health Insurance Premium Bank
Reston Association has established a program to help regular full-time and regular part-time employees pay their portion of the health insurance premium This program is only available to employees who are enrolled in or plan to enroll in the Kaiser Permanente HMO health insurance plans offered by the Reston Association Employees are eligible to apply to the Health Insurance Premium Bank if their adjusted gross household incomes are less than or equal to $60000 Requests for assistance must be made annually or at any time there is a qualifying event and submitted to Human Resources with necessary documentation by December 12th of each year To apply complete a request form (available in CommonHumResBenefits) and submit to HR with a copy of your most recent tax return showing adjusted gross household income This threshold is subject to change
16
Life and ADampD Insurance
Basic LifeADampD Insurance Reston Association provides 100 employer paid Life and ADampD Insurance through Sun Life to employees working 25 or more hours per week Coverage becomes effective the first of the month following six months of service
Benefit 2x Annual Earnings to a maximum of $200000 Age reduction Benefit reduced to 65 at age 65 and to 50 at age 70
Optional LifeADampD Insurance for Employee Spouse and Dependent Children
Optional Life Insurance for the employee spouse and dependent children is available at the employeersquos cost Optional Life is not available for domestic partners
Employee Benefit Increments of $10000 to a maximum of the lesser of $300000 or 3x your Basic Annual Earnings
Spouse Benefit Increments of $5000 to a maximum of $150000 Dependent Child Benefit Increments of $1000 to a maximum of $10000
Your amount of Dependent Spouse and Dependent Child Optional Life Insurance cannot exceed 50 of your amount of Optional Life Insurance Initial eligibility period will require evidence of insurability
STD amp LTD Insurance
Short Term and Long Term Disability Reston Association provides eligible employees with short and long-term disability income benefits through Sun Life In the event you become disabled from a non work-related injury or sickness disability income benefits are provided as a source of income These benefits are 100 employer paid
Benefit Short-Term Disability Long-Term Disability
Income Replacement -Eligible Employees -Executives
60 60
Elimination Period - Accidental Injury - Sickness
29 days 90 days
Benefit Period 9 weeks maximum To Social Security
normal retirement age
Benefit Maximum -Eligible Employees -Executives
$1000 per week $6000 per month $8000 per month 17
At a cost of $19month you can enroll in the Legal Resources benefit As a Legal Resources Member you have immediate and ongoing access to comprehensive legal coverage services and expertise that will easily save you money mdash and could save you a whole lot more Covered legal services include
Legal Advice and Consultation Tenant Dispute with Landlord District Court Representation for Civil Action Review of a Financial Contract or Lease Purchase sale or refinance of primary home Traffic Court Representation (includes 1st DUI) Will Preparation Uncontested Divorce Representation Defense of Child in Court (misdemeanor)
Legal Resources
Employee Assistance Program (EAP)
Reston Association offers a free confidential Employee Assistance Program (EAP) to all employees and their eligible dependents Through RArsquos EAP provider Lytle EAP Partners you and your immediate family members have immediate access on your date of hire to confidential professional counseling and referral services for help with anything that affects you or your dependentsrsquo well-being You can reach an EAP counselor by dialing 1-800-327-7272 24 hours a day or you may visit their website at wwwLytleEAPcom (password is reston) for more information Visit wwwLytleEAPcom for web-based legal financial worklife resources There are also work-related resources available online for managers Note Since EAP services are provided as a benefit only RA makes no representation concerning quality of care
18
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Compensation
Base Pay Reston Association strives to be competitive with wages within our industry and within our community We believe in an equitable balanced total pay program that offers competitive pay RA hires employees within the minimum of market pay range or RArsquos salary grade range whichever is greater for the job with variations based on job-related skills education ability experience and the current job market RArsquos salary ranges and job descriptions are available to view in CommonHumRes
Annual Performance Reviews amp Merit Increases Performance reviews are scheduled annually A merit increase may be applied to your base pay in conjunction with your performance review You and your supervisor should also review your job description at this time and inform HR if any updates are necessary
Recognition amp Rewards
Kudos Notes Take a minute to recognize a co-worker for something positive by writing them a Kudos Note There is never a reason too small There is a Kudos board at CSF and WNEC (Nature House) and there are three Kudos boards at Headquarters There will be periodic Kudos Note drawings throughout the year
Reston Employee Awards Program (REAP) The purpose of REAP is to recognize and reward employees for going above and beyond in performing their responsibilities and service to the organization Nominations for REAP awards are reviewed by the REAP Committee on a monthly basis Employees can receive an individual or group REAP award
3
Recognition amp Rewards
Reston Association recognizes and rewards employees for going above and beyond in performing their responsibilities and service to the organization and to all that Reston encompasses Employees can be recognized and rewarded by their peers by receiving an Achievement award or a Recognition award
Achievement Recognizing and rewarding employees for achieving a sustainable impact Award criteria includes bull Progressive for RA and RArsquos goals bull Innovative bull Sustained Excellence bull Saves RA timemoneyother resources
Recognition Recognizing and rewarding employees for a moment of excellence Award criteria includes bull A moment of excellence performed under challenging or uncommon circumstances bull A single event of outstanding service that goes beyond onersquos core job responsibilities and that demonstrates
an employeersquos willingness to take initiative in assisting internal andor external customers
Service Awards Reston Association provides awards for reaching years of service milestones Awards are given in December of the year in which you reach one of the following service milestones 5 years bull 10 years bull 15 years bull 20 years bull 25 years bull 30 years bull 35 years
Employee of the Year Every year Reston Association selects an Employee of the Year The purpose of the Employee of the Year award is to honor those who have invested their time and taken initiative to make significant contributions to the organization and community over the course of the year with consideration given to past achievements and contributions The Employee of the Year receives one paid day off certificate a $500 bonus and dedication of a tree in Reston
4
Benefits ndash RArsquos Wellness Program
Reston Association is committed to providing a culture that promotes healthy living through education and resources RArsquos Wellness Program works to achieve this commitment through its goals
To help employees reduce lifestyle risk factors and become better health care consumers
To raise employee awareness about the importance of preventative health care and overall wellness including financial and mental
To provide employees a work environment that supports positive health and fitness practices
Every year at RArsquos annual wellness and benefits fair in November you will be given a Passport to Wellness where you earn stamps for individual and group activities Benefits of participating in the Wellness Program include
Wellness screenings and flu shots at the Benefits Fair in November Quarterly Brown Bag presentations related to wellness and workplace topics Activities events and team challenges such as the YMCA Corporate Challenge car
free days blood drives water-only challenges smoothie days and more Earn stamps for participation in individual and group activities Redeem your stamps
for prizes including the grand prize
5
Benefits ndash PlanContact Information
Enrollment in the majority of these benefits must be done within 30 days of hire during open enrollment or within 30 days of a qualifying life change event Open enrollment occurs annually from mid-November to mid-December
Benefits elected during open enrollment will take effect January 1
The employee their spouse or domestic partner (regardless of sex) and their children under age 26 are eligible to enroll in benefits
Insurance Benefits
Health Insurance Provider Name Kaiser Permanente group 3007-4 (HMO Select) 3007-6 (POS) 3007-10 (HRA-DHMO) Provider Contact Member Services 301-468-6000 Provider Web Address wwwkporg
Dental Insurance Provider Name MetLife group 5469528 Provider Contact Member Services 800-ASK-4MET Provider Web Address httpsmybenefitsmetlifecom
Supplemental Vision Insurance ndash two options 1Provider Name VSP group 30017163
Provider Contact Member Services 800-877-7195 Provider Web Address wwwvspcom
2Provider Name SpecteraUHC group GA9N9747BW Provider Contact Member Services 800-839-3242 Provider Web Address wwwmyuhccom
Flexible Spending Accounts (FSA) amp Dependent Care Accounts (DCA) Contact Optum Health Provider Contact Member Services 800-243-5543 Provider Web Address httpssecureoptumhealthfinancialcom
LifeADampD Short-term Disability (STD) amp Long-term Disability (LTD) Insurance Provider Name Sun Life group 211628 Provider Contact Member Services 800-247-6875 Provider Web Address wwwsunlifecomus
Savings Benefits 401(k) Retirement Savings Plan (pre-tax and Roth)
Provider Name Ascensus Broker Contact Mark Ivcevich 301-326-1521 markqp-consultingcom Web Address httpsmyaccountascensuscomrplink
529 College Savings Plan Contact Human Resources
6
Medical Premium Costs per Paycheck for Employees Hired Prior to 1-1-2019
The amount of your paycheck cost difference will be dependent on the type of coverage you choose
for 2020 (see last column on the table below)
Rates are effective January 1 2020
HRA-HMO
Signature
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $50725 $3512
Employee + 1 $101444 $8193
Employee + Family $147096 $12408
HMO Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $58173 $4027
Employee + 1 $116340 $9397
Employee + Family $168696 $14229
POS Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $85966 $5951
Employee + 1 $171932 $13887
Employee + Family $249293 $21028
NOTE The Health Insurance Premium Bank is still available to those who qualify Request for
assistance must be made annually by December 15th or within 30 days of a qualifying event
7
Medical Premium Costs per Paycheck for Employees Hired After 1-1-2019
The amount of your paycheck cost difference will be dependent on the type of coverage you choose
for 2020 (see last column on the table below)
Rates are effective January 1 2020
HRA-HMO
Signature
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $50725 $4682
Employee + 1 $101444 $10535
Employee + Family $147096 $15802
HMO Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $58173 5370
Employee + 1 $116340 $12081
Employee + Family $168696 $18122
POS Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $85966 $7935
Employee + 1 $171932 $17854
Employee + Family $249293 $26781
NOTE The Health Insurance Premium Bank is still available to those who qualify Request for
assistance must be made annually by December 12th or within 30 days of a qualifying event
8
Dental amp Vision Premium Costs per Paycheck
The following rates represent your monthly Dental and Vision premiums effective January 1 2020
MetLife Dental Per Paycheck
FULL-TIME Cost
Per Paycheck
PART-TIME Cost
Employee $000
Contact HR for cost Employee + 1 $000
Employee + Family $000
VSP Vision Per Paycheck Cost
Employee $513
Employee + Adult $864
Employee + Child $882
Employee + Family $1423
SpecteraUHC Vision Per Paycheck Cost
Employee $415
Employee + Adult $843
Employee + Child $883
Employee + Family $1116
9
Health Insurance ndash Option 1
DHMO HRA Signature In Network You Pay Out-of-Network You Pay
Deductible Coinsurance Out-of-Pocket
$750 Individual$1500 Family (RA funds) 9010
$3000 Individual $6000 Family
(less than regular HMO)
NA
Primary Care and Specialist Office Visit $15 PCP$25 Specialist NO COVERAGE
Emergency Room Visits $75 per visit (waived
if admitted) NO COVERAGE
Hospital ndash Inpatient Stay 10 after deductible NO COVERAGE
Home Health Care 10 after deductible NO COVERAGE
Outpatient Facility Services 10 after deductible NO COVERAGE
X-Ray and Laboratory Services 10 after deductible NO COVERAGE
Specialty Imaging (CTMRIPET scan) 10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $15 PCP$25 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $30 Participating $50 Plan $45 Participating $65
$20$30$45
Kaiser Permanente D-HMO HRA Signature (Facilities Only) With the Signature Network members receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Medical centers offer convenient services including primary care specialty care laboratory radiology and pharmacy at most locations and in some locations optical Signature members also have access to more than 40 hospitals in the region
10
Health Insurance ndash Option 2
Kaiser Permanente HMO Select (Facilities amp Contracted Providers Only) With the Select Network members may receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Building on the Signature physician network the Select network adds access to more than 15000 contracted community physicians in private practice Select members also have access to more than 40 hospitals in the region
HMO Select In-Network You Pay Out-of-Network
You Pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
NA
Primary Care and Specialist Office Visit $30 PCP$40 Specialist NO COVERAGE
Emergency Room Visits $100 per visit
(waived if admitted) NO COVERAGE
Hospital ndash Inpatient Stay $250 per admission NO COVERAGE
Home Health Care No charge NO COVERAGE
Outpatient Facility Services $100 NO COVERAGE
X-Ray and Laboratory Services No charge NO COVERAGE
Specialty Imaging (CTMRIPET scan) $50 per test NO COVERAGE
Chiropractic amp Acupuncture Services $40 copay
20 visits per contract year NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$15 copay-group therapy $30 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $30 PCP$40 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
11
Kaiser Permanente POS Select (Facilities amp Contracted Providers with an Out of Network Option) Members can use in-plan benefits by using a Kaiser facility or a contracted primary care physician Your chosen PCP will provide care and coordinate referrals and hospital admissions Members also have the freedom to choose any other licensed provider outside the provider network however you will be responsible for deductibles and coinsurance above the health planrsquos payment
POS Select In-Network You Pay Out-of-Network
you pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
$300 Individual $600 Family
8020 $3000 Individual
$6000 Family
Primary Care and Specialist Office Visit $15 PCP$30 Specialist 20 of UCR
Emergency Room Visits $75 per visit (waived if
admitted) $75 per visit
(waived if admitted)
Hospital ndash Inpatient Stay $250 per admission 20 of UCR
Home Health Care No charge 20 of UCR
Outpatient Facility Services $50 20 of UCR
X-Ray and Laboratory Services No charge 20 of UCR
Specialty Imaging (CTMRIPET scan) No charge 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
20 of UCR
Vision (Children Only) $15 PCP$30 Specialist per visit 20 of UCR
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
Health Insurance ndash Option 3
12
Dental Insurance
MetLife Dental PPO The Dental PPO plan is 100 Employer Paid for all tiers and provides comprehensive coverage with a nationwide PPO network This gives members access to more in-network dentists making it easier for them to reduce out-of-pocket costs for covered procedures and treatments Dental procedure frequencies Preventative care covers an exam and cleaning (once every 6 months) Fluoride treatment (two per benefit period under age 19 only) Full mouth X-ray (once every 60 months) Bitewing X-ray (once every 12 months age 14 and over once every 12 months under age 14)
PPO Dental Plan Features In-Network Out-of-Network
Type A Preventive Care Services (oral exams cleanings x-rays sealants)
100 of Fee Schedule 100 of Usual amp Customary
Charge
Type B Basic Restorative Dental Services (fillings simple extractions space maintainers)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type B Major Surgical Dental Services (Endodontics amp Periodontics)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type C Major Restorative Dental Services (bridges crowns dentures implants)
50 of Fee Schedule 50 of Usual amp Customary
Charge
Orthodontia (under age 19 only)
Lifetime maximum - $1000 50 of allowed benefit
Calendar Year Deductible Applies to Type B amp C services only
$25 Single $75 Family
Calendar Year Maximum Per Person $1500 combined maxper calendar year
Prior to receiving dental services it is recommended that you first obtain a pre-determination of benefits from your dentist so you know exactly how much your dental insurance will cover Spouses domestic partners and dependent children to age 26 (regardless of student status) are eligible
13
Vision Insurance ndash Option 1
Vision Plan through VSP (Voluntary) VSP is the largest private provider vision carrier in the country VSP contracts with Costcoreg Optical Eye Care Centers of America Inctrade which includes popular stores like EyeMasters VisionWorld and Hour Eyes and other quality retail chains When you visit a VSP participating provider your benefits include routine vision exams lenses and preferred pricing on all patient options Frequency Eye Exam 12 monthsLenses 12 monthsFrames 24 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $45
Eyeglass Lenses (standard) Single Bifocal Trifocal
Covered in Full Covered in Full Covered in Full
Plan pays up to $30 Plan pays up to $50 Plan pays up to $65
Frames $130 allowance then 20 off remaining balance
Plan pays up to $70
Necessary Contact Lenses Covered in Full Plan pays up to $210
Elective Contact Lenses $130 allowance Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $60
copay Not Available
Spouses domestic partners and dependent children to age 19 (or to age 25 if FT student) are eligible
14
Vision Insurance ndash Option 2
Vision Plan through Spectera UHC (Voluntary)
UHC offers you one of the largest vision care networks in the industry Their network includes convenient retail locations including My Eye Dr and Hour Eyes Best of all ndash when you receive care from a participating provider you receive the greatest benefits and money-saving discounts
Frequency Eye Exam 12 monthsLenses 12 monthsFrames 12 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $40
Eyeglass Lenses (standard) Single Bifocal Trifocal
$25 copay $25 copay $25 copay
Plan pays up to $40 Plan pays up to $60 Plan pays up to $80
Frames $2500 copay $130 retail frame
allowance 30 discount above allowance
Plan pays up to $45
Necessary Contact Lenses $25 copay Plan pays up to $210
Elective Contact Lenses
$25 copay from the ldquoCovered contact lens
selectionrdquo All others- $105
allowance
Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $25
copay Not Available
Spouses and dependent children to age 26 are eligible
15
Pre-tax FSA amp DCA
Flexible Spending Account (FSA) through Optum Health The Flexible Spending Account provides employees a means to reduce their taxes by the amount of their out of pocket health-related expenses (subject to eligibility) This tax free savings program allows employees to submit receipts for reimbursement for medical dental vision care prescription drug co-payments and other expenses not covered by our insurance In 2020 employees may contribute up to $2750 per year toward their FSA Employees have until March 14 2020 to use the money in their FSA or else they lose it (This contribution amount could change based on IRS guideline updates)
Dependent Care Spending Account (DCA) through Optum Health The Dependent Care Spending Account provides employees a means to reduce their taxes by the amount of their child care costs to a licensed provider up to $5000 annually
Health Insurance Premium Bank
Reston Association has established a program to help regular full-time and regular part-time employees pay their portion of the health insurance premium This program is only available to employees who are enrolled in or plan to enroll in the Kaiser Permanente HMO health insurance plans offered by the Reston Association Employees are eligible to apply to the Health Insurance Premium Bank if their adjusted gross household incomes are less than or equal to $60000 Requests for assistance must be made annually or at any time there is a qualifying event and submitted to Human Resources with necessary documentation by December 12th of each year To apply complete a request form (available in CommonHumResBenefits) and submit to HR with a copy of your most recent tax return showing adjusted gross household income This threshold is subject to change
16
Life and ADampD Insurance
Basic LifeADampD Insurance Reston Association provides 100 employer paid Life and ADampD Insurance through Sun Life to employees working 25 or more hours per week Coverage becomes effective the first of the month following six months of service
Benefit 2x Annual Earnings to a maximum of $200000 Age reduction Benefit reduced to 65 at age 65 and to 50 at age 70
Optional LifeADampD Insurance for Employee Spouse and Dependent Children
Optional Life Insurance for the employee spouse and dependent children is available at the employeersquos cost Optional Life is not available for domestic partners
Employee Benefit Increments of $10000 to a maximum of the lesser of $300000 or 3x your Basic Annual Earnings
Spouse Benefit Increments of $5000 to a maximum of $150000 Dependent Child Benefit Increments of $1000 to a maximum of $10000
Your amount of Dependent Spouse and Dependent Child Optional Life Insurance cannot exceed 50 of your amount of Optional Life Insurance Initial eligibility period will require evidence of insurability
STD amp LTD Insurance
Short Term and Long Term Disability Reston Association provides eligible employees with short and long-term disability income benefits through Sun Life In the event you become disabled from a non work-related injury or sickness disability income benefits are provided as a source of income These benefits are 100 employer paid
Benefit Short-Term Disability Long-Term Disability
Income Replacement -Eligible Employees -Executives
60 60
Elimination Period - Accidental Injury - Sickness
29 days 90 days
Benefit Period 9 weeks maximum To Social Security
normal retirement age
Benefit Maximum -Eligible Employees -Executives
$1000 per week $6000 per month $8000 per month 17
At a cost of $19month you can enroll in the Legal Resources benefit As a Legal Resources Member you have immediate and ongoing access to comprehensive legal coverage services and expertise that will easily save you money mdash and could save you a whole lot more Covered legal services include
Legal Advice and Consultation Tenant Dispute with Landlord District Court Representation for Civil Action Review of a Financial Contract or Lease Purchase sale or refinance of primary home Traffic Court Representation (includes 1st DUI) Will Preparation Uncontested Divorce Representation Defense of Child in Court (misdemeanor)
Legal Resources
Employee Assistance Program (EAP)
Reston Association offers a free confidential Employee Assistance Program (EAP) to all employees and their eligible dependents Through RArsquos EAP provider Lytle EAP Partners you and your immediate family members have immediate access on your date of hire to confidential professional counseling and referral services for help with anything that affects you or your dependentsrsquo well-being You can reach an EAP counselor by dialing 1-800-327-7272 24 hours a day or you may visit their website at wwwLytleEAPcom (password is reston) for more information Visit wwwLytleEAPcom for web-based legal financial worklife resources There are also work-related resources available online for managers Note Since EAP services are provided as a benefit only RA makes no representation concerning quality of care
18
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Recognition amp Rewards
Reston Association recognizes and rewards employees for going above and beyond in performing their responsibilities and service to the organization and to all that Reston encompasses Employees can be recognized and rewarded by their peers by receiving an Achievement award or a Recognition award
Achievement Recognizing and rewarding employees for achieving a sustainable impact Award criteria includes bull Progressive for RA and RArsquos goals bull Innovative bull Sustained Excellence bull Saves RA timemoneyother resources
Recognition Recognizing and rewarding employees for a moment of excellence Award criteria includes bull A moment of excellence performed under challenging or uncommon circumstances bull A single event of outstanding service that goes beyond onersquos core job responsibilities and that demonstrates
an employeersquos willingness to take initiative in assisting internal andor external customers
Service Awards Reston Association provides awards for reaching years of service milestones Awards are given in December of the year in which you reach one of the following service milestones 5 years bull 10 years bull 15 years bull 20 years bull 25 years bull 30 years bull 35 years
Employee of the Year Every year Reston Association selects an Employee of the Year The purpose of the Employee of the Year award is to honor those who have invested their time and taken initiative to make significant contributions to the organization and community over the course of the year with consideration given to past achievements and contributions The Employee of the Year receives one paid day off certificate a $500 bonus and dedication of a tree in Reston
4
Benefits ndash RArsquos Wellness Program
Reston Association is committed to providing a culture that promotes healthy living through education and resources RArsquos Wellness Program works to achieve this commitment through its goals
To help employees reduce lifestyle risk factors and become better health care consumers
To raise employee awareness about the importance of preventative health care and overall wellness including financial and mental
To provide employees a work environment that supports positive health and fitness practices
Every year at RArsquos annual wellness and benefits fair in November you will be given a Passport to Wellness where you earn stamps for individual and group activities Benefits of participating in the Wellness Program include
Wellness screenings and flu shots at the Benefits Fair in November Quarterly Brown Bag presentations related to wellness and workplace topics Activities events and team challenges such as the YMCA Corporate Challenge car
free days blood drives water-only challenges smoothie days and more Earn stamps for participation in individual and group activities Redeem your stamps
for prizes including the grand prize
5
Benefits ndash PlanContact Information
Enrollment in the majority of these benefits must be done within 30 days of hire during open enrollment or within 30 days of a qualifying life change event Open enrollment occurs annually from mid-November to mid-December
Benefits elected during open enrollment will take effect January 1
The employee their spouse or domestic partner (regardless of sex) and their children under age 26 are eligible to enroll in benefits
Insurance Benefits
Health Insurance Provider Name Kaiser Permanente group 3007-4 (HMO Select) 3007-6 (POS) 3007-10 (HRA-DHMO) Provider Contact Member Services 301-468-6000 Provider Web Address wwwkporg
Dental Insurance Provider Name MetLife group 5469528 Provider Contact Member Services 800-ASK-4MET Provider Web Address httpsmybenefitsmetlifecom
Supplemental Vision Insurance ndash two options 1Provider Name VSP group 30017163
Provider Contact Member Services 800-877-7195 Provider Web Address wwwvspcom
2Provider Name SpecteraUHC group GA9N9747BW Provider Contact Member Services 800-839-3242 Provider Web Address wwwmyuhccom
Flexible Spending Accounts (FSA) amp Dependent Care Accounts (DCA) Contact Optum Health Provider Contact Member Services 800-243-5543 Provider Web Address httpssecureoptumhealthfinancialcom
LifeADampD Short-term Disability (STD) amp Long-term Disability (LTD) Insurance Provider Name Sun Life group 211628 Provider Contact Member Services 800-247-6875 Provider Web Address wwwsunlifecomus
Savings Benefits 401(k) Retirement Savings Plan (pre-tax and Roth)
Provider Name Ascensus Broker Contact Mark Ivcevich 301-326-1521 markqp-consultingcom Web Address httpsmyaccountascensuscomrplink
529 College Savings Plan Contact Human Resources
6
Medical Premium Costs per Paycheck for Employees Hired Prior to 1-1-2019
The amount of your paycheck cost difference will be dependent on the type of coverage you choose
for 2020 (see last column on the table below)
Rates are effective January 1 2020
HRA-HMO
Signature
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $50725 $3512
Employee + 1 $101444 $8193
Employee + Family $147096 $12408
HMO Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $58173 $4027
Employee + 1 $116340 $9397
Employee + Family $168696 $14229
POS Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $85966 $5951
Employee + 1 $171932 $13887
Employee + Family $249293 $21028
NOTE The Health Insurance Premium Bank is still available to those who qualify Request for
assistance must be made annually by December 15th or within 30 days of a qualifying event
7
Medical Premium Costs per Paycheck for Employees Hired After 1-1-2019
The amount of your paycheck cost difference will be dependent on the type of coverage you choose
for 2020 (see last column on the table below)
Rates are effective January 1 2020
HRA-HMO
Signature
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $50725 $4682
Employee + 1 $101444 $10535
Employee + Family $147096 $15802
HMO Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $58173 5370
Employee + 1 $116340 $12081
Employee + Family $168696 $18122
POS Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $85966 $7935
Employee + 1 $171932 $17854
Employee + Family $249293 $26781
NOTE The Health Insurance Premium Bank is still available to those who qualify Request for
assistance must be made annually by December 12th or within 30 days of a qualifying event
8
Dental amp Vision Premium Costs per Paycheck
The following rates represent your monthly Dental and Vision premiums effective January 1 2020
MetLife Dental Per Paycheck
FULL-TIME Cost
Per Paycheck
PART-TIME Cost
Employee $000
Contact HR for cost Employee + 1 $000
Employee + Family $000
VSP Vision Per Paycheck Cost
Employee $513
Employee + Adult $864
Employee + Child $882
Employee + Family $1423
SpecteraUHC Vision Per Paycheck Cost
Employee $415
Employee + Adult $843
Employee + Child $883
Employee + Family $1116
9
Health Insurance ndash Option 1
DHMO HRA Signature In Network You Pay Out-of-Network You Pay
Deductible Coinsurance Out-of-Pocket
$750 Individual$1500 Family (RA funds) 9010
$3000 Individual $6000 Family
(less than regular HMO)
NA
Primary Care and Specialist Office Visit $15 PCP$25 Specialist NO COVERAGE
Emergency Room Visits $75 per visit (waived
if admitted) NO COVERAGE
Hospital ndash Inpatient Stay 10 after deductible NO COVERAGE
Home Health Care 10 after deductible NO COVERAGE
Outpatient Facility Services 10 after deductible NO COVERAGE
X-Ray and Laboratory Services 10 after deductible NO COVERAGE
Specialty Imaging (CTMRIPET scan) 10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $15 PCP$25 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $30 Participating $50 Plan $45 Participating $65
$20$30$45
Kaiser Permanente D-HMO HRA Signature (Facilities Only) With the Signature Network members receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Medical centers offer convenient services including primary care specialty care laboratory radiology and pharmacy at most locations and in some locations optical Signature members also have access to more than 40 hospitals in the region
10
Health Insurance ndash Option 2
Kaiser Permanente HMO Select (Facilities amp Contracted Providers Only) With the Select Network members may receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Building on the Signature physician network the Select network adds access to more than 15000 contracted community physicians in private practice Select members also have access to more than 40 hospitals in the region
HMO Select In-Network You Pay Out-of-Network
You Pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
NA
Primary Care and Specialist Office Visit $30 PCP$40 Specialist NO COVERAGE
Emergency Room Visits $100 per visit
(waived if admitted) NO COVERAGE
Hospital ndash Inpatient Stay $250 per admission NO COVERAGE
Home Health Care No charge NO COVERAGE
Outpatient Facility Services $100 NO COVERAGE
X-Ray and Laboratory Services No charge NO COVERAGE
Specialty Imaging (CTMRIPET scan) $50 per test NO COVERAGE
Chiropractic amp Acupuncture Services $40 copay
20 visits per contract year NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$15 copay-group therapy $30 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $30 PCP$40 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
11
Kaiser Permanente POS Select (Facilities amp Contracted Providers with an Out of Network Option) Members can use in-plan benefits by using a Kaiser facility or a contracted primary care physician Your chosen PCP will provide care and coordinate referrals and hospital admissions Members also have the freedom to choose any other licensed provider outside the provider network however you will be responsible for deductibles and coinsurance above the health planrsquos payment
POS Select In-Network You Pay Out-of-Network
you pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
$300 Individual $600 Family
8020 $3000 Individual
$6000 Family
Primary Care and Specialist Office Visit $15 PCP$30 Specialist 20 of UCR
Emergency Room Visits $75 per visit (waived if
admitted) $75 per visit
(waived if admitted)
Hospital ndash Inpatient Stay $250 per admission 20 of UCR
Home Health Care No charge 20 of UCR
Outpatient Facility Services $50 20 of UCR
X-Ray and Laboratory Services No charge 20 of UCR
Specialty Imaging (CTMRIPET scan) No charge 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
20 of UCR
Vision (Children Only) $15 PCP$30 Specialist per visit 20 of UCR
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
Health Insurance ndash Option 3
12
Dental Insurance
MetLife Dental PPO The Dental PPO plan is 100 Employer Paid for all tiers and provides comprehensive coverage with a nationwide PPO network This gives members access to more in-network dentists making it easier for them to reduce out-of-pocket costs for covered procedures and treatments Dental procedure frequencies Preventative care covers an exam and cleaning (once every 6 months) Fluoride treatment (two per benefit period under age 19 only) Full mouth X-ray (once every 60 months) Bitewing X-ray (once every 12 months age 14 and over once every 12 months under age 14)
PPO Dental Plan Features In-Network Out-of-Network
Type A Preventive Care Services (oral exams cleanings x-rays sealants)
100 of Fee Schedule 100 of Usual amp Customary
Charge
Type B Basic Restorative Dental Services (fillings simple extractions space maintainers)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type B Major Surgical Dental Services (Endodontics amp Periodontics)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type C Major Restorative Dental Services (bridges crowns dentures implants)
50 of Fee Schedule 50 of Usual amp Customary
Charge
Orthodontia (under age 19 only)
Lifetime maximum - $1000 50 of allowed benefit
Calendar Year Deductible Applies to Type B amp C services only
$25 Single $75 Family
Calendar Year Maximum Per Person $1500 combined maxper calendar year
Prior to receiving dental services it is recommended that you first obtain a pre-determination of benefits from your dentist so you know exactly how much your dental insurance will cover Spouses domestic partners and dependent children to age 26 (regardless of student status) are eligible
13
Vision Insurance ndash Option 1
Vision Plan through VSP (Voluntary) VSP is the largest private provider vision carrier in the country VSP contracts with Costcoreg Optical Eye Care Centers of America Inctrade which includes popular stores like EyeMasters VisionWorld and Hour Eyes and other quality retail chains When you visit a VSP participating provider your benefits include routine vision exams lenses and preferred pricing on all patient options Frequency Eye Exam 12 monthsLenses 12 monthsFrames 24 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $45
Eyeglass Lenses (standard) Single Bifocal Trifocal
Covered in Full Covered in Full Covered in Full
Plan pays up to $30 Plan pays up to $50 Plan pays up to $65
Frames $130 allowance then 20 off remaining balance
Plan pays up to $70
Necessary Contact Lenses Covered in Full Plan pays up to $210
Elective Contact Lenses $130 allowance Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $60
copay Not Available
Spouses domestic partners and dependent children to age 19 (or to age 25 if FT student) are eligible
14
Vision Insurance ndash Option 2
Vision Plan through Spectera UHC (Voluntary)
UHC offers you one of the largest vision care networks in the industry Their network includes convenient retail locations including My Eye Dr and Hour Eyes Best of all ndash when you receive care from a participating provider you receive the greatest benefits and money-saving discounts
Frequency Eye Exam 12 monthsLenses 12 monthsFrames 12 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $40
Eyeglass Lenses (standard) Single Bifocal Trifocal
$25 copay $25 copay $25 copay
Plan pays up to $40 Plan pays up to $60 Plan pays up to $80
Frames $2500 copay $130 retail frame
allowance 30 discount above allowance
Plan pays up to $45
Necessary Contact Lenses $25 copay Plan pays up to $210
Elective Contact Lenses
$25 copay from the ldquoCovered contact lens
selectionrdquo All others- $105
allowance
Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $25
copay Not Available
Spouses and dependent children to age 26 are eligible
15
Pre-tax FSA amp DCA
Flexible Spending Account (FSA) through Optum Health The Flexible Spending Account provides employees a means to reduce their taxes by the amount of their out of pocket health-related expenses (subject to eligibility) This tax free savings program allows employees to submit receipts for reimbursement for medical dental vision care prescription drug co-payments and other expenses not covered by our insurance In 2020 employees may contribute up to $2750 per year toward their FSA Employees have until March 14 2020 to use the money in their FSA or else they lose it (This contribution amount could change based on IRS guideline updates)
Dependent Care Spending Account (DCA) through Optum Health The Dependent Care Spending Account provides employees a means to reduce their taxes by the amount of their child care costs to a licensed provider up to $5000 annually
Health Insurance Premium Bank
Reston Association has established a program to help regular full-time and regular part-time employees pay their portion of the health insurance premium This program is only available to employees who are enrolled in or plan to enroll in the Kaiser Permanente HMO health insurance plans offered by the Reston Association Employees are eligible to apply to the Health Insurance Premium Bank if their adjusted gross household incomes are less than or equal to $60000 Requests for assistance must be made annually or at any time there is a qualifying event and submitted to Human Resources with necessary documentation by December 12th of each year To apply complete a request form (available in CommonHumResBenefits) and submit to HR with a copy of your most recent tax return showing adjusted gross household income This threshold is subject to change
16
Life and ADampD Insurance
Basic LifeADampD Insurance Reston Association provides 100 employer paid Life and ADampD Insurance through Sun Life to employees working 25 or more hours per week Coverage becomes effective the first of the month following six months of service
Benefit 2x Annual Earnings to a maximum of $200000 Age reduction Benefit reduced to 65 at age 65 and to 50 at age 70
Optional LifeADampD Insurance for Employee Spouse and Dependent Children
Optional Life Insurance for the employee spouse and dependent children is available at the employeersquos cost Optional Life is not available for domestic partners
Employee Benefit Increments of $10000 to a maximum of the lesser of $300000 or 3x your Basic Annual Earnings
Spouse Benefit Increments of $5000 to a maximum of $150000 Dependent Child Benefit Increments of $1000 to a maximum of $10000
Your amount of Dependent Spouse and Dependent Child Optional Life Insurance cannot exceed 50 of your amount of Optional Life Insurance Initial eligibility period will require evidence of insurability
STD amp LTD Insurance
Short Term and Long Term Disability Reston Association provides eligible employees with short and long-term disability income benefits through Sun Life In the event you become disabled from a non work-related injury or sickness disability income benefits are provided as a source of income These benefits are 100 employer paid
Benefit Short-Term Disability Long-Term Disability
Income Replacement -Eligible Employees -Executives
60 60
Elimination Period - Accidental Injury - Sickness
29 days 90 days
Benefit Period 9 weeks maximum To Social Security
normal retirement age
Benefit Maximum -Eligible Employees -Executives
$1000 per week $6000 per month $8000 per month 17
At a cost of $19month you can enroll in the Legal Resources benefit As a Legal Resources Member you have immediate and ongoing access to comprehensive legal coverage services and expertise that will easily save you money mdash and could save you a whole lot more Covered legal services include
Legal Advice and Consultation Tenant Dispute with Landlord District Court Representation for Civil Action Review of a Financial Contract or Lease Purchase sale or refinance of primary home Traffic Court Representation (includes 1st DUI) Will Preparation Uncontested Divorce Representation Defense of Child in Court (misdemeanor)
Legal Resources
Employee Assistance Program (EAP)
Reston Association offers a free confidential Employee Assistance Program (EAP) to all employees and their eligible dependents Through RArsquos EAP provider Lytle EAP Partners you and your immediate family members have immediate access on your date of hire to confidential professional counseling and referral services for help with anything that affects you or your dependentsrsquo well-being You can reach an EAP counselor by dialing 1-800-327-7272 24 hours a day or you may visit their website at wwwLytleEAPcom (password is reston) for more information Visit wwwLytleEAPcom for web-based legal financial worklife resources There are also work-related resources available online for managers Note Since EAP services are provided as a benefit only RA makes no representation concerning quality of care
18
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Benefits ndash RArsquos Wellness Program
Reston Association is committed to providing a culture that promotes healthy living through education and resources RArsquos Wellness Program works to achieve this commitment through its goals
To help employees reduce lifestyle risk factors and become better health care consumers
To raise employee awareness about the importance of preventative health care and overall wellness including financial and mental
To provide employees a work environment that supports positive health and fitness practices
Every year at RArsquos annual wellness and benefits fair in November you will be given a Passport to Wellness where you earn stamps for individual and group activities Benefits of participating in the Wellness Program include
Wellness screenings and flu shots at the Benefits Fair in November Quarterly Brown Bag presentations related to wellness and workplace topics Activities events and team challenges such as the YMCA Corporate Challenge car
free days blood drives water-only challenges smoothie days and more Earn stamps for participation in individual and group activities Redeem your stamps
for prizes including the grand prize
5
Benefits ndash PlanContact Information
Enrollment in the majority of these benefits must be done within 30 days of hire during open enrollment or within 30 days of a qualifying life change event Open enrollment occurs annually from mid-November to mid-December
Benefits elected during open enrollment will take effect January 1
The employee their spouse or domestic partner (regardless of sex) and their children under age 26 are eligible to enroll in benefits
Insurance Benefits
Health Insurance Provider Name Kaiser Permanente group 3007-4 (HMO Select) 3007-6 (POS) 3007-10 (HRA-DHMO) Provider Contact Member Services 301-468-6000 Provider Web Address wwwkporg
Dental Insurance Provider Name MetLife group 5469528 Provider Contact Member Services 800-ASK-4MET Provider Web Address httpsmybenefitsmetlifecom
Supplemental Vision Insurance ndash two options 1Provider Name VSP group 30017163
Provider Contact Member Services 800-877-7195 Provider Web Address wwwvspcom
2Provider Name SpecteraUHC group GA9N9747BW Provider Contact Member Services 800-839-3242 Provider Web Address wwwmyuhccom
Flexible Spending Accounts (FSA) amp Dependent Care Accounts (DCA) Contact Optum Health Provider Contact Member Services 800-243-5543 Provider Web Address httpssecureoptumhealthfinancialcom
LifeADampD Short-term Disability (STD) amp Long-term Disability (LTD) Insurance Provider Name Sun Life group 211628 Provider Contact Member Services 800-247-6875 Provider Web Address wwwsunlifecomus
Savings Benefits 401(k) Retirement Savings Plan (pre-tax and Roth)
Provider Name Ascensus Broker Contact Mark Ivcevich 301-326-1521 markqp-consultingcom Web Address httpsmyaccountascensuscomrplink
529 College Savings Plan Contact Human Resources
6
Medical Premium Costs per Paycheck for Employees Hired Prior to 1-1-2019
The amount of your paycheck cost difference will be dependent on the type of coverage you choose
for 2020 (see last column on the table below)
Rates are effective January 1 2020
HRA-HMO
Signature
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $50725 $3512
Employee + 1 $101444 $8193
Employee + Family $147096 $12408
HMO Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $58173 $4027
Employee + 1 $116340 $9397
Employee + Family $168696 $14229
POS Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $85966 $5951
Employee + 1 $171932 $13887
Employee + Family $249293 $21028
NOTE The Health Insurance Premium Bank is still available to those who qualify Request for
assistance must be made annually by December 15th or within 30 days of a qualifying event
7
Medical Premium Costs per Paycheck for Employees Hired After 1-1-2019
The amount of your paycheck cost difference will be dependent on the type of coverage you choose
for 2020 (see last column on the table below)
Rates are effective January 1 2020
HRA-HMO
Signature
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $50725 $4682
Employee + 1 $101444 $10535
Employee + Family $147096 $15802
HMO Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $58173 5370
Employee + 1 $116340 $12081
Employee + Family $168696 $18122
POS Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $85966 $7935
Employee + 1 $171932 $17854
Employee + Family $249293 $26781
NOTE The Health Insurance Premium Bank is still available to those who qualify Request for
assistance must be made annually by December 12th or within 30 days of a qualifying event
8
Dental amp Vision Premium Costs per Paycheck
The following rates represent your monthly Dental and Vision premiums effective January 1 2020
MetLife Dental Per Paycheck
FULL-TIME Cost
Per Paycheck
PART-TIME Cost
Employee $000
Contact HR for cost Employee + 1 $000
Employee + Family $000
VSP Vision Per Paycheck Cost
Employee $513
Employee + Adult $864
Employee + Child $882
Employee + Family $1423
SpecteraUHC Vision Per Paycheck Cost
Employee $415
Employee + Adult $843
Employee + Child $883
Employee + Family $1116
9
Health Insurance ndash Option 1
DHMO HRA Signature In Network You Pay Out-of-Network You Pay
Deductible Coinsurance Out-of-Pocket
$750 Individual$1500 Family (RA funds) 9010
$3000 Individual $6000 Family
(less than regular HMO)
NA
Primary Care and Specialist Office Visit $15 PCP$25 Specialist NO COVERAGE
Emergency Room Visits $75 per visit (waived
if admitted) NO COVERAGE
Hospital ndash Inpatient Stay 10 after deductible NO COVERAGE
Home Health Care 10 after deductible NO COVERAGE
Outpatient Facility Services 10 after deductible NO COVERAGE
X-Ray and Laboratory Services 10 after deductible NO COVERAGE
Specialty Imaging (CTMRIPET scan) 10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $15 PCP$25 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $30 Participating $50 Plan $45 Participating $65
$20$30$45
Kaiser Permanente D-HMO HRA Signature (Facilities Only) With the Signature Network members receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Medical centers offer convenient services including primary care specialty care laboratory radiology and pharmacy at most locations and in some locations optical Signature members also have access to more than 40 hospitals in the region
10
Health Insurance ndash Option 2
Kaiser Permanente HMO Select (Facilities amp Contracted Providers Only) With the Select Network members may receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Building on the Signature physician network the Select network adds access to more than 15000 contracted community physicians in private practice Select members also have access to more than 40 hospitals in the region
HMO Select In-Network You Pay Out-of-Network
You Pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
NA
Primary Care and Specialist Office Visit $30 PCP$40 Specialist NO COVERAGE
Emergency Room Visits $100 per visit
(waived if admitted) NO COVERAGE
Hospital ndash Inpatient Stay $250 per admission NO COVERAGE
Home Health Care No charge NO COVERAGE
Outpatient Facility Services $100 NO COVERAGE
X-Ray and Laboratory Services No charge NO COVERAGE
Specialty Imaging (CTMRIPET scan) $50 per test NO COVERAGE
Chiropractic amp Acupuncture Services $40 copay
20 visits per contract year NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$15 copay-group therapy $30 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $30 PCP$40 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
11
Kaiser Permanente POS Select (Facilities amp Contracted Providers with an Out of Network Option) Members can use in-plan benefits by using a Kaiser facility or a contracted primary care physician Your chosen PCP will provide care and coordinate referrals and hospital admissions Members also have the freedom to choose any other licensed provider outside the provider network however you will be responsible for deductibles and coinsurance above the health planrsquos payment
POS Select In-Network You Pay Out-of-Network
you pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
$300 Individual $600 Family
8020 $3000 Individual
$6000 Family
Primary Care and Specialist Office Visit $15 PCP$30 Specialist 20 of UCR
Emergency Room Visits $75 per visit (waived if
admitted) $75 per visit
(waived if admitted)
Hospital ndash Inpatient Stay $250 per admission 20 of UCR
Home Health Care No charge 20 of UCR
Outpatient Facility Services $50 20 of UCR
X-Ray and Laboratory Services No charge 20 of UCR
Specialty Imaging (CTMRIPET scan) No charge 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
20 of UCR
Vision (Children Only) $15 PCP$30 Specialist per visit 20 of UCR
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
Health Insurance ndash Option 3
12
Dental Insurance
MetLife Dental PPO The Dental PPO plan is 100 Employer Paid for all tiers and provides comprehensive coverage with a nationwide PPO network This gives members access to more in-network dentists making it easier for them to reduce out-of-pocket costs for covered procedures and treatments Dental procedure frequencies Preventative care covers an exam and cleaning (once every 6 months) Fluoride treatment (two per benefit period under age 19 only) Full mouth X-ray (once every 60 months) Bitewing X-ray (once every 12 months age 14 and over once every 12 months under age 14)
PPO Dental Plan Features In-Network Out-of-Network
Type A Preventive Care Services (oral exams cleanings x-rays sealants)
100 of Fee Schedule 100 of Usual amp Customary
Charge
Type B Basic Restorative Dental Services (fillings simple extractions space maintainers)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type B Major Surgical Dental Services (Endodontics amp Periodontics)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type C Major Restorative Dental Services (bridges crowns dentures implants)
50 of Fee Schedule 50 of Usual amp Customary
Charge
Orthodontia (under age 19 only)
Lifetime maximum - $1000 50 of allowed benefit
Calendar Year Deductible Applies to Type B amp C services only
$25 Single $75 Family
Calendar Year Maximum Per Person $1500 combined maxper calendar year
Prior to receiving dental services it is recommended that you first obtain a pre-determination of benefits from your dentist so you know exactly how much your dental insurance will cover Spouses domestic partners and dependent children to age 26 (regardless of student status) are eligible
13
Vision Insurance ndash Option 1
Vision Plan through VSP (Voluntary) VSP is the largest private provider vision carrier in the country VSP contracts with Costcoreg Optical Eye Care Centers of America Inctrade which includes popular stores like EyeMasters VisionWorld and Hour Eyes and other quality retail chains When you visit a VSP participating provider your benefits include routine vision exams lenses and preferred pricing on all patient options Frequency Eye Exam 12 monthsLenses 12 monthsFrames 24 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $45
Eyeglass Lenses (standard) Single Bifocal Trifocal
Covered in Full Covered in Full Covered in Full
Plan pays up to $30 Plan pays up to $50 Plan pays up to $65
Frames $130 allowance then 20 off remaining balance
Plan pays up to $70
Necessary Contact Lenses Covered in Full Plan pays up to $210
Elective Contact Lenses $130 allowance Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $60
copay Not Available
Spouses domestic partners and dependent children to age 19 (or to age 25 if FT student) are eligible
14
Vision Insurance ndash Option 2
Vision Plan through Spectera UHC (Voluntary)
UHC offers you one of the largest vision care networks in the industry Their network includes convenient retail locations including My Eye Dr and Hour Eyes Best of all ndash when you receive care from a participating provider you receive the greatest benefits and money-saving discounts
Frequency Eye Exam 12 monthsLenses 12 monthsFrames 12 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $40
Eyeglass Lenses (standard) Single Bifocal Trifocal
$25 copay $25 copay $25 copay
Plan pays up to $40 Plan pays up to $60 Plan pays up to $80
Frames $2500 copay $130 retail frame
allowance 30 discount above allowance
Plan pays up to $45
Necessary Contact Lenses $25 copay Plan pays up to $210
Elective Contact Lenses
$25 copay from the ldquoCovered contact lens
selectionrdquo All others- $105
allowance
Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $25
copay Not Available
Spouses and dependent children to age 26 are eligible
15
Pre-tax FSA amp DCA
Flexible Spending Account (FSA) through Optum Health The Flexible Spending Account provides employees a means to reduce their taxes by the amount of their out of pocket health-related expenses (subject to eligibility) This tax free savings program allows employees to submit receipts for reimbursement for medical dental vision care prescription drug co-payments and other expenses not covered by our insurance In 2020 employees may contribute up to $2750 per year toward their FSA Employees have until March 14 2020 to use the money in their FSA or else they lose it (This contribution amount could change based on IRS guideline updates)
Dependent Care Spending Account (DCA) through Optum Health The Dependent Care Spending Account provides employees a means to reduce their taxes by the amount of their child care costs to a licensed provider up to $5000 annually
Health Insurance Premium Bank
Reston Association has established a program to help regular full-time and regular part-time employees pay their portion of the health insurance premium This program is only available to employees who are enrolled in or plan to enroll in the Kaiser Permanente HMO health insurance plans offered by the Reston Association Employees are eligible to apply to the Health Insurance Premium Bank if their adjusted gross household incomes are less than or equal to $60000 Requests for assistance must be made annually or at any time there is a qualifying event and submitted to Human Resources with necessary documentation by December 12th of each year To apply complete a request form (available in CommonHumResBenefits) and submit to HR with a copy of your most recent tax return showing adjusted gross household income This threshold is subject to change
16
Life and ADampD Insurance
Basic LifeADampD Insurance Reston Association provides 100 employer paid Life and ADampD Insurance through Sun Life to employees working 25 or more hours per week Coverage becomes effective the first of the month following six months of service
Benefit 2x Annual Earnings to a maximum of $200000 Age reduction Benefit reduced to 65 at age 65 and to 50 at age 70
Optional LifeADampD Insurance for Employee Spouse and Dependent Children
Optional Life Insurance for the employee spouse and dependent children is available at the employeersquos cost Optional Life is not available for domestic partners
Employee Benefit Increments of $10000 to a maximum of the lesser of $300000 or 3x your Basic Annual Earnings
Spouse Benefit Increments of $5000 to a maximum of $150000 Dependent Child Benefit Increments of $1000 to a maximum of $10000
Your amount of Dependent Spouse and Dependent Child Optional Life Insurance cannot exceed 50 of your amount of Optional Life Insurance Initial eligibility period will require evidence of insurability
STD amp LTD Insurance
Short Term and Long Term Disability Reston Association provides eligible employees with short and long-term disability income benefits through Sun Life In the event you become disabled from a non work-related injury or sickness disability income benefits are provided as a source of income These benefits are 100 employer paid
Benefit Short-Term Disability Long-Term Disability
Income Replacement -Eligible Employees -Executives
60 60
Elimination Period - Accidental Injury - Sickness
29 days 90 days
Benefit Period 9 weeks maximum To Social Security
normal retirement age
Benefit Maximum -Eligible Employees -Executives
$1000 per week $6000 per month $8000 per month 17
At a cost of $19month you can enroll in the Legal Resources benefit As a Legal Resources Member you have immediate and ongoing access to comprehensive legal coverage services and expertise that will easily save you money mdash and could save you a whole lot more Covered legal services include
Legal Advice and Consultation Tenant Dispute with Landlord District Court Representation for Civil Action Review of a Financial Contract or Lease Purchase sale or refinance of primary home Traffic Court Representation (includes 1st DUI) Will Preparation Uncontested Divorce Representation Defense of Child in Court (misdemeanor)
Legal Resources
Employee Assistance Program (EAP)
Reston Association offers a free confidential Employee Assistance Program (EAP) to all employees and their eligible dependents Through RArsquos EAP provider Lytle EAP Partners you and your immediate family members have immediate access on your date of hire to confidential professional counseling and referral services for help with anything that affects you or your dependentsrsquo well-being You can reach an EAP counselor by dialing 1-800-327-7272 24 hours a day or you may visit their website at wwwLytleEAPcom (password is reston) for more information Visit wwwLytleEAPcom for web-based legal financial worklife resources There are also work-related resources available online for managers Note Since EAP services are provided as a benefit only RA makes no representation concerning quality of care
18
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Benefits ndash PlanContact Information
Enrollment in the majority of these benefits must be done within 30 days of hire during open enrollment or within 30 days of a qualifying life change event Open enrollment occurs annually from mid-November to mid-December
Benefits elected during open enrollment will take effect January 1
The employee their spouse or domestic partner (regardless of sex) and their children under age 26 are eligible to enroll in benefits
Insurance Benefits
Health Insurance Provider Name Kaiser Permanente group 3007-4 (HMO Select) 3007-6 (POS) 3007-10 (HRA-DHMO) Provider Contact Member Services 301-468-6000 Provider Web Address wwwkporg
Dental Insurance Provider Name MetLife group 5469528 Provider Contact Member Services 800-ASK-4MET Provider Web Address httpsmybenefitsmetlifecom
Supplemental Vision Insurance ndash two options 1Provider Name VSP group 30017163
Provider Contact Member Services 800-877-7195 Provider Web Address wwwvspcom
2Provider Name SpecteraUHC group GA9N9747BW Provider Contact Member Services 800-839-3242 Provider Web Address wwwmyuhccom
Flexible Spending Accounts (FSA) amp Dependent Care Accounts (DCA) Contact Optum Health Provider Contact Member Services 800-243-5543 Provider Web Address httpssecureoptumhealthfinancialcom
LifeADampD Short-term Disability (STD) amp Long-term Disability (LTD) Insurance Provider Name Sun Life group 211628 Provider Contact Member Services 800-247-6875 Provider Web Address wwwsunlifecomus
Savings Benefits 401(k) Retirement Savings Plan (pre-tax and Roth)
Provider Name Ascensus Broker Contact Mark Ivcevich 301-326-1521 markqp-consultingcom Web Address httpsmyaccountascensuscomrplink
529 College Savings Plan Contact Human Resources
6
Medical Premium Costs per Paycheck for Employees Hired Prior to 1-1-2019
The amount of your paycheck cost difference will be dependent on the type of coverage you choose
for 2020 (see last column on the table below)
Rates are effective January 1 2020
HRA-HMO
Signature
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $50725 $3512
Employee + 1 $101444 $8193
Employee + Family $147096 $12408
HMO Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $58173 $4027
Employee + 1 $116340 $9397
Employee + Family $168696 $14229
POS Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $85966 $5951
Employee + 1 $171932 $13887
Employee + Family $249293 $21028
NOTE The Health Insurance Premium Bank is still available to those who qualify Request for
assistance must be made annually by December 15th or within 30 days of a qualifying event
7
Medical Premium Costs per Paycheck for Employees Hired After 1-1-2019
The amount of your paycheck cost difference will be dependent on the type of coverage you choose
for 2020 (see last column on the table below)
Rates are effective January 1 2020
HRA-HMO
Signature
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $50725 $4682
Employee + 1 $101444 $10535
Employee + Family $147096 $15802
HMO Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $58173 5370
Employee + 1 $116340 $12081
Employee + Family $168696 $18122
POS Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $85966 $7935
Employee + 1 $171932 $17854
Employee + Family $249293 $26781
NOTE The Health Insurance Premium Bank is still available to those who qualify Request for
assistance must be made annually by December 12th or within 30 days of a qualifying event
8
Dental amp Vision Premium Costs per Paycheck
The following rates represent your monthly Dental and Vision premiums effective January 1 2020
MetLife Dental Per Paycheck
FULL-TIME Cost
Per Paycheck
PART-TIME Cost
Employee $000
Contact HR for cost Employee + 1 $000
Employee + Family $000
VSP Vision Per Paycheck Cost
Employee $513
Employee + Adult $864
Employee + Child $882
Employee + Family $1423
SpecteraUHC Vision Per Paycheck Cost
Employee $415
Employee + Adult $843
Employee + Child $883
Employee + Family $1116
9
Health Insurance ndash Option 1
DHMO HRA Signature In Network You Pay Out-of-Network You Pay
Deductible Coinsurance Out-of-Pocket
$750 Individual$1500 Family (RA funds) 9010
$3000 Individual $6000 Family
(less than regular HMO)
NA
Primary Care and Specialist Office Visit $15 PCP$25 Specialist NO COVERAGE
Emergency Room Visits $75 per visit (waived
if admitted) NO COVERAGE
Hospital ndash Inpatient Stay 10 after deductible NO COVERAGE
Home Health Care 10 after deductible NO COVERAGE
Outpatient Facility Services 10 after deductible NO COVERAGE
X-Ray and Laboratory Services 10 after deductible NO COVERAGE
Specialty Imaging (CTMRIPET scan) 10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $15 PCP$25 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $30 Participating $50 Plan $45 Participating $65
$20$30$45
Kaiser Permanente D-HMO HRA Signature (Facilities Only) With the Signature Network members receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Medical centers offer convenient services including primary care specialty care laboratory radiology and pharmacy at most locations and in some locations optical Signature members also have access to more than 40 hospitals in the region
10
Health Insurance ndash Option 2
Kaiser Permanente HMO Select (Facilities amp Contracted Providers Only) With the Select Network members may receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Building on the Signature physician network the Select network adds access to more than 15000 contracted community physicians in private practice Select members also have access to more than 40 hospitals in the region
HMO Select In-Network You Pay Out-of-Network
You Pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
NA
Primary Care and Specialist Office Visit $30 PCP$40 Specialist NO COVERAGE
Emergency Room Visits $100 per visit
(waived if admitted) NO COVERAGE
Hospital ndash Inpatient Stay $250 per admission NO COVERAGE
Home Health Care No charge NO COVERAGE
Outpatient Facility Services $100 NO COVERAGE
X-Ray and Laboratory Services No charge NO COVERAGE
Specialty Imaging (CTMRIPET scan) $50 per test NO COVERAGE
Chiropractic amp Acupuncture Services $40 copay
20 visits per contract year NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$15 copay-group therapy $30 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $30 PCP$40 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
11
Kaiser Permanente POS Select (Facilities amp Contracted Providers with an Out of Network Option) Members can use in-plan benefits by using a Kaiser facility or a contracted primary care physician Your chosen PCP will provide care and coordinate referrals and hospital admissions Members also have the freedom to choose any other licensed provider outside the provider network however you will be responsible for deductibles and coinsurance above the health planrsquos payment
POS Select In-Network You Pay Out-of-Network
you pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
$300 Individual $600 Family
8020 $3000 Individual
$6000 Family
Primary Care and Specialist Office Visit $15 PCP$30 Specialist 20 of UCR
Emergency Room Visits $75 per visit (waived if
admitted) $75 per visit
(waived if admitted)
Hospital ndash Inpatient Stay $250 per admission 20 of UCR
Home Health Care No charge 20 of UCR
Outpatient Facility Services $50 20 of UCR
X-Ray and Laboratory Services No charge 20 of UCR
Specialty Imaging (CTMRIPET scan) No charge 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
20 of UCR
Vision (Children Only) $15 PCP$30 Specialist per visit 20 of UCR
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
Health Insurance ndash Option 3
12
Dental Insurance
MetLife Dental PPO The Dental PPO plan is 100 Employer Paid for all tiers and provides comprehensive coverage with a nationwide PPO network This gives members access to more in-network dentists making it easier for them to reduce out-of-pocket costs for covered procedures and treatments Dental procedure frequencies Preventative care covers an exam and cleaning (once every 6 months) Fluoride treatment (two per benefit period under age 19 only) Full mouth X-ray (once every 60 months) Bitewing X-ray (once every 12 months age 14 and over once every 12 months under age 14)
PPO Dental Plan Features In-Network Out-of-Network
Type A Preventive Care Services (oral exams cleanings x-rays sealants)
100 of Fee Schedule 100 of Usual amp Customary
Charge
Type B Basic Restorative Dental Services (fillings simple extractions space maintainers)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type B Major Surgical Dental Services (Endodontics amp Periodontics)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type C Major Restorative Dental Services (bridges crowns dentures implants)
50 of Fee Schedule 50 of Usual amp Customary
Charge
Orthodontia (under age 19 only)
Lifetime maximum - $1000 50 of allowed benefit
Calendar Year Deductible Applies to Type B amp C services only
$25 Single $75 Family
Calendar Year Maximum Per Person $1500 combined maxper calendar year
Prior to receiving dental services it is recommended that you first obtain a pre-determination of benefits from your dentist so you know exactly how much your dental insurance will cover Spouses domestic partners and dependent children to age 26 (regardless of student status) are eligible
13
Vision Insurance ndash Option 1
Vision Plan through VSP (Voluntary) VSP is the largest private provider vision carrier in the country VSP contracts with Costcoreg Optical Eye Care Centers of America Inctrade which includes popular stores like EyeMasters VisionWorld and Hour Eyes and other quality retail chains When you visit a VSP participating provider your benefits include routine vision exams lenses and preferred pricing on all patient options Frequency Eye Exam 12 monthsLenses 12 monthsFrames 24 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $45
Eyeglass Lenses (standard) Single Bifocal Trifocal
Covered in Full Covered in Full Covered in Full
Plan pays up to $30 Plan pays up to $50 Plan pays up to $65
Frames $130 allowance then 20 off remaining balance
Plan pays up to $70
Necessary Contact Lenses Covered in Full Plan pays up to $210
Elective Contact Lenses $130 allowance Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $60
copay Not Available
Spouses domestic partners and dependent children to age 19 (or to age 25 if FT student) are eligible
14
Vision Insurance ndash Option 2
Vision Plan through Spectera UHC (Voluntary)
UHC offers you one of the largest vision care networks in the industry Their network includes convenient retail locations including My Eye Dr and Hour Eyes Best of all ndash when you receive care from a participating provider you receive the greatest benefits and money-saving discounts
Frequency Eye Exam 12 monthsLenses 12 monthsFrames 12 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $40
Eyeglass Lenses (standard) Single Bifocal Trifocal
$25 copay $25 copay $25 copay
Plan pays up to $40 Plan pays up to $60 Plan pays up to $80
Frames $2500 copay $130 retail frame
allowance 30 discount above allowance
Plan pays up to $45
Necessary Contact Lenses $25 copay Plan pays up to $210
Elective Contact Lenses
$25 copay from the ldquoCovered contact lens
selectionrdquo All others- $105
allowance
Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $25
copay Not Available
Spouses and dependent children to age 26 are eligible
15
Pre-tax FSA amp DCA
Flexible Spending Account (FSA) through Optum Health The Flexible Spending Account provides employees a means to reduce their taxes by the amount of their out of pocket health-related expenses (subject to eligibility) This tax free savings program allows employees to submit receipts for reimbursement for medical dental vision care prescription drug co-payments and other expenses not covered by our insurance In 2020 employees may contribute up to $2750 per year toward their FSA Employees have until March 14 2020 to use the money in their FSA or else they lose it (This contribution amount could change based on IRS guideline updates)
Dependent Care Spending Account (DCA) through Optum Health The Dependent Care Spending Account provides employees a means to reduce their taxes by the amount of their child care costs to a licensed provider up to $5000 annually
Health Insurance Premium Bank
Reston Association has established a program to help regular full-time and regular part-time employees pay their portion of the health insurance premium This program is only available to employees who are enrolled in or plan to enroll in the Kaiser Permanente HMO health insurance plans offered by the Reston Association Employees are eligible to apply to the Health Insurance Premium Bank if their adjusted gross household incomes are less than or equal to $60000 Requests for assistance must be made annually or at any time there is a qualifying event and submitted to Human Resources with necessary documentation by December 12th of each year To apply complete a request form (available in CommonHumResBenefits) and submit to HR with a copy of your most recent tax return showing adjusted gross household income This threshold is subject to change
16
Life and ADampD Insurance
Basic LifeADampD Insurance Reston Association provides 100 employer paid Life and ADampD Insurance through Sun Life to employees working 25 or more hours per week Coverage becomes effective the first of the month following six months of service
Benefit 2x Annual Earnings to a maximum of $200000 Age reduction Benefit reduced to 65 at age 65 and to 50 at age 70
Optional LifeADampD Insurance for Employee Spouse and Dependent Children
Optional Life Insurance for the employee spouse and dependent children is available at the employeersquos cost Optional Life is not available for domestic partners
Employee Benefit Increments of $10000 to a maximum of the lesser of $300000 or 3x your Basic Annual Earnings
Spouse Benefit Increments of $5000 to a maximum of $150000 Dependent Child Benefit Increments of $1000 to a maximum of $10000
Your amount of Dependent Spouse and Dependent Child Optional Life Insurance cannot exceed 50 of your amount of Optional Life Insurance Initial eligibility period will require evidence of insurability
STD amp LTD Insurance
Short Term and Long Term Disability Reston Association provides eligible employees with short and long-term disability income benefits through Sun Life In the event you become disabled from a non work-related injury or sickness disability income benefits are provided as a source of income These benefits are 100 employer paid
Benefit Short-Term Disability Long-Term Disability
Income Replacement -Eligible Employees -Executives
60 60
Elimination Period - Accidental Injury - Sickness
29 days 90 days
Benefit Period 9 weeks maximum To Social Security
normal retirement age
Benefit Maximum -Eligible Employees -Executives
$1000 per week $6000 per month $8000 per month 17
At a cost of $19month you can enroll in the Legal Resources benefit As a Legal Resources Member you have immediate and ongoing access to comprehensive legal coverage services and expertise that will easily save you money mdash and could save you a whole lot more Covered legal services include
Legal Advice and Consultation Tenant Dispute with Landlord District Court Representation for Civil Action Review of a Financial Contract or Lease Purchase sale or refinance of primary home Traffic Court Representation (includes 1st DUI) Will Preparation Uncontested Divorce Representation Defense of Child in Court (misdemeanor)
Legal Resources
Employee Assistance Program (EAP)
Reston Association offers a free confidential Employee Assistance Program (EAP) to all employees and their eligible dependents Through RArsquos EAP provider Lytle EAP Partners you and your immediate family members have immediate access on your date of hire to confidential professional counseling and referral services for help with anything that affects you or your dependentsrsquo well-being You can reach an EAP counselor by dialing 1-800-327-7272 24 hours a day or you may visit their website at wwwLytleEAPcom (password is reston) for more information Visit wwwLytleEAPcom for web-based legal financial worklife resources There are also work-related resources available online for managers Note Since EAP services are provided as a benefit only RA makes no representation concerning quality of care
18
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Medical Premium Costs per Paycheck for Employees Hired Prior to 1-1-2019
The amount of your paycheck cost difference will be dependent on the type of coverage you choose
for 2020 (see last column on the table below)
Rates are effective January 1 2020
HRA-HMO
Signature
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $50725 $3512
Employee + 1 $101444 $8193
Employee + Family $147096 $12408
HMO Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $58173 $4027
Employee + 1 $116340 $9397
Employee + Family $168696 $14229
POS Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $85966 $5951
Employee + 1 $171932 $13887
Employee + Family $249293 $21028
NOTE The Health Insurance Premium Bank is still available to those who qualify Request for
assistance must be made annually by December 15th or within 30 days of a qualifying event
7
Medical Premium Costs per Paycheck for Employees Hired After 1-1-2019
The amount of your paycheck cost difference will be dependent on the type of coverage you choose
for 2020 (see last column on the table below)
Rates are effective January 1 2020
HRA-HMO
Signature
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $50725 $4682
Employee + 1 $101444 $10535
Employee + Family $147096 $15802
HMO Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $58173 5370
Employee + 1 $116340 $12081
Employee + Family $168696 $18122
POS Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $85966 $7935
Employee + 1 $171932 $17854
Employee + Family $249293 $26781
NOTE The Health Insurance Premium Bank is still available to those who qualify Request for
assistance must be made annually by December 12th or within 30 days of a qualifying event
8
Dental amp Vision Premium Costs per Paycheck
The following rates represent your monthly Dental and Vision premiums effective January 1 2020
MetLife Dental Per Paycheck
FULL-TIME Cost
Per Paycheck
PART-TIME Cost
Employee $000
Contact HR for cost Employee + 1 $000
Employee + Family $000
VSP Vision Per Paycheck Cost
Employee $513
Employee + Adult $864
Employee + Child $882
Employee + Family $1423
SpecteraUHC Vision Per Paycheck Cost
Employee $415
Employee + Adult $843
Employee + Child $883
Employee + Family $1116
9
Health Insurance ndash Option 1
DHMO HRA Signature In Network You Pay Out-of-Network You Pay
Deductible Coinsurance Out-of-Pocket
$750 Individual$1500 Family (RA funds) 9010
$3000 Individual $6000 Family
(less than regular HMO)
NA
Primary Care and Specialist Office Visit $15 PCP$25 Specialist NO COVERAGE
Emergency Room Visits $75 per visit (waived
if admitted) NO COVERAGE
Hospital ndash Inpatient Stay 10 after deductible NO COVERAGE
Home Health Care 10 after deductible NO COVERAGE
Outpatient Facility Services 10 after deductible NO COVERAGE
X-Ray and Laboratory Services 10 after deductible NO COVERAGE
Specialty Imaging (CTMRIPET scan) 10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $15 PCP$25 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $30 Participating $50 Plan $45 Participating $65
$20$30$45
Kaiser Permanente D-HMO HRA Signature (Facilities Only) With the Signature Network members receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Medical centers offer convenient services including primary care specialty care laboratory radiology and pharmacy at most locations and in some locations optical Signature members also have access to more than 40 hospitals in the region
10
Health Insurance ndash Option 2
Kaiser Permanente HMO Select (Facilities amp Contracted Providers Only) With the Select Network members may receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Building on the Signature physician network the Select network adds access to more than 15000 contracted community physicians in private practice Select members also have access to more than 40 hospitals in the region
HMO Select In-Network You Pay Out-of-Network
You Pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
NA
Primary Care and Specialist Office Visit $30 PCP$40 Specialist NO COVERAGE
Emergency Room Visits $100 per visit
(waived if admitted) NO COVERAGE
Hospital ndash Inpatient Stay $250 per admission NO COVERAGE
Home Health Care No charge NO COVERAGE
Outpatient Facility Services $100 NO COVERAGE
X-Ray and Laboratory Services No charge NO COVERAGE
Specialty Imaging (CTMRIPET scan) $50 per test NO COVERAGE
Chiropractic amp Acupuncture Services $40 copay
20 visits per contract year NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$15 copay-group therapy $30 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $30 PCP$40 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
11
Kaiser Permanente POS Select (Facilities amp Contracted Providers with an Out of Network Option) Members can use in-plan benefits by using a Kaiser facility or a contracted primary care physician Your chosen PCP will provide care and coordinate referrals and hospital admissions Members also have the freedom to choose any other licensed provider outside the provider network however you will be responsible for deductibles and coinsurance above the health planrsquos payment
POS Select In-Network You Pay Out-of-Network
you pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
$300 Individual $600 Family
8020 $3000 Individual
$6000 Family
Primary Care and Specialist Office Visit $15 PCP$30 Specialist 20 of UCR
Emergency Room Visits $75 per visit (waived if
admitted) $75 per visit
(waived if admitted)
Hospital ndash Inpatient Stay $250 per admission 20 of UCR
Home Health Care No charge 20 of UCR
Outpatient Facility Services $50 20 of UCR
X-Ray and Laboratory Services No charge 20 of UCR
Specialty Imaging (CTMRIPET scan) No charge 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
20 of UCR
Vision (Children Only) $15 PCP$30 Specialist per visit 20 of UCR
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
Health Insurance ndash Option 3
12
Dental Insurance
MetLife Dental PPO The Dental PPO plan is 100 Employer Paid for all tiers and provides comprehensive coverage with a nationwide PPO network This gives members access to more in-network dentists making it easier for them to reduce out-of-pocket costs for covered procedures and treatments Dental procedure frequencies Preventative care covers an exam and cleaning (once every 6 months) Fluoride treatment (two per benefit period under age 19 only) Full mouth X-ray (once every 60 months) Bitewing X-ray (once every 12 months age 14 and over once every 12 months under age 14)
PPO Dental Plan Features In-Network Out-of-Network
Type A Preventive Care Services (oral exams cleanings x-rays sealants)
100 of Fee Schedule 100 of Usual amp Customary
Charge
Type B Basic Restorative Dental Services (fillings simple extractions space maintainers)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type B Major Surgical Dental Services (Endodontics amp Periodontics)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type C Major Restorative Dental Services (bridges crowns dentures implants)
50 of Fee Schedule 50 of Usual amp Customary
Charge
Orthodontia (under age 19 only)
Lifetime maximum - $1000 50 of allowed benefit
Calendar Year Deductible Applies to Type B amp C services only
$25 Single $75 Family
Calendar Year Maximum Per Person $1500 combined maxper calendar year
Prior to receiving dental services it is recommended that you first obtain a pre-determination of benefits from your dentist so you know exactly how much your dental insurance will cover Spouses domestic partners and dependent children to age 26 (regardless of student status) are eligible
13
Vision Insurance ndash Option 1
Vision Plan through VSP (Voluntary) VSP is the largest private provider vision carrier in the country VSP contracts with Costcoreg Optical Eye Care Centers of America Inctrade which includes popular stores like EyeMasters VisionWorld and Hour Eyes and other quality retail chains When you visit a VSP participating provider your benefits include routine vision exams lenses and preferred pricing on all patient options Frequency Eye Exam 12 monthsLenses 12 monthsFrames 24 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $45
Eyeglass Lenses (standard) Single Bifocal Trifocal
Covered in Full Covered in Full Covered in Full
Plan pays up to $30 Plan pays up to $50 Plan pays up to $65
Frames $130 allowance then 20 off remaining balance
Plan pays up to $70
Necessary Contact Lenses Covered in Full Plan pays up to $210
Elective Contact Lenses $130 allowance Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $60
copay Not Available
Spouses domestic partners and dependent children to age 19 (or to age 25 if FT student) are eligible
14
Vision Insurance ndash Option 2
Vision Plan through Spectera UHC (Voluntary)
UHC offers you one of the largest vision care networks in the industry Their network includes convenient retail locations including My Eye Dr and Hour Eyes Best of all ndash when you receive care from a participating provider you receive the greatest benefits and money-saving discounts
Frequency Eye Exam 12 monthsLenses 12 monthsFrames 12 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $40
Eyeglass Lenses (standard) Single Bifocal Trifocal
$25 copay $25 copay $25 copay
Plan pays up to $40 Plan pays up to $60 Plan pays up to $80
Frames $2500 copay $130 retail frame
allowance 30 discount above allowance
Plan pays up to $45
Necessary Contact Lenses $25 copay Plan pays up to $210
Elective Contact Lenses
$25 copay from the ldquoCovered contact lens
selectionrdquo All others- $105
allowance
Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $25
copay Not Available
Spouses and dependent children to age 26 are eligible
15
Pre-tax FSA amp DCA
Flexible Spending Account (FSA) through Optum Health The Flexible Spending Account provides employees a means to reduce their taxes by the amount of their out of pocket health-related expenses (subject to eligibility) This tax free savings program allows employees to submit receipts for reimbursement for medical dental vision care prescription drug co-payments and other expenses not covered by our insurance In 2020 employees may contribute up to $2750 per year toward their FSA Employees have until March 14 2020 to use the money in their FSA or else they lose it (This contribution amount could change based on IRS guideline updates)
Dependent Care Spending Account (DCA) through Optum Health The Dependent Care Spending Account provides employees a means to reduce their taxes by the amount of their child care costs to a licensed provider up to $5000 annually
Health Insurance Premium Bank
Reston Association has established a program to help regular full-time and regular part-time employees pay their portion of the health insurance premium This program is only available to employees who are enrolled in or plan to enroll in the Kaiser Permanente HMO health insurance plans offered by the Reston Association Employees are eligible to apply to the Health Insurance Premium Bank if their adjusted gross household incomes are less than or equal to $60000 Requests for assistance must be made annually or at any time there is a qualifying event and submitted to Human Resources with necessary documentation by December 12th of each year To apply complete a request form (available in CommonHumResBenefits) and submit to HR with a copy of your most recent tax return showing adjusted gross household income This threshold is subject to change
16
Life and ADampD Insurance
Basic LifeADampD Insurance Reston Association provides 100 employer paid Life and ADampD Insurance through Sun Life to employees working 25 or more hours per week Coverage becomes effective the first of the month following six months of service
Benefit 2x Annual Earnings to a maximum of $200000 Age reduction Benefit reduced to 65 at age 65 and to 50 at age 70
Optional LifeADampD Insurance for Employee Spouse and Dependent Children
Optional Life Insurance for the employee spouse and dependent children is available at the employeersquos cost Optional Life is not available for domestic partners
Employee Benefit Increments of $10000 to a maximum of the lesser of $300000 or 3x your Basic Annual Earnings
Spouse Benefit Increments of $5000 to a maximum of $150000 Dependent Child Benefit Increments of $1000 to a maximum of $10000
Your amount of Dependent Spouse and Dependent Child Optional Life Insurance cannot exceed 50 of your amount of Optional Life Insurance Initial eligibility period will require evidence of insurability
STD amp LTD Insurance
Short Term and Long Term Disability Reston Association provides eligible employees with short and long-term disability income benefits through Sun Life In the event you become disabled from a non work-related injury or sickness disability income benefits are provided as a source of income These benefits are 100 employer paid
Benefit Short-Term Disability Long-Term Disability
Income Replacement -Eligible Employees -Executives
60 60
Elimination Period - Accidental Injury - Sickness
29 days 90 days
Benefit Period 9 weeks maximum To Social Security
normal retirement age
Benefit Maximum -Eligible Employees -Executives
$1000 per week $6000 per month $8000 per month 17
At a cost of $19month you can enroll in the Legal Resources benefit As a Legal Resources Member you have immediate and ongoing access to comprehensive legal coverage services and expertise that will easily save you money mdash and could save you a whole lot more Covered legal services include
Legal Advice and Consultation Tenant Dispute with Landlord District Court Representation for Civil Action Review of a Financial Contract or Lease Purchase sale or refinance of primary home Traffic Court Representation (includes 1st DUI) Will Preparation Uncontested Divorce Representation Defense of Child in Court (misdemeanor)
Legal Resources
Employee Assistance Program (EAP)
Reston Association offers a free confidential Employee Assistance Program (EAP) to all employees and their eligible dependents Through RArsquos EAP provider Lytle EAP Partners you and your immediate family members have immediate access on your date of hire to confidential professional counseling and referral services for help with anything that affects you or your dependentsrsquo well-being You can reach an EAP counselor by dialing 1-800-327-7272 24 hours a day or you may visit their website at wwwLytleEAPcom (password is reston) for more information Visit wwwLytleEAPcom for web-based legal financial worklife resources There are also work-related resources available online for managers Note Since EAP services are provided as a benefit only RA makes no representation concerning quality of care
18
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Medical Premium Costs per Paycheck for Employees Hired After 1-1-2019
The amount of your paycheck cost difference will be dependent on the type of coverage you choose
for 2020 (see last column on the table below)
Rates are effective January 1 2020
HRA-HMO
Signature
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $50725 $4682
Employee + 1 $101444 $10535
Employee + Family $147096 $15802
HMO Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $58173 5370
Employee + 1 $116340 $12081
Employee + Family $168696 $18122
POS Select
(Kaiser)
Monthly
Billed
Premium to
RA
2020 EE Per
Paycheck
Cost
Employee $85966 $7935
Employee + 1 $171932 $17854
Employee + Family $249293 $26781
NOTE The Health Insurance Premium Bank is still available to those who qualify Request for
assistance must be made annually by December 12th or within 30 days of a qualifying event
8
Dental amp Vision Premium Costs per Paycheck
The following rates represent your monthly Dental and Vision premiums effective January 1 2020
MetLife Dental Per Paycheck
FULL-TIME Cost
Per Paycheck
PART-TIME Cost
Employee $000
Contact HR for cost Employee + 1 $000
Employee + Family $000
VSP Vision Per Paycheck Cost
Employee $513
Employee + Adult $864
Employee + Child $882
Employee + Family $1423
SpecteraUHC Vision Per Paycheck Cost
Employee $415
Employee + Adult $843
Employee + Child $883
Employee + Family $1116
9
Health Insurance ndash Option 1
DHMO HRA Signature In Network You Pay Out-of-Network You Pay
Deductible Coinsurance Out-of-Pocket
$750 Individual$1500 Family (RA funds) 9010
$3000 Individual $6000 Family
(less than regular HMO)
NA
Primary Care and Specialist Office Visit $15 PCP$25 Specialist NO COVERAGE
Emergency Room Visits $75 per visit (waived
if admitted) NO COVERAGE
Hospital ndash Inpatient Stay 10 after deductible NO COVERAGE
Home Health Care 10 after deductible NO COVERAGE
Outpatient Facility Services 10 after deductible NO COVERAGE
X-Ray and Laboratory Services 10 after deductible NO COVERAGE
Specialty Imaging (CTMRIPET scan) 10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $15 PCP$25 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $30 Participating $50 Plan $45 Participating $65
$20$30$45
Kaiser Permanente D-HMO HRA Signature (Facilities Only) With the Signature Network members receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Medical centers offer convenient services including primary care specialty care laboratory radiology and pharmacy at most locations and in some locations optical Signature members also have access to more than 40 hospitals in the region
10
Health Insurance ndash Option 2
Kaiser Permanente HMO Select (Facilities amp Contracted Providers Only) With the Select Network members may receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Building on the Signature physician network the Select network adds access to more than 15000 contracted community physicians in private practice Select members also have access to more than 40 hospitals in the region
HMO Select In-Network You Pay Out-of-Network
You Pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
NA
Primary Care and Specialist Office Visit $30 PCP$40 Specialist NO COVERAGE
Emergency Room Visits $100 per visit
(waived if admitted) NO COVERAGE
Hospital ndash Inpatient Stay $250 per admission NO COVERAGE
Home Health Care No charge NO COVERAGE
Outpatient Facility Services $100 NO COVERAGE
X-Ray and Laboratory Services No charge NO COVERAGE
Specialty Imaging (CTMRIPET scan) $50 per test NO COVERAGE
Chiropractic amp Acupuncture Services $40 copay
20 visits per contract year NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$15 copay-group therapy $30 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $30 PCP$40 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
11
Kaiser Permanente POS Select (Facilities amp Contracted Providers with an Out of Network Option) Members can use in-plan benefits by using a Kaiser facility or a contracted primary care physician Your chosen PCP will provide care and coordinate referrals and hospital admissions Members also have the freedom to choose any other licensed provider outside the provider network however you will be responsible for deductibles and coinsurance above the health planrsquos payment
POS Select In-Network You Pay Out-of-Network
you pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
$300 Individual $600 Family
8020 $3000 Individual
$6000 Family
Primary Care and Specialist Office Visit $15 PCP$30 Specialist 20 of UCR
Emergency Room Visits $75 per visit (waived if
admitted) $75 per visit
(waived if admitted)
Hospital ndash Inpatient Stay $250 per admission 20 of UCR
Home Health Care No charge 20 of UCR
Outpatient Facility Services $50 20 of UCR
X-Ray and Laboratory Services No charge 20 of UCR
Specialty Imaging (CTMRIPET scan) No charge 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
20 of UCR
Vision (Children Only) $15 PCP$30 Specialist per visit 20 of UCR
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
Health Insurance ndash Option 3
12
Dental Insurance
MetLife Dental PPO The Dental PPO plan is 100 Employer Paid for all tiers and provides comprehensive coverage with a nationwide PPO network This gives members access to more in-network dentists making it easier for them to reduce out-of-pocket costs for covered procedures and treatments Dental procedure frequencies Preventative care covers an exam and cleaning (once every 6 months) Fluoride treatment (two per benefit period under age 19 only) Full mouth X-ray (once every 60 months) Bitewing X-ray (once every 12 months age 14 and over once every 12 months under age 14)
PPO Dental Plan Features In-Network Out-of-Network
Type A Preventive Care Services (oral exams cleanings x-rays sealants)
100 of Fee Schedule 100 of Usual amp Customary
Charge
Type B Basic Restorative Dental Services (fillings simple extractions space maintainers)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type B Major Surgical Dental Services (Endodontics amp Periodontics)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type C Major Restorative Dental Services (bridges crowns dentures implants)
50 of Fee Schedule 50 of Usual amp Customary
Charge
Orthodontia (under age 19 only)
Lifetime maximum - $1000 50 of allowed benefit
Calendar Year Deductible Applies to Type B amp C services only
$25 Single $75 Family
Calendar Year Maximum Per Person $1500 combined maxper calendar year
Prior to receiving dental services it is recommended that you first obtain a pre-determination of benefits from your dentist so you know exactly how much your dental insurance will cover Spouses domestic partners and dependent children to age 26 (regardless of student status) are eligible
13
Vision Insurance ndash Option 1
Vision Plan through VSP (Voluntary) VSP is the largest private provider vision carrier in the country VSP contracts with Costcoreg Optical Eye Care Centers of America Inctrade which includes popular stores like EyeMasters VisionWorld and Hour Eyes and other quality retail chains When you visit a VSP participating provider your benefits include routine vision exams lenses and preferred pricing on all patient options Frequency Eye Exam 12 monthsLenses 12 monthsFrames 24 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $45
Eyeglass Lenses (standard) Single Bifocal Trifocal
Covered in Full Covered in Full Covered in Full
Plan pays up to $30 Plan pays up to $50 Plan pays up to $65
Frames $130 allowance then 20 off remaining balance
Plan pays up to $70
Necessary Contact Lenses Covered in Full Plan pays up to $210
Elective Contact Lenses $130 allowance Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $60
copay Not Available
Spouses domestic partners and dependent children to age 19 (or to age 25 if FT student) are eligible
14
Vision Insurance ndash Option 2
Vision Plan through Spectera UHC (Voluntary)
UHC offers you one of the largest vision care networks in the industry Their network includes convenient retail locations including My Eye Dr and Hour Eyes Best of all ndash when you receive care from a participating provider you receive the greatest benefits and money-saving discounts
Frequency Eye Exam 12 monthsLenses 12 monthsFrames 12 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $40
Eyeglass Lenses (standard) Single Bifocal Trifocal
$25 copay $25 copay $25 copay
Plan pays up to $40 Plan pays up to $60 Plan pays up to $80
Frames $2500 copay $130 retail frame
allowance 30 discount above allowance
Plan pays up to $45
Necessary Contact Lenses $25 copay Plan pays up to $210
Elective Contact Lenses
$25 copay from the ldquoCovered contact lens
selectionrdquo All others- $105
allowance
Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $25
copay Not Available
Spouses and dependent children to age 26 are eligible
15
Pre-tax FSA amp DCA
Flexible Spending Account (FSA) through Optum Health The Flexible Spending Account provides employees a means to reduce their taxes by the amount of their out of pocket health-related expenses (subject to eligibility) This tax free savings program allows employees to submit receipts for reimbursement for medical dental vision care prescription drug co-payments and other expenses not covered by our insurance In 2020 employees may contribute up to $2750 per year toward their FSA Employees have until March 14 2020 to use the money in their FSA or else they lose it (This contribution amount could change based on IRS guideline updates)
Dependent Care Spending Account (DCA) through Optum Health The Dependent Care Spending Account provides employees a means to reduce their taxes by the amount of their child care costs to a licensed provider up to $5000 annually
Health Insurance Premium Bank
Reston Association has established a program to help regular full-time and regular part-time employees pay their portion of the health insurance premium This program is only available to employees who are enrolled in or plan to enroll in the Kaiser Permanente HMO health insurance plans offered by the Reston Association Employees are eligible to apply to the Health Insurance Premium Bank if their adjusted gross household incomes are less than or equal to $60000 Requests for assistance must be made annually or at any time there is a qualifying event and submitted to Human Resources with necessary documentation by December 12th of each year To apply complete a request form (available in CommonHumResBenefits) and submit to HR with a copy of your most recent tax return showing adjusted gross household income This threshold is subject to change
16
Life and ADampD Insurance
Basic LifeADampD Insurance Reston Association provides 100 employer paid Life and ADampD Insurance through Sun Life to employees working 25 or more hours per week Coverage becomes effective the first of the month following six months of service
Benefit 2x Annual Earnings to a maximum of $200000 Age reduction Benefit reduced to 65 at age 65 and to 50 at age 70
Optional LifeADampD Insurance for Employee Spouse and Dependent Children
Optional Life Insurance for the employee spouse and dependent children is available at the employeersquos cost Optional Life is not available for domestic partners
Employee Benefit Increments of $10000 to a maximum of the lesser of $300000 or 3x your Basic Annual Earnings
Spouse Benefit Increments of $5000 to a maximum of $150000 Dependent Child Benefit Increments of $1000 to a maximum of $10000
Your amount of Dependent Spouse and Dependent Child Optional Life Insurance cannot exceed 50 of your amount of Optional Life Insurance Initial eligibility period will require evidence of insurability
STD amp LTD Insurance
Short Term and Long Term Disability Reston Association provides eligible employees with short and long-term disability income benefits through Sun Life In the event you become disabled from a non work-related injury or sickness disability income benefits are provided as a source of income These benefits are 100 employer paid
Benefit Short-Term Disability Long-Term Disability
Income Replacement -Eligible Employees -Executives
60 60
Elimination Period - Accidental Injury - Sickness
29 days 90 days
Benefit Period 9 weeks maximum To Social Security
normal retirement age
Benefit Maximum -Eligible Employees -Executives
$1000 per week $6000 per month $8000 per month 17
At a cost of $19month you can enroll in the Legal Resources benefit As a Legal Resources Member you have immediate and ongoing access to comprehensive legal coverage services and expertise that will easily save you money mdash and could save you a whole lot more Covered legal services include
Legal Advice and Consultation Tenant Dispute with Landlord District Court Representation for Civil Action Review of a Financial Contract or Lease Purchase sale or refinance of primary home Traffic Court Representation (includes 1st DUI) Will Preparation Uncontested Divorce Representation Defense of Child in Court (misdemeanor)
Legal Resources
Employee Assistance Program (EAP)
Reston Association offers a free confidential Employee Assistance Program (EAP) to all employees and their eligible dependents Through RArsquos EAP provider Lytle EAP Partners you and your immediate family members have immediate access on your date of hire to confidential professional counseling and referral services for help with anything that affects you or your dependentsrsquo well-being You can reach an EAP counselor by dialing 1-800-327-7272 24 hours a day or you may visit their website at wwwLytleEAPcom (password is reston) for more information Visit wwwLytleEAPcom for web-based legal financial worklife resources There are also work-related resources available online for managers Note Since EAP services are provided as a benefit only RA makes no representation concerning quality of care
18
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Dental amp Vision Premium Costs per Paycheck
The following rates represent your monthly Dental and Vision premiums effective January 1 2020
MetLife Dental Per Paycheck
FULL-TIME Cost
Per Paycheck
PART-TIME Cost
Employee $000
Contact HR for cost Employee + 1 $000
Employee + Family $000
VSP Vision Per Paycheck Cost
Employee $513
Employee + Adult $864
Employee + Child $882
Employee + Family $1423
SpecteraUHC Vision Per Paycheck Cost
Employee $415
Employee + Adult $843
Employee + Child $883
Employee + Family $1116
9
Health Insurance ndash Option 1
DHMO HRA Signature In Network You Pay Out-of-Network You Pay
Deductible Coinsurance Out-of-Pocket
$750 Individual$1500 Family (RA funds) 9010
$3000 Individual $6000 Family
(less than regular HMO)
NA
Primary Care and Specialist Office Visit $15 PCP$25 Specialist NO COVERAGE
Emergency Room Visits $75 per visit (waived
if admitted) NO COVERAGE
Hospital ndash Inpatient Stay 10 after deductible NO COVERAGE
Home Health Care 10 after deductible NO COVERAGE
Outpatient Facility Services 10 after deductible NO COVERAGE
X-Ray and Laboratory Services 10 after deductible NO COVERAGE
Specialty Imaging (CTMRIPET scan) 10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $15 PCP$25 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $30 Participating $50 Plan $45 Participating $65
$20$30$45
Kaiser Permanente D-HMO HRA Signature (Facilities Only) With the Signature Network members receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Medical centers offer convenient services including primary care specialty care laboratory radiology and pharmacy at most locations and in some locations optical Signature members also have access to more than 40 hospitals in the region
10
Health Insurance ndash Option 2
Kaiser Permanente HMO Select (Facilities amp Contracted Providers Only) With the Select Network members may receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Building on the Signature physician network the Select network adds access to more than 15000 contracted community physicians in private practice Select members also have access to more than 40 hospitals in the region
HMO Select In-Network You Pay Out-of-Network
You Pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
NA
Primary Care and Specialist Office Visit $30 PCP$40 Specialist NO COVERAGE
Emergency Room Visits $100 per visit
(waived if admitted) NO COVERAGE
Hospital ndash Inpatient Stay $250 per admission NO COVERAGE
Home Health Care No charge NO COVERAGE
Outpatient Facility Services $100 NO COVERAGE
X-Ray and Laboratory Services No charge NO COVERAGE
Specialty Imaging (CTMRIPET scan) $50 per test NO COVERAGE
Chiropractic amp Acupuncture Services $40 copay
20 visits per contract year NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$15 copay-group therapy $30 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $30 PCP$40 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
11
Kaiser Permanente POS Select (Facilities amp Contracted Providers with an Out of Network Option) Members can use in-plan benefits by using a Kaiser facility or a contracted primary care physician Your chosen PCP will provide care and coordinate referrals and hospital admissions Members also have the freedom to choose any other licensed provider outside the provider network however you will be responsible for deductibles and coinsurance above the health planrsquos payment
POS Select In-Network You Pay Out-of-Network
you pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
$300 Individual $600 Family
8020 $3000 Individual
$6000 Family
Primary Care and Specialist Office Visit $15 PCP$30 Specialist 20 of UCR
Emergency Room Visits $75 per visit (waived if
admitted) $75 per visit
(waived if admitted)
Hospital ndash Inpatient Stay $250 per admission 20 of UCR
Home Health Care No charge 20 of UCR
Outpatient Facility Services $50 20 of UCR
X-Ray and Laboratory Services No charge 20 of UCR
Specialty Imaging (CTMRIPET scan) No charge 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
20 of UCR
Vision (Children Only) $15 PCP$30 Specialist per visit 20 of UCR
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
Health Insurance ndash Option 3
12
Dental Insurance
MetLife Dental PPO The Dental PPO plan is 100 Employer Paid for all tiers and provides comprehensive coverage with a nationwide PPO network This gives members access to more in-network dentists making it easier for them to reduce out-of-pocket costs for covered procedures and treatments Dental procedure frequencies Preventative care covers an exam and cleaning (once every 6 months) Fluoride treatment (two per benefit period under age 19 only) Full mouth X-ray (once every 60 months) Bitewing X-ray (once every 12 months age 14 and over once every 12 months under age 14)
PPO Dental Plan Features In-Network Out-of-Network
Type A Preventive Care Services (oral exams cleanings x-rays sealants)
100 of Fee Schedule 100 of Usual amp Customary
Charge
Type B Basic Restorative Dental Services (fillings simple extractions space maintainers)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type B Major Surgical Dental Services (Endodontics amp Periodontics)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type C Major Restorative Dental Services (bridges crowns dentures implants)
50 of Fee Schedule 50 of Usual amp Customary
Charge
Orthodontia (under age 19 only)
Lifetime maximum - $1000 50 of allowed benefit
Calendar Year Deductible Applies to Type B amp C services only
$25 Single $75 Family
Calendar Year Maximum Per Person $1500 combined maxper calendar year
Prior to receiving dental services it is recommended that you first obtain a pre-determination of benefits from your dentist so you know exactly how much your dental insurance will cover Spouses domestic partners and dependent children to age 26 (regardless of student status) are eligible
13
Vision Insurance ndash Option 1
Vision Plan through VSP (Voluntary) VSP is the largest private provider vision carrier in the country VSP contracts with Costcoreg Optical Eye Care Centers of America Inctrade which includes popular stores like EyeMasters VisionWorld and Hour Eyes and other quality retail chains When you visit a VSP participating provider your benefits include routine vision exams lenses and preferred pricing on all patient options Frequency Eye Exam 12 monthsLenses 12 monthsFrames 24 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $45
Eyeglass Lenses (standard) Single Bifocal Trifocal
Covered in Full Covered in Full Covered in Full
Plan pays up to $30 Plan pays up to $50 Plan pays up to $65
Frames $130 allowance then 20 off remaining balance
Plan pays up to $70
Necessary Contact Lenses Covered in Full Plan pays up to $210
Elective Contact Lenses $130 allowance Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $60
copay Not Available
Spouses domestic partners and dependent children to age 19 (or to age 25 if FT student) are eligible
14
Vision Insurance ndash Option 2
Vision Plan through Spectera UHC (Voluntary)
UHC offers you one of the largest vision care networks in the industry Their network includes convenient retail locations including My Eye Dr and Hour Eyes Best of all ndash when you receive care from a participating provider you receive the greatest benefits and money-saving discounts
Frequency Eye Exam 12 monthsLenses 12 monthsFrames 12 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $40
Eyeglass Lenses (standard) Single Bifocal Trifocal
$25 copay $25 copay $25 copay
Plan pays up to $40 Plan pays up to $60 Plan pays up to $80
Frames $2500 copay $130 retail frame
allowance 30 discount above allowance
Plan pays up to $45
Necessary Contact Lenses $25 copay Plan pays up to $210
Elective Contact Lenses
$25 copay from the ldquoCovered contact lens
selectionrdquo All others- $105
allowance
Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $25
copay Not Available
Spouses and dependent children to age 26 are eligible
15
Pre-tax FSA amp DCA
Flexible Spending Account (FSA) through Optum Health The Flexible Spending Account provides employees a means to reduce their taxes by the amount of their out of pocket health-related expenses (subject to eligibility) This tax free savings program allows employees to submit receipts for reimbursement for medical dental vision care prescription drug co-payments and other expenses not covered by our insurance In 2020 employees may contribute up to $2750 per year toward their FSA Employees have until March 14 2020 to use the money in their FSA or else they lose it (This contribution amount could change based on IRS guideline updates)
Dependent Care Spending Account (DCA) through Optum Health The Dependent Care Spending Account provides employees a means to reduce their taxes by the amount of their child care costs to a licensed provider up to $5000 annually
Health Insurance Premium Bank
Reston Association has established a program to help regular full-time and regular part-time employees pay their portion of the health insurance premium This program is only available to employees who are enrolled in or plan to enroll in the Kaiser Permanente HMO health insurance plans offered by the Reston Association Employees are eligible to apply to the Health Insurance Premium Bank if their adjusted gross household incomes are less than or equal to $60000 Requests for assistance must be made annually or at any time there is a qualifying event and submitted to Human Resources with necessary documentation by December 12th of each year To apply complete a request form (available in CommonHumResBenefits) and submit to HR with a copy of your most recent tax return showing adjusted gross household income This threshold is subject to change
16
Life and ADampD Insurance
Basic LifeADampD Insurance Reston Association provides 100 employer paid Life and ADampD Insurance through Sun Life to employees working 25 or more hours per week Coverage becomes effective the first of the month following six months of service
Benefit 2x Annual Earnings to a maximum of $200000 Age reduction Benefit reduced to 65 at age 65 and to 50 at age 70
Optional LifeADampD Insurance for Employee Spouse and Dependent Children
Optional Life Insurance for the employee spouse and dependent children is available at the employeersquos cost Optional Life is not available for domestic partners
Employee Benefit Increments of $10000 to a maximum of the lesser of $300000 or 3x your Basic Annual Earnings
Spouse Benefit Increments of $5000 to a maximum of $150000 Dependent Child Benefit Increments of $1000 to a maximum of $10000
Your amount of Dependent Spouse and Dependent Child Optional Life Insurance cannot exceed 50 of your amount of Optional Life Insurance Initial eligibility period will require evidence of insurability
STD amp LTD Insurance
Short Term and Long Term Disability Reston Association provides eligible employees with short and long-term disability income benefits through Sun Life In the event you become disabled from a non work-related injury or sickness disability income benefits are provided as a source of income These benefits are 100 employer paid
Benefit Short-Term Disability Long-Term Disability
Income Replacement -Eligible Employees -Executives
60 60
Elimination Period - Accidental Injury - Sickness
29 days 90 days
Benefit Period 9 weeks maximum To Social Security
normal retirement age
Benefit Maximum -Eligible Employees -Executives
$1000 per week $6000 per month $8000 per month 17
At a cost of $19month you can enroll in the Legal Resources benefit As a Legal Resources Member you have immediate and ongoing access to comprehensive legal coverage services and expertise that will easily save you money mdash and could save you a whole lot more Covered legal services include
Legal Advice and Consultation Tenant Dispute with Landlord District Court Representation for Civil Action Review of a Financial Contract or Lease Purchase sale or refinance of primary home Traffic Court Representation (includes 1st DUI) Will Preparation Uncontested Divorce Representation Defense of Child in Court (misdemeanor)
Legal Resources
Employee Assistance Program (EAP)
Reston Association offers a free confidential Employee Assistance Program (EAP) to all employees and their eligible dependents Through RArsquos EAP provider Lytle EAP Partners you and your immediate family members have immediate access on your date of hire to confidential professional counseling and referral services for help with anything that affects you or your dependentsrsquo well-being You can reach an EAP counselor by dialing 1-800-327-7272 24 hours a day or you may visit their website at wwwLytleEAPcom (password is reston) for more information Visit wwwLytleEAPcom for web-based legal financial worklife resources There are also work-related resources available online for managers Note Since EAP services are provided as a benefit only RA makes no representation concerning quality of care
18
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Health Insurance ndash Option 1
DHMO HRA Signature In Network You Pay Out-of-Network You Pay
Deductible Coinsurance Out-of-Pocket
$750 Individual$1500 Family (RA funds) 9010
$3000 Individual $6000 Family
(less than regular HMO)
NA
Primary Care and Specialist Office Visit $15 PCP$25 Specialist NO COVERAGE
Emergency Room Visits $75 per visit (waived
if admitted) NO COVERAGE
Hospital ndash Inpatient Stay 10 after deductible NO COVERAGE
Home Health Care 10 after deductible NO COVERAGE
Outpatient Facility Services 10 after deductible NO COVERAGE
X-Ray and Laboratory Services 10 after deductible NO COVERAGE
Specialty Imaging (CTMRIPET scan) 10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
10 after deductible NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $15 PCP$25 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $30 Participating $50 Plan $45 Participating $65
$20$30$45
Kaiser Permanente D-HMO HRA Signature (Facilities Only) With the Signature Network members receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Medical centers offer convenient services including primary care specialty care laboratory radiology and pharmacy at most locations and in some locations optical Signature members also have access to more than 40 hospitals in the region
10
Health Insurance ndash Option 2
Kaiser Permanente HMO Select (Facilities amp Contracted Providers Only) With the Select Network members may receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Building on the Signature physician network the Select network adds access to more than 15000 contracted community physicians in private practice Select members also have access to more than 40 hospitals in the region
HMO Select In-Network You Pay Out-of-Network
You Pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
NA
Primary Care and Specialist Office Visit $30 PCP$40 Specialist NO COVERAGE
Emergency Room Visits $100 per visit
(waived if admitted) NO COVERAGE
Hospital ndash Inpatient Stay $250 per admission NO COVERAGE
Home Health Care No charge NO COVERAGE
Outpatient Facility Services $100 NO COVERAGE
X-Ray and Laboratory Services No charge NO COVERAGE
Specialty Imaging (CTMRIPET scan) $50 per test NO COVERAGE
Chiropractic amp Acupuncture Services $40 copay
20 visits per contract year NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$15 copay-group therapy $30 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $30 PCP$40 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
11
Kaiser Permanente POS Select (Facilities amp Contracted Providers with an Out of Network Option) Members can use in-plan benefits by using a Kaiser facility or a contracted primary care physician Your chosen PCP will provide care and coordinate referrals and hospital admissions Members also have the freedom to choose any other licensed provider outside the provider network however you will be responsible for deductibles and coinsurance above the health planrsquos payment
POS Select In-Network You Pay Out-of-Network
you pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
$300 Individual $600 Family
8020 $3000 Individual
$6000 Family
Primary Care and Specialist Office Visit $15 PCP$30 Specialist 20 of UCR
Emergency Room Visits $75 per visit (waived if
admitted) $75 per visit
(waived if admitted)
Hospital ndash Inpatient Stay $250 per admission 20 of UCR
Home Health Care No charge 20 of UCR
Outpatient Facility Services $50 20 of UCR
X-Ray and Laboratory Services No charge 20 of UCR
Specialty Imaging (CTMRIPET scan) No charge 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
20 of UCR
Vision (Children Only) $15 PCP$30 Specialist per visit 20 of UCR
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
Health Insurance ndash Option 3
12
Dental Insurance
MetLife Dental PPO The Dental PPO plan is 100 Employer Paid for all tiers and provides comprehensive coverage with a nationwide PPO network This gives members access to more in-network dentists making it easier for them to reduce out-of-pocket costs for covered procedures and treatments Dental procedure frequencies Preventative care covers an exam and cleaning (once every 6 months) Fluoride treatment (two per benefit period under age 19 only) Full mouth X-ray (once every 60 months) Bitewing X-ray (once every 12 months age 14 and over once every 12 months under age 14)
PPO Dental Plan Features In-Network Out-of-Network
Type A Preventive Care Services (oral exams cleanings x-rays sealants)
100 of Fee Schedule 100 of Usual amp Customary
Charge
Type B Basic Restorative Dental Services (fillings simple extractions space maintainers)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type B Major Surgical Dental Services (Endodontics amp Periodontics)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type C Major Restorative Dental Services (bridges crowns dentures implants)
50 of Fee Schedule 50 of Usual amp Customary
Charge
Orthodontia (under age 19 only)
Lifetime maximum - $1000 50 of allowed benefit
Calendar Year Deductible Applies to Type B amp C services only
$25 Single $75 Family
Calendar Year Maximum Per Person $1500 combined maxper calendar year
Prior to receiving dental services it is recommended that you first obtain a pre-determination of benefits from your dentist so you know exactly how much your dental insurance will cover Spouses domestic partners and dependent children to age 26 (regardless of student status) are eligible
13
Vision Insurance ndash Option 1
Vision Plan through VSP (Voluntary) VSP is the largest private provider vision carrier in the country VSP contracts with Costcoreg Optical Eye Care Centers of America Inctrade which includes popular stores like EyeMasters VisionWorld and Hour Eyes and other quality retail chains When you visit a VSP participating provider your benefits include routine vision exams lenses and preferred pricing on all patient options Frequency Eye Exam 12 monthsLenses 12 monthsFrames 24 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $45
Eyeglass Lenses (standard) Single Bifocal Trifocal
Covered in Full Covered in Full Covered in Full
Plan pays up to $30 Plan pays up to $50 Plan pays up to $65
Frames $130 allowance then 20 off remaining balance
Plan pays up to $70
Necessary Contact Lenses Covered in Full Plan pays up to $210
Elective Contact Lenses $130 allowance Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $60
copay Not Available
Spouses domestic partners and dependent children to age 19 (or to age 25 if FT student) are eligible
14
Vision Insurance ndash Option 2
Vision Plan through Spectera UHC (Voluntary)
UHC offers you one of the largest vision care networks in the industry Their network includes convenient retail locations including My Eye Dr and Hour Eyes Best of all ndash when you receive care from a participating provider you receive the greatest benefits and money-saving discounts
Frequency Eye Exam 12 monthsLenses 12 monthsFrames 12 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $40
Eyeglass Lenses (standard) Single Bifocal Trifocal
$25 copay $25 copay $25 copay
Plan pays up to $40 Plan pays up to $60 Plan pays up to $80
Frames $2500 copay $130 retail frame
allowance 30 discount above allowance
Plan pays up to $45
Necessary Contact Lenses $25 copay Plan pays up to $210
Elective Contact Lenses
$25 copay from the ldquoCovered contact lens
selectionrdquo All others- $105
allowance
Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $25
copay Not Available
Spouses and dependent children to age 26 are eligible
15
Pre-tax FSA amp DCA
Flexible Spending Account (FSA) through Optum Health The Flexible Spending Account provides employees a means to reduce their taxes by the amount of their out of pocket health-related expenses (subject to eligibility) This tax free savings program allows employees to submit receipts for reimbursement for medical dental vision care prescription drug co-payments and other expenses not covered by our insurance In 2020 employees may contribute up to $2750 per year toward their FSA Employees have until March 14 2020 to use the money in their FSA or else they lose it (This contribution amount could change based on IRS guideline updates)
Dependent Care Spending Account (DCA) through Optum Health The Dependent Care Spending Account provides employees a means to reduce their taxes by the amount of their child care costs to a licensed provider up to $5000 annually
Health Insurance Premium Bank
Reston Association has established a program to help regular full-time and regular part-time employees pay their portion of the health insurance premium This program is only available to employees who are enrolled in or plan to enroll in the Kaiser Permanente HMO health insurance plans offered by the Reston Association Employees are eligible to apply to the Health Insurance Premium Bank if their adjusted gross household incomes are less than or equal to $60000 Requests for assistance must be made annually or at any time there is a qualifying event and submitted to Human Resources with necessary documentation by December 12th of each year To apply complete a request form (available in CommonHumResBenefits) and submit to HR with a copy of your most recent tax return showing adjusted gross household income This threshold is subject to change
16
Life and ADampD Insurance
Basic LifeADampD Insurance Reston Association provides 100 employer paid Life and ADampD Insurance through Sun Life to employees working 25 or more hours per week Coverage becomes effective the first of the month following six months of service
Benefit 2x Annual Earnings to a maximum of $200000 Age reduction Benefit reduced to 65 at age 65 and to 50 at age 70
Optional LifeADampD Insurance for Employee Spouse and Dependent Children
Optional Life Insurance for the employee spouse and dependent children is available at the employeersquos cost Optional Life is not available for domestic partners
Employee Benefit Increments of $10000 to a maximum of the lesser of $300000 or 3x your Basic Annual Earnings
Spouse Benefit Increments of $5000 to a maximum of $150000 Dependent Child Benefit Increments of $1000 to a maximum of $10000
Your amount of Dependent Spouse and Dependent Child Optional Life Insurance cannot exceed 50 of your amount of Optional Life Insurance Initial eligibility period will require evidence of insurability
STD amp LTD Insurance
Short Term and Long Term Disability Reston Association provides eligible employees with short and long-term disability income benefits through Sun Life In the event you become disabled from a non work-related injury or sickness disability income benefits are provided as a source of income These benefits are 100 employer paid
Benefit Short-Term Disability Long-Term Disability
Income Replacement -Eligible Employees -Executives
60 60
Elimination Period - Accidental Injury - Sickness
29 days 90 days
Benefit Period 9 weeks maximum To Social Security
normal retirement age
Benefit Maximum -Eligible Employees -Executives
$1000 per week $6000 per month $8000 per month 17
At a cost of $19month you can enroll in the Legal Resources benefit As a Legal Resources Member you have immediate and ongoing access to comprehensive legal coverage services and expertise that will easily save you money mdash and could save you a whole lot more Covered legal services include
Legal Advice and Consultation Tenant Dispute with Landlord District Court Representation for Civil Action Review of a Financial Contract or Lease Purchase sale or refinance of primary home Traffic Court Representation (includes 1st DUI) Will Preparation Uncontested Divorce Representation Defense of Child in Court (misdemeanor)
Legal Resources
Employee Assistance Program (EAP)
Reston Association offers a free confidential Employee Assistance Program (EAP) to all employees and their eligible dependents Through RArsquos EAP provider Lytle EAP Partners you and your immediate family members have immediate access on your date of hire to confidential professional counseling and referral services for help with anything that affects you or your dependentsrsquo well-being You can reach an EAP counselor by dialing 1-800-327-7272 24 hours a day or you may visit their website at wwwLytleEAPcom (password is reston) for more information Visit wwwLytleEAPcom for web-based legal financial worklife resources There are also work-related resources available online for managers Note Since EAP services are provided as a benefit only RA makes no representation concerning quality of care
18
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Health Insurance ndash Option 2
Kaiser Permanente HMO Select (Facilities amp Contracted Providers Only) With the Select Network members may receive quality care at the Kaiser medical centers in Maryland Virginia and the District of Columbia Building on the Signature physician network the Select network adds access to more than 15000 contracted community physicians in private practice Select members also have access to more than 40 hospitals in the region
HMO Select In-Network You Pay Out-of-Network
You Pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
NA
Primary Care and Specialist Office Visit $30 PCP$40 Specialist NO COVERAGE
Emergency Room Visits $100 per visit
(waived if admitted) NO COVERAGE
Hospital ndash Inpatient Stay $250 per admission NO COVERAGE
Home Health Care No charge NO COVERAGE
Outpatient Facility Services $100 NO COVERAGE
X-Ray and Laboratory Services No charge NO COVERAGE
Specialty Imaging (CTMRIPET scan) $50 per test NO COVERAGE
Chiropractic amp Acupuncture Services $40 copay
20 visits per contract year NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission NO COVERAGE
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$15 copay-group therapy $30 copay-individual therapy per visit
NO COVERAGE
Vision (Children Only) $30 PCP$40 Specialist NO COVERAGE
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
11
Kaiser Permanente POS Select (Facilities amp Contracted Providers with an Out of Network Option) Members can use in-plan benefits by using a Kaiser facility or a contracted primary care physician Your chosen PCP will provide care and coordinate referrals and hospital admissions Members also have the freedom to choose any other licensed provider outside the provider network however you will be responsible for deductibles and coinsurance above the health planrsquos payment
POS Select In-Network You Pay Out-of-Network
you pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
$300 Individual $600 Family
8020 $3000 Individual
$6000 Family
Primary Care and Specialist Office Visit $15 PCP$30 Specialist 20 of UCR
Emergency Room Visits $75 per visit (waived if
admitted) $75 per visit
(waived if admitted)
Hospital ndash Inpatient Stay $250 per admission 20 of UCR
Home Health Care No charge 20 of UCR
Outpatient Facility Services $50 20 of UCR
X-Ray and Laboratory Services No charge 20 of UCR
Specialty Imaging (CTMRIPET scan) No charge 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
20 of UCR
Vision (Children Only) $15 PCP$30 Specialist per visit 20 of UCR
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
Health Insurance ndash Option 3
12
Dental Insurance
MetLife Dental PPO The Dental PPO plan is 100 Employer Paid for all tiers and provides comprehensive coverage with a nationwide PPO network This gives members access to more in-network dentists making it easier for them to reduce out-of-pocket costs for covered procedures and treatments Dental procedure frequencies Preventative care covers an exam and cleaning (once every 6 months) Fluoride treatment (two per benefit period under age 19 only) Full mouth X-ray (once every 60 months) Bitewing X-ray (once every 12 months age 14 and over once every 12 months under age 14)
PPO Dental Plan Features In-Network Out-of-Network
Type A Preventive Care Services (oral exams cleanings x-rays sealants)
100 of Fee Schedule 100 of Usual amp Customary
Charge
Type B Basic Restorative Dental Services (fillings simple extractions space maintainers)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type B Major Surgical Dental Services (Endodontics amp Periodontics)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type C Major Restorative Dental Services (bridges crowns dentures implants)
50 of Fee Schedule 50 of Usual amp Customary
Charge
Orthodontia (under age 19 only)
Lifetime maximum - $1000 50 of allowed benefit
Calendar Year Deductible Applies to Type B amp C services only
$25 Single $75 Family
Calendar Year Maximum Per Person $1500 combined maxper calendar year
Prior to receiving dental services it is recommended that you first obtain a pre-determination of benefits from your dentist so you know exactly how much your dental insurance will cover Spouses domestic partners and dependent children to age 26 (regardless of student status) are eligible
13
Vision Insurance ndash Option 1
Vision Plan through VSP (Voluntary) VSP is the largest private provider vision carrier in the country VSP contracts with Costcoreg Optical Eye Care Centers of America Inctrade which includes popular stores like EyeMasters VisionWorld and Hour Eyes and other quality retail chains When you visit a VSP participating provider your benefits include routine vision exams lenses and preferred pricing on all patient options Frequency Eye Exam 12 monthsLenses 12 monthsFrames 24 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $45
Eyeglass Lenses (standard) Single Bifocal Trifocal
Covered in Full Covered in Full Covered in Full
Plan pays up to $30 Plan pays up to $50 Plan pays up to $65
Frames $130 allowance then 20 off remaining balance
Plan pays up to $70
Necessary Contact Lenses Covered in Full Plan pays up to $210
Elective Contact Lenses $130 allowance Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $60
copay Not Available
Spouses domestic partners and dependent children to age 19 (or to age 25 if FT student) are eligible
14
Vision Insurance ndash Option 2
Vision Plan through Spectera UHC (Voluntary)
UHC offers you one of the largest vision care networks in the industry Their network includes convenient retail locations including My Eye Dr and Hour Eyes Best of all ndash when you receive care from a participating provider you receive the greatest benefits and money-saving discounts
Frequency Eye Exam 12 monthsLenses 12 monthsFrames 12 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $40
Eyeglass Lenses (standard) Single Bifocal Trifocal
$25 copay $25 copay $25 copay
Plan pays up to $40 Plan pays up to $60 Plan pays up to $80
Frames $2500 copay $130 retail frame
allowance 30 discount above allowance
Plan pays up to $45
Necessary Contact Lenses $25 copay Plan pays up to $210
Elective Contact Lenses
$25 copay from the ldquoCovered contact lens
selectionrdquo All others- $105
allowance
Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $25
copay Not Available
Spouses and dependent children to age 26 are eligible
15
Pre-tax FSA amp DCA
Flexible Spending Account (FSA) through Optum Health The Flexible Spending Account provides employees a means to reduce their taxes by the amount of their out of pocket health-related expenses (subject to eligibility) This tax free savings program allows employees to submit receipts for reimbursement for medical dental vision care prescription drug co-payments and other expenses not covered by our insurance In 2020 employees may contribute up to $2750 per year toward their FSA Employees have until March 14 2020 to use the money in their FSA or else they lose it (This contribution amount could change based on IRS guideline updates)
Dependent Care Spending Account (DCA) through Optum Health The Dependent Care Spending Account provides employees a means to reduce their taxes by the amount of their child care costs to a licensed provider up to $5000 annually
Health Insurance Premium Bank
Reston Association has established a program to help regular full-time and regular part-time employees pay their portion of the health insurance premium This program is only available to employees who are enrolled in or plan to enroll in the Kaiser Permanente HMO health insurance plans offered by the Reston Association Employees are eligible to apply to the Health Insurance Premium Bank if their adjusted gross household incomes are less than or equal to $60000 Requests for assistance must be made annually or at any time there is a qualifying event and submitted to Human Resources with necessary documentation by December 12th of each year To apply complete a request form (available in CommonHumResBenefits) and submit to HR with a copy of your most recent tax return showing adjusted gross household income This threshold is subject to change
16
Life and ADampD Insurance
Basic LifeADampD Insurance Reston Association provides 100 employer paid Life and ADampD Insurance through Sun Life to employees working 25 or more hours per week Coverage becomes effective the first of the month following six months of service
Benefit 2x Annual Earnings to a maximum of $200000 Age reduction Benefit reduced to 65 at age 65 and to 50 at age 70
Optional LifeADampD Insurance for Employee Spouse and Dependent Children
Optional Life Insurance for the employee spouse and dependent children is available at the employeersquos cost Optional Life is not available for domestic partners
Employee Benefit Increments of $10000 to a maximum of the lesser of $300000 or 3x your Basic Annual Earnings
Spouse Benefit Increments of $5000 to a maximum of $150000 Dependent Child Benefit Increments of $1000 to a maximum of $10000
Your amount of Dependent Spouse and Dependent Child Optional Life Insurance cannot exceed 50 of your amount of Optional Life Insurance Initial eligibility period will require evidence of insurability
STD amp LTD Insurance
Short Term and Long Term Disability Reston Association provides eligible employees with short and long-term disability income benefits through Sun Life In the event you become disabled from a non work-related injury or sickness disability income benefits are provided as a source of income These benefits are 100 employer paid
Benefit Short-Term Disability Long-Term Disability
Income Replacement -Eligible Employees -Executives
60 60
Elimination Period - Accidental Injury - Sickness
29 days 90 days
Benefit Period 9 weeks maximum To Social Security
normal retirement age
Benefit Maximum -Eligible Employees -Executives
$1000 per week $6000 per month $8000 per month 17
At a cost of $19month you can enroll in the Legal Resources benefit As a Legal Resources Member you have immediate and ongoing access to comprehensive legal coverage services and expertise that will easily save you money mdash and could save you a whole lot more Covered legal services include
Legal Advice and Consultation Tenant Dispute with Landlord District Court Representation for Civil Action Review of a Financial Contract or Lease Purchase sale or refinance of primary home Traffic Court Representation (includes 1st DUI) Will Preparation Uncontested Divorce Representation Defense of Child in Court (misdemeanor)
Legal Resources
Employee Assistance Program (EAP)
Reston Association offers a free confidential Employee Assistance Program (EAP) to all employees and their eligible dependents Through RArsquos EAP provider Lytle EAP Partners you and your immediate family members have immediate access on your date of hire to confidential professional counseling and referral services for help with anything that affects you or your dependentsrsquo well-being You can reach an EAP counselor by dialing 1-800-327-7272 24 hours a day or you may visit their website at wwwLytleEAPcom (password is reston) for more information Visit wwwLytleEAPcom for web-based legal financial worklife resources There are also work-related resources available online for managers Note Since EAP services are provided as a benefit only RA makes no representation concerning quality of care
18
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Kaiser Permanente POS Select (Facilities amp Contracted Providers with an Out of Network Option) Members can use in-plan benefits by using a Kaiser facility or a contracted primary care physician Your chosen PCP will provide care and coordinate referrals and hospital admissions Members also have the freedom to choose any other licensed provider outside the provider network however you will be responsible for deductibles and coinsurance above the health planrsquos payment
POS Select In-Network You Pay Out-of-Network
you pay
Deductible Coinsurance Out-of-Pocket
None 100
$3500 Individual $9400 Family
$300 Individual $600 Family
8020 $3000 Individual
$6000 Family
Primary Care and Specialist Office Visit $15 PCP$30 Specialist 20 of UCR
Emergency Room Visits $75 per visit (waived if
admitted) $75 per visit
(waived if admitted)
Hospital ndash Inpatient Stay $250 per admission 20 of UCR
Home Health Care No charge 20 of UCR
Outpatient Facility Services $50 20 of UCR
X-Ray and Laboratory Services No charge 20 of UCR
Specialty Imaging (CTMRIPET scan) No charge 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Inpatient Facility
$250 per admission 20 of UCR
Mental Health (MG) amp Substance Abuse (SA) ndash Outpatient Facility
$7 copay-group therapy $15 copay-individual therapy per visit
20 of UCR
Vision (Children Only) $15 PCP$30 Specialist per visit 20 of UCR
Prescription Drug Program (30 day supply) Generic Drug (Tier 1) Preferred Brand Name Drug (Tier 2) Non-Preferred Brand Drug (Tier 3) Up to 90 day supply ndash 3 co-pays for Plan and Participating Pharmacies Mail Order Up to 90 day supply- 2 co-pays
$0 deductible
Plan $20 Participating $30 Plan $35 Participating $50 Plan $50 Participating $75
$20$35$50
Health Insurance ndash Option 3
12
Dental Insurance
MetLife Dental PPO The Dental PPO plan is 100 Employer Paid for all tiers and provides comprehensive coverage with a nationwide PPO network This gives members access to more in-network dentists making it easier for them to reduce out-of-pocket costs for covered procedures and treatments Dental procedure frequencies Preventative care covers an exam and cleaning (once every 6 months) Fluoride treatment (two per benefit period under age 19 only) Full mouth X-ray (once every 60 months) Bitewing X-ray (once every 12 months age 14 and over once every 12 months under age 14)
PPO Dental Plan Features In-Network Out-of-Network
Type A Preventive Care Services (oral exams cleanings x-rays sealants)
100 of Fee Schedule 100 of Usual amp Customary
Charge
Type B Basic Restorative Dental Services (fillings simple extractions space maintainers)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type B Major Surgical Dental Services (Endodontics amp Periodontics)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type C Major Restorative Dental Services (bridges crowns dentures implants)
50 of Fee Schedule 50 of Usual amp Customary
Charge
Orthodontia (under age 19 only)
Lifetime maximum - $1000 50 of allowed benefit
Calendar Year Deductible Applies to Type B amp C services only
$25 Single $75 Family
Calendar Year Maximum Per Person $1500 combined maxper calendar year
Prior to receiving dental services it is recommended that you first obtain a pre-determination of benefits from your dentist so you know exactly how much your dental insurance will cover Spouses domestic partners and dependent children to age 26 (regardless of student status) are eligible
13
Vision Insurance ndash Option 1
Vision Plan through VSP (Voluntary) VSP is the largest private provider vision carrier in the country VSP contracts with Costcoreg Optical Eye Care Centers of America Inctrade which includes popular stores like EyeMasters VisionWorld and Hour Eyes and other quality retail chains When you visit a VSP participating provider your benefits include routine vision exams lenses and preferred pricing on all patient options Frequency Eye Exam 12 monthsLenses 12 monthsFrames 24 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $45
Eyeglass Lenses (standard) Single Bifocal Trifocal
Covered in Full Covered in Full Covered in Full
Plan pays up to $30 Plan pays up to $50 Plan pays up to $65
Frames $130 allowance then 20 off remaining balance
Plan pays up to $70
Necessary Contact Lenses Covered in Full Plan pays up to $210
Elective Contact Lenses $130 allowance Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $60
copay Not Available
Spouses domestic partners and dependent children to age 19 (or to age 25 if FT student) are eligible
14
Vision Insurance ndash Option 2
Vision Plan through Spectera UHC (Voluntary)
UHC offers you one of the largest vision care networks in the industry Their network includes convenient retail locations including My Eye Dr and Hour Eyes Best of all ndash when you receive care from a participating provider you receive the greatest benefits and money-saving discounts
Frequency Eye Exam 12 monthsLenses 12 monthsFrames 12 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $40
Eyeglass Lenses (standard) Single Bifocal Trifocal
$25 copay $25 copay $25 copay
Plan pays up to $40 Plan pays up to $60 Plan pays up to $80
Frames $2500 copay $130 retail frame
allowance 30 discount above allowance
Plan pays up to $45
Necessary Contact Lenses $25 copay Plan pays up to $210
Elective Contact Lenses
$25 copay from the ldquoCovered contact lens
selectionrdquo All others- $105
allowance
Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $25
copay Not Available
Spouses and dependent children to age 26 are eligible
15
Pre-tax FSA amp DCA
Flexible Spending Account (FSA) through Optum Health The Flexible Spending Account provides employees a means to reduce their taxes by the amount of their out of pocket health-related expenses (subject to eligibility) This tax free savings program allows employees to submit receipts for reimbursement for medical dental vision care prescription drug co-payments and other expenses not covered by our insurance In 2020 employees may contribute up to $2750 per year toward their FSA Employees have until March 14 2020 to use the money in their FSA or else they lose it (This contribution amount could change based on IRS guideline updates)
Dependent Care Spending Account (DCA) through Optum Health The Dependent Care Spending Account provides employees a means to reduce their taxes by the amount of their child care costs to a licensed provider up to $5000 annually
Health Insurance Premium Bank
Reston Association has established a program to help regular full-time and regular part-time employees pay their portion of the health insurance premium This program is only available to employees who are enrolled in or plan to enroll in the Kaiser Permanente HMO health insurance plans offered by the Reston Association Employees are eligible to apply to the Health Insurance Premium Bank if their adjusted gross household incomes are less than or equal to $60000 Requests for assistance must be made annually or at any time there is a qualifying event and submitted to Human Resources with necessary documentation by December 12th of each year To apply complete a request form (available in CommonHumResBenefits) and submit to HR with a copy of your most recent tax return showing adjusted gross household income This threshold is subject to change
16
Life and ADampD Insurance
Basic LifeADampD Insurance Reston Association provides 100 employer paid Life and ADampD Insurance through Sun Life to employees working 25 or more hours per week Coverage becomes effective the first of the month following six months of service
Benefit 2x Annual Earnings to a maximum of $200000 Age reduction Benefit reduced to 65 at age 65 and to 50 at age 70
Optional LifeADampD Insurance for Employee Spouse and Dependent Children
Optional Life Insurance for the employee spouse and dependent children is available at the employeersquos cost Optional Life is not available for domestic partners
Employee Benefit Increments of $10000 to a maximum of the lesser of $300000 or 3x your Basic Annual Earnings
Spouse Benefit Increments of $5000 to a maximum of $150000 Dependent Child Benefit Increments of $1000 to a maximum of $10000
Your amount of Dependent Spouse and Dependent Child Optional Life Insurance cannot exceed 50 of your amount of Optional Life Insurance Initial eligibility period will require evidence of insurability
STD amp LTD Insurance
Short Term and Long Term Disability Reston Association provides eligible employees with short and long-term disability income benefits through Sun Life In the event you become disabled from a non work-related injury or sickness disability income benefits are provided as a source of income These benefits are 100 employer paid
Benefit Short-Term Disability Long-Term Disability
Income Replacement -Eligible Employees -Executives
60 60
Elimination Period - Accidental Injury - Sickness
29 days 90 days
Benefit Period 9 weeks maximum To Social Security
normal retirement age
Benefit Maximum -Eligible Employees -Executives
$1000 per week $6000 per month $8000 per month 17
At a cost of $19month you can enroll in the Legal Resources benefit As a Legal Resources Member you have immediate and ongoing access to comprehensive legal coverage services and expertise that will easily save you money mdash and could save you a whole lot more Covered legal services include
Legal Advice and Consultation Tenant Dispute with Landlord District Court Representation for Civil Action Review of a Financial Contract or Lease Purchase sale or refinance of primary home Traffic Court Representation (includes 1st DUI) Will Preparation Uncontested Divorce Representation Defense of Child in Court (misdemeanor)
Legal Resources
Employee Assistance Program (EAP)
Reston Association offers a free confidential Employee Assistance Program (EAP) to all employees and their eligible dependents Through RArsquos EAP provider Lytle EAP Partners you and your immediate family members have immediate access on your date of hire to confidential professional counseling and referral services for help with anything that affects you or your dependentsrsquo well-being You can reach an EAP counselor by dialing 1-800-327-7272 24 hours a day or you may visit their website at wwwLytleEAPcom (password is reston) for more information Visit wwwLytleEAPcom for web-based legal financial worklife resources There are also work-related resources available online for managers Note Since EAP services are provided as a benefit only RA makes no representation concerning quality of care
18
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Dental Insurance
MetLife Dental PPO The Dental PPO plan is 100 Employer Paid for all tiers and provides comprehensive coverage with a nationwide PPO network This gives members access to more in-network dentists making it easier for them to reduce out-of-pocket costs for covered procedures and treatments Dental procedure frequencies Preventative care covers an exam and cleaning (once every 6 months) Fluoride treatment (two per benefit period under age 19 only) Full mouth X-ray (once every 60 months) Bitewing X-ray (once every 12 months age 14 and over once every 12 months under age 14)
PPO Dental Plan Features In-Network Out-of-Network
Type A Preventive Care Services (oral exams cleanings x-rays sealants)
100 of Fee Schedule 100 of Usual amp Customary
Charge
Type B Basic Restorative Dental Services (fillings simple extractions space maintainers)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type B Major Surgical Dental Services (Endodontics amp Periodontics)
80 of Fee Schedule 80 of Usual amp Customary
Charge
Type C Major Restorative Dental Services (bridges crowns dentures implants)
50 of Fee Schedule 50 of Usual amp Customary
Charge
Orthodontia (under age 19 only)
Lifetime maximum - $1000 50 of allowed benefit
Calendar Year Deductible Applies to Type B amp C services only
$25 Single $75 Family
Calendar Year Maximum Per Person $1500 combined maxper calendar year
Prior to receiving dental services it is recommended that you first obtain a pre-determination of benefits from your dentist so you know exactly how much your dental insurance will cover Spouses domestic partners and dependent children to age 26 (regardless of student status) are eligible
13
Vision Insurance ndash Option 1
Vision Plan through VSP (Voluntary) VSP is the largest private provider vision carrier in the country VSP contracts with Costcoreg Optical Eye Care Centers of America Inctrade which includes popular stores like EyeMasters VisionWorld and Hour Eyes and other quality retail chains When you visit a VSP participating provider your benefits include routine vision exams lenses and preferred pricing on all patient options Frequency Eye Exam 12 monthsLenses 12 monthsFrames 24 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $45
Eyeglass Lenses (standard) Single Bifocal Trifocal
Covered in Full Covered in Full Covered in Full
Plan pays up to $30 Plan pays up to $50 Plan pays up to $65
Frames $130 allowance then 20 off remaining balance
Plan pays up to $70
Necessary Contact Lenses Covered in Full Plan pays up to $210
Elective Contact Lenses $130 allowance Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $60
copay Not Available
Spouses domestic partners and dependent children to age 19 (or to age 25 if FT student) are eligible
14
Vision Insurance ndash Option 2
Vision Plan through Spectera UHC (Voluntary)
UHC offers you one of the largest vision care networks in the industry Their network includes convenient retail locations including My Eye Dr and Hour Eyes Best of all ndash when you receive care from a participating provider you receive the greatest benefits and money-saving discounts
Frequency Eye Exam 12 monthsLenses 12 monthsFrames 12 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $40
Eyeglass Lenses (standard) Single Bifocal Trifocal
$25 copay $25 copay $25 copay
Plan pays up to $40 Plan pays up to $60 Plan pays up to $80
Frames $2500 copay $130 retail frame
allowance 30 discount above allowance
Plan pays up to $45
Necessary Contact Lenses $25 copay Plan pays up to $210
Elective Contact Lenses
$25 copay from the ldquoCovered contact lens
selectionrdquo All others- $105
allowance
Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $25
copay Not Available
Spouses and dependent children to age 26 are eligible
15
Pre-tax FSA amp DCA
Flexible Spending Account (FSA) through Optum Health The Flexible Spending Account provides employees a means to reduce their taxes by the amount of their out of pocket health-related expenses (subject to eligibility) This tax free savings program allows employees to submit receipts for reimbursement for medical dental vision care prescription drug co-payments and other expenses not covered by our insurance In 2020 employees may contribute up to $2750 per year toward their FSA Employees have until March 14 2020 to use the money in their FSA or else they lose it (This contribution amount could change based on IRS guideline updates)
Dependent Care Spending Account (DCA) through Optum Health The Dependent Care Spending Account provides employees a means to reduce their taxes by the amount of their child care costs to a licensed provider up to $5000 annually
Health Insurance Premium Bank
Reston Association has established a program to help regular full-time and regular part-time employees pay their portion of the health insurance premium This program is only available to employees who are enrolled in or plan to enroll in the Kaiser Permanente HMO health insurance plans offered by the Reston Association Employees are eligible to apply to the Health Insurance Premium Bank if their adjusted gross household incomes are less than or equal to $60000 Requests for assistance must be made annually or at any time there is a qualifying event and submitted to Human Resources with necessary documentation by December 12th of each year To apply complete a request form (available in CommonHumResBenefits) and submit to HR with a copy of your most recent tax return showing adjusted gross household income This threshold is subject to change
16
Life and ADampD Insurance
Basic LifeADampD Insurance Reston Association provides 100 employer paid Life and ADampD Insurance through Sun Life to employees working 25 or more hours per week Coverage becomes effective the first of the month following six months of service
Benefit 2x Annual Earnings to a maximum of $200000 Age reduction Benefit reduced to 65 at age 65 and to 50 at age 70
Optional LifeADampD Insurance for Employee Spouse and Dependent Children
Optional Life Insurance for the employee spouse and dependent children is available at the employeersquos cost Optional Life is not available for domestic partners
Employee Benefit Increments of $10000 to a maximum of the lesser of $300000 or 3x your Basic Annual Earnings
Spouse Benefit Increments of $5000 to a maximum of $150000 Dependent Child Benefit Increments of $1000 to a maximum of $10000
Your amount of Dependent Spouse and Dependent Child Optional Life Insurance cannot exceed 50 of your amount of Optional Life Insurance Initial eligibility period will require evidence of insurability
STD amp LTD Insurance
Short Term and Long Term Disability Reston Association provides eligible employees with short and long-term disability income benefits through Sun Life In the event you become disabled from a non work-related injury or sickness disability income benefits are provided as a source of income These benefits are 100 employer paid
Benefit Short-Term Disability Long-Term Disability
Income Replacement -Eligible Employees -Executives
60 60
Elimination Period - Accidental Injury - Sickness
29 days 90 days
Benefit Period 9 weeks maximum To Social Security
normal retirement age
Benefit Maximum -Eligible Employees -Executives
$1000 per week $6000 per month $8000 per month 17
At a cost of $19month you can enroll in the Legal Resources benefit As a Legal Resources Member you have immediate and ongoing access to comprehensive legal coverage services and expertise that will easily save you money mdash and could save you a whole lot more Covered legal services include
Legal Advice and Consultation Tenant Dispute with Landlord District Court Representation for Civil Action Review of a Financial Contract or Lease Purchase sale or refinance of primary home Traffic Court Representation (includes 1st DUI) Will Preparation Uncontested Divorce Representation Defense of Child in Court (misdemeanor)
Legal Resources
Employee Assistance Program (EAP)
Reston Association offers a free confidential Employee Assistance Program (EAP) to all employees and their eligible dependents Through RArsquos EAP provider Lytle EAP Partners you and your immediate family members have immediate access on your date of hire to confidential professional counseling and referral services for help with anything that affects you or your dependentsrsquo well-being You can reach an EAP counselor by dialing 1-800-327-7272 24 hours a day or you may visit their website at wwwLytleEAPcom (password is reston) for more information Visit wwwLytleEAPcom for web-based legal financial worklife resources There are also work-related resources available online for managers Note Since EAP services are provided as a benefit only RA makes no representation concerning quality of care
18
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Vision Insurance ndash Option 1
Vision Plan through VSP (Voluntary) VSP is the largest private provider vision carrier in the country VSP contracts with Costcoreg Optical Eye Care Centers of America Inctrade which includes popular stores like EyeMasters VisionWorld and Hour Eyes and other quality retail chains When you visit a VSP participating provider your benefits include routine vision exams lenses and preferred pricing on all patient options Frequency Eye Exam 12 monthsLenses 12 monthsFrames 24 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $45
Eyeglass Lenses (standard) Single Bifocal Trifocal
Covered in Full Covered in Full Covered in Full
Plan pays up to $30 Plan pays up to $50 Plan pays up to $65
Frames $130 allowance then 20 off remaining balance
Plan pays up to $70
Necessary Contact Lenses Covered in Full Plan pays up to $210
Elective Contact Lenses $130 allowance Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $60
copay Not Available
Spouses domestic partners and dependent children to age 19 (or to age 25 if FT student) are eligible
14
Vision Insurance ndash Option 2
Vision Plan through Spectera UHC (Voluntary)
UHC offers you one of the largest vision care networks in the industry Their network includes convenient retail locations including My Eye Dr and Hour Eyes Best of all ndash when you receive care from a participating provider you receive the greatest benefits and money-saving discounts
Frequency Eye Exam 12 monthsLenses 12 monthsFrames 12 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $40
Eyeglass Lenses (standard) Single Bifocal Trifocal
$25 copay $25 copay $25 copay
Plan pays up to $40 Plan pays up to $60 Plan pays up to $80
Frames $2500 copay $130 retail frame
allowance 30 discount above allowance
Plan pays up to $45
Necessary Contact Lenses $25 copay Plan pays up to $210
Elective Contact Lenses
$25 copay from the ldquoCovered contact lens
selectionrdquo All others- $105
allowance
Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $25
copay Not Available
Spouses and dependent children to age 26 are eligible
15
Pre-tax FSA amp DCA
Flexible Spending Account (FSA) through Optum Health The Flexible Spending Account provides employees a means to reduce their taxes by the amount of their out of pocket health-related expenses (subject to eligibility) This tax free savings program allows employees to submit receipts for reimbursement for medical dental vision care prescription drug co-payments and other expenses not covered by our insurance In 2020 employees may contribute up to $2750 per year toward their FSA Employees have until March 14 2020 to use the money in their FSA or else they lose it (This contribution amount could change based on IRS guideline updates)
Dependent Care Spending Account (DCA) through Optum Health The Dependent Care Spending Account provides employees a means to reduce their taxes by the amount of their child care costs to a licensed provider up to $5000 annually
Health Insurance Premium Bank
Reston Association has established a program to help regular full-time and regular part-time employees pay their portion of the health insurance premium This program is only available to employees who are enrolled in or plan to enroll in the Kaiser Permanente HMO health insurance plans offered by the Reston Association Employees are eligible to apply to the Health Insurance Premium Bank if their adjusted gross household incomes are less than or equal to $60000 Requests for assistance must be made annually or at any time there is a qualifying event and submitted to Human Resources with necessary documentation by December 12th of each year To apply complete a request form (available in CommonHumResBenefits) and submit to HR with a copy of your most recent tax return showing adjusted gross household income This threshold is subject to change
16
Life and ADampD Insurance
Basic LifeADampD Insurance Reston Association provides 100 employer paid Life and ADampD Insurance through Sun Life to employees working 25 or more hours per week Coverage becomes effective the first of the month following six months of service
Benefit 2x Annual Earnings to a maximum of $200000 Age reduction Benefit reduced to 65 at age 65 and to 50 at age 70
Optional LifeADampD Insurance for Employee Spouse and Dependent Children
Optional Life Insurance for the employee spouse and dependent children is available at the employeersquos cost Optional Life is not available for domestic partners
Employee Benefit Increments of $10000 to a maximum of the lesser of $300000 or 3x your Basic Annual Earnings
Spouse Benefit Increments of $5000 to a maximum of $150000 Dependent Child Benefit Increments of $1000 to a maximum of $10000
Your amount of Dependent Spouse and Dependent Child Optional Life Insurance cannot exceed 50 of your amount of Optional Life Insurance Initial eligibility period will require evidence of insurability
STD amp LTD Insurance
Short Term and Long Term Disability Reston Association provides eligible employees with short and long-term disability income benefits through Sun Life In the event you become disabled from a non work-related injury or sickness disability income benefits are provided as a source of income These benefits are 100 employer paid
Benefit Short-Term Disability Long-Term Disability
Income Replacement -Eligible Employees -Executives
60 60
Elimination Period - Accidental Injury - Sickness
29 days 90 days
Benefit Period 9 weeks maximum To Social Security
normal retirement age
Benefit Maximum -Eligible Employees -Executives
$1000 per week $6000 per month $8000 per month 17
At a cost of $19month you can enroll in the Legal Resources benefit As a Legal Resources Member you have immediate and ongoing access to comprehensive legal coverage services and expertise that will easily save you money mdash and could save you a whole lot more Covered legal services include
Legal Advice and Consultation Tenant Dispute with Landlord District Court Representation for Civil Action Review of a Financial Contract or Lease Purchase sale or refinance of primary home Traffic Court Representation (includes 1st DUI) Will Preparation Uncontested Divorce Representation Defense of Child in Court (misdemeanor)
Legal Resources
Employee Assistance Program (EAP)
Reston Association offers a free confidential Employee Assistance Program (EAP) to all employees and their eligible dependents Through RArsquos EAP provider Lytle EAP Partners you and your immediate family members have immediate access on your date of hire to confidential professional counseling and referral services for help with anything that affects you or your dependentsrsquo well-being You can reach an EAP counselor by dialing 1-800-327-7272 24 hours a day or you may visit their website at wwwLytleEAPcom (password is reston) for more information Visit wwwLytleEAPcom for web-based legal financial worklife resources There are also work-related resources available online for managers Note Since EAP services are provided as a benefit only RA makes no representation concerning quality of care
18
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Vision Insurance ndash Option 2
Vision Plan through Spectera UHC (Voluntary)
UHC offers you one of the largest vision care networks in the industry Their network includes convenient retail locations including My Eye Dr and Hour Eyes Best of all ndash when you receive care from a participating provider you receive the greatest benefits and money-saving discounts
Frequency Eye Exam 12 monthsLenses 12 monthsFrames 12 monthsContact Lenses 12 months
Vision Plan Features In-Network Out-of-Network
Annual Routine Eye Exam $10 copay Plan pays up to $40
Eyeglass Lenses (standard) Single Bifocal Trifocal
$25 copay $25 copay $25 copay
Plan pays up to $40 Plan pays up to $60 Plan pays up to $80
Frames $2500 copay $130 retail frame
allowance 30 discount above allowance
Plan pays up to $45
Necessary Contact Lenses $25 copay Plan pays up to $210
Elective Contact Lenses
$25 copay from the ldquoCovered contact lens
selectionrdquo All others- $105
allowance
Plan pays up to $105
Elective Contact Lenses fitting and evaluation Covered in Full after $25
copay Not Available
Spouses and dependent children to age 26 are eligible
15
Pre-tax FSA amp DCA
Flexible Spending Account (FSA) through Optum Health The Flexible Spending Account provides employees a means to reduce their taxes by the amount of their out of pocket health-related expenses (subject to eligibility) This tax free savings program allows employees to submit receipts for reimbursement for medical dental vision care prescription drug co-payments and other expenses not covered by our insurance In 2020 employees may contribute up to $2750 per year toward their FSA Employees have until March 14 2020 to use the money in their FSA or else they lose it (This contribution amount could change based on IRS guideline updates)
Dependent Care Spending Account (DCA) through Optum Health The Dependent Care Spending Account provides employees a means to reduce their taxes by the amount of their child care costs to a licensed provider up to $5000 annually
Health Insurance Premium Bank
Reston Association has established a program to help regular full-time and regular part-time employees pay their portion of the health insurance premium This program is only available to employees who are enrolled in or plan to enroll in the Kaiser Permanente HMO health insurance plans offered by the Reston Association Employees are eligible to apply to the Health Insurance Premium Bank if their adjusted gross household incomes are less than or equal to $60000 Requests for assistance must be made annually or at any time there is a qualifying event and submitted to Human Resources with necessary documentation by December 12th of each year To apply complete a request form (available in CommonHumResBenefits) and submit to HR with a copy of your most recent tax return showing adjusted gross household income This threshold is subject to change
16
Life and ADampD Insurance
Basic LifeADampD Insurance Reston Association provides 100 employer paid Life and ADampD Insurance through Sun Life to employees working 25 or more hours per week Coverage becomes effective the first of the month following six months of service
Benefit 2x Annual Earnings to a maximum of $200000 Age reduction Benefit reduced to 65 at age 65 and to 50 at age 70
Optional LifeADampD Insurance for Employee Spouse and Dependent Children
Optional Life Insurance for the employee spouse and dependent children is available at the employeersquos cost Optional Life is not available for domestic partners
Employee Benefit Increments of $10000 to a maximum of the lesser of $300000 or 3x your Basic Annual Earnings
Spouse Benefit Increments of $5000 to a maximum of $150000 Dependent Child Benefit Increments of $1000 to a maximum of $10000
Your amount of Dependent Spouse and Dependent Child Optional Life Insurance cannot exceed 50 of your amount of Optional Life Insurance Initial eligibility period will require evidence of insurability
STD amp LTD Insurance
Short Term and Long Term Disability Reston Association provides eligible employees with short and long-term disability income benefits through Sun Life In the event you become disabled from a non work-related injury or sickness disability income benefits are provided as a source of income These benefits are 100 employer paid
Benefit Short-Term Disability Long-Term Disability
Income Replacement -Eligible Employees -Executives
60 60
Elimination Period - Accidental Injury - Sickness
29 days 90 days
Benefit Period 9 weeks maximum To Social Security
normal retirement age
Benefit Maximum -Eligible Employees -Executives
$1000 per week $6000 per month $8000 per month 17
At a cost of $19month you can enroll in the Legal Resources benefit As a Legal Resources Member you have immediate and ongoing access to comprehensive legal coverage services and expertise that will easily save you money mdash and could save you a whole lot more Covered legal services include
Legal Advice and Consultation Tenant Dispute with Landlord District Court Representation for Civil Action Review of a Financial Contract or Lease Purchase sale or refinance of primary home Traffic Court Representation (includes 1st DUI) Will Preparation Uncontested Divorce Representation Defense of Child in Court (misdemeanor)
Legal Resources
Employee Assistance Program (EAP)
Reston Association offers a free confidential Employee Assistance Program (EAP) to all employees and their eligible dependents Through RArsquos EAP provider Lytle EAP Partners you and your immediate family members have immediate access on your date of hire to confidential professional counseling and referral services for help with anything that affects you or your dependentsrsquo well-being You can reach an EAP counselor by dialing 1-800-327-7272 24 hours a day or you may visit their website at wwwLytleEAPcom (password is reston) for more information Visit wwwLytleEAPcom for web-based legal financial worklife resources There are also work-related resources available online for managers Note Since EAP services are provided as a benefit only RA makes no representation concerning quality of care
18
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Pre-tax FSA amp DCA
Flexible Spending Account (FSA) through Optum Health The Flexible Spending Account provides employees a means to reduce their taxes by the amount of their out of pocket health-related expenses (subject to eligibility) This tax free savings program allows employees to submit receipts for reimbursement for medical dental vision care prescription drug co-payments and other expenses not covered by our insurance In 2020 employees may contribute up to $2750 per year toward their FSA Employees have until March 14 2020 to use the money in their FSA or else they lose it (This contribution amount could change based on IRS guideline updates)
Dependent Care Spending Account (DCA) through Optum Health The Dependent Care Spending Account provides employees a means to reduce their taxes by the amount of their child care costs to a licensed provider up to $5000 annually
Health Insurance Premium Bank
Reston Association has established a program to help regular full-time and regular part-time employees pay their portion of the health insurance premium This program is only available to employees who are enrolled in or plan to enroll in the Kaiser Permanente HMO health insurance plans offered by the Reston Association Employees are eligible to apply to the Health Insurance Premium Bank if their adjusted gross household incomes are less than or equal to $60000 Requests for assistance must be made annually or at any time there is a qualifying event and submitted to Human Resources with necessary documentation by December 12th of each year To apply complete a request form (available in CommonHumResBenefits) and submit to HR with a copy of your most recent tax return showing adjusted gross household income This threshold is subject to change
16
Life and ADampD Insurance
Basic LifeADampD Insurance Reston Association provides 100 employer paid Life and ADampD Insurance through Sun Life to employees working 25 or more hours per week Coverage becomes effective the first of the month following six months of service
Benefit 2x Annual Earnings to a maximum of $200000 Age reduction Benefit reduced to 65 at age 65 and to 50 at age 70
Optional LifeADampD Insurance for Employee Spouse and Dependent Children
Optional Life Insurance for the employee spouse and dependent children is available at the employeersquos cost Optional Life is not available for domestic partners
Employee Benefit Increments of $10000 to a maximum of the lesser of $300000 or 3x your Basic Annual Earnings
Spouse Benefit Increments of $5000 to a maximum of $150000 Dependent Child Benefit Increments of $1000 to a maximum of $10000
Your amount of Dependent Spouse and Dependent Child Optional Life Insurance cannot exceed 50 of your amount of Optional Life Insurance Initial eligibility period will require evidence of insurability
STD amp LTD Insurance
Short Term and Long Term Disability Reston Association provides eligible employees with short and long-term disability income benefits through Sun Life In the event you become disabled from a non work-related injury or sickness disability income benefits are provided as a source of income These benefits are 100 employer paid
Benefit Short-Term Disability Long-Term Disability
Income Replacement -Eligible Employees -Executives
60 60
Elimination Period - Accidental Injury - Sickness
29 days 90 days
Benefit Period 9 weeks maximum To Social Security
normal retirement age
Benefit Maximum -Eligible Employees -Executives
$1000 per week $6000 per month $8000 per month 17
At a cost of $19month you can enroll in the Legal Resources benefit As a Legal Resources Member you have immediate and ongoing access to comprehensive legal coverage services and expertise that will easily save you money mdash and could save you a whole lot more Covered legal services include
Legal Advice and Consultation Tenant Dispute with Landlord District Court Representation for Civil Action Review of a Financial Contract or Lease Purchase sale or refinance of primary home Traffic Court Representation (includes 1st DUI) Will Preparation Uncontested Divorce Representation Defense of Child in Court (misdemeanor)
Legal Resources
Employee Assistance Program (EAP)
Reston Association offers a free confidential Employee Assistance Program (EAP) to all employees and their eligible dependents Through RArsquos EAP provider Lytle EAP Partners you and your immediate family members have immediate access on your date of hire to confidential professional counseling and referral services for help with anything that affects you or your dependentsrsquo well-being You can reach an EAP counselor by dialing 1-800-327-7272 24 hours a day or you may visit their website at wwwLytleEAPcom (password is reston) for more information Visit wwwLytleEAPcom for web-based legal financial worklife resources There are also work-related resources available online for managers Note Since EAP services are provided as a benefit only RA makes no representation concerning quality of care
18
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Life and ADampD Insurance
Basic LifeADampD Insurance Reston Association provides 100 employer paid Life and ADampD Insurance through Sun Life to employees working 25 or more hours per week Coverage becomes effective the first of the month following six months of service
Benefit 2x Annual Earnings to a maximum of $200000 Age reduction Benefit reduced to 65 at age 65 and to 50 at age 70
Optional LifeADampD Insurance for Employee Spouse and Dependent Children
Optional Life Insurance for the employee spouse and dependent children is available at the employeersquos cost Optional Life is not available for domestic partners
Employee Benefit Increments of $10000 to a maximum of the lesser of $300000 or 3x your Basic Annual Earnings
Spouse Benefit Increments of $5000 to a maximum of $150000 Dependent Child Benefit Increments of $1000 to a maximum of $10000
Your amount of Dependent Spouse and Dependent Child Optional Life Insurance cannot exceed 50 of your amount of Optional Life Insurance Initial eligibility period will require evidence of insurability
STD amp LTD Insurance
Short Term and Long Term Disability Reston Association provides eligible employees with short and long-term disability income benefits through Sun Life In the event you become disabled from a non work-related injury or sickness disability income benefits are provided as a source of income These benefits are 100 employer paid
Benefit Short-Term Disability Long-Term Disability
Income Replacement -Eligible Employees -Executives
60 60
Elimination Period - Accidental Injury - Sickness
29 days 90 days
Benefit Period 9 weeks maximum To Social Security
normal retirement age
Benefit Maximum -Eligible Employees -Executives
$1000 per week $6000 per month $8000 per month 17
At a cost of $19month you can enroll in the Legal Resources benefit As a Legal Resources Member you have immediate and ongoing access to comprehensive legal coverage services and expertise that will easily save you money mdash and could save you a whole lot more Covered legal services include
Legal Advice and Consultation Tenant Dispute with Landlord District Court Representation for Civil Action Review of a Financial Contract or Lease Purchase sale or refinance of primary home Traffic Court Representation (includes 1st DUI) Will Preparation Uncontested Divorce Representation Defense of Child in Court (misdemeanor)
Legal Resources
Employee Assistance Program (EAP)
Reston Association offers a free confidential Employee Assistance Program (EAP) to all employees and their eligible dependents Through RArsquos EAP provider Lytle EAP Partners you and your immediate family members have immediate access on your date of hire to confidential professional counseling and referral services for help with anything that affects you or your dependentsrsquo well-being You can reach an EAP counselor by dialing 1-800-327-7272 24 hours a day or you may visit their website at wwwLytleEAPcom (password is reston) for more information Visit wwwLytleEAPcom for web-based legal financial worklife resources There are also work-related resources available online for managers Note Since EAP services are provided as a benefit only RA makes no representation concerning quality of care
18
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
At a cost of $19month you can enroll in the Legal Resources benefit As a Legal Resources Member you have immediate and ongoing access to comprehensive legal coverage services and expertise that will easily save you money mdash and could save you a whole lot more Covered legal services include
Legal Advice and Consultation Tenant Dispute with Landlord District Court Representation for Civil Action Review of a Financial Contract or Lease Purchase sale or refinance of primary home Traffic Court Representation (includes 1st DUI) Will Preparation Uncontested Divorce Representation Defense of Child in Court (misdemeanor)
Legal Resources
Employee Assistance Program (EAP)
Reston Association offers a free confidential Employee Assistance Program (EAP) to all employees and their eligible dependents Through RArsquos EAP provider Lytle EAP Partners you and your immediate family members have immediate access on your date of hire to confidential professional counseling and referral services for help with anything that affects you or your dependentsrsquo well-being You can reach an EAP counselor by dialing 1-800-327-7272 24 hours a day or you may visit their website at wwwLytleEAPcom (password is reston) for more information Visit wwwLytleEAPcom for web-based legal financial worklife resources There are also work-related resources available online for managers Note Since EAP services are provided as a benefit only RA makes no representation concerning quality of care
18
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
401(k) Retirement Savings Plan
Reston Association offers two 401(k) retirement savings plans through Ascensusmdasha traditional 401(k) plan in which employee contributions are made pre-tax and a 401(k) Roth in which employee contributions are made after tax RA matches employee contributions dollar for dollar up to a total of 7 of your annual salary You can begin making contributions to the 401(k) plan and become eligible for RArsquos match following six months of service You always own 100 of your salary contributions
It is possible to borrow against a portion of your vested 401(k) account balance by taking a 401(k) loan You may request a participant loan using an application form which can be obtained by contacting Human Resources Your ability to obtain a 401(k) loan will depend on specific qualifying factors (defined in the 401(k) Summary Plan Description document) The 401(k) Plan Administrator will determine whether you satisfy these factors To access your 401(k) plan online httpsmyaccountascensuscomrplink Check account balance and rate of return Change fund elections Request a 401k loan View fund pricing and performance View and print quarterly statements
19
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
529 College Savings Plan (employer-sponsored)
A 529 college savings plan provides those saving for college with an unmatched combination of benefits You can open a 529 plan for anyone mdash your child grandchild spouse a friend or even yourself Assets in a 529 plan can be used to pay for a variety of higher education expenses including required books tuition room and board supplies and certain other required fees and expenses Earnings in 529 accounts can grow free from federal tax Withdrawals for qualified higher education expenses are free from federal tax Option to set up recurring automatic fund transfers directly from your bank account making it easy for you to invest The account owner rather than the beneficiary maintains control of account assets and determines the timing and amount of distributions Account owners can change beneficiaries without penalty provided the new beneficiary is a member of the previous beneficiaryrsquos family For more information please contact Human Resources
Additional Benefits
Free passes for employees and their dependents to all of RArsquos pools and tennis courts as well as discounted rates for all RA Programs and Camps Some restrictions may apply
Discounted gym membership rates at the Reston YMCA and Crunch Fitness Bike Share Program - Reston Association makes bicycles and helmets available to employees to rent on a daily
basis Please contact Member Services Discounted Tennis Rackets amp Shoes ndash Employees can purchase certain tennis shoes and rackets at wholesale
prices through RArsquos Tennis Department Contact the Tennis Department for more information Discounted autohome insurance - Liberty Mutual Insurance Company partners with RA to offer all employees
discounts on automobile and homeowner insurance Contact John Valenti at JohnValentilibertymutualcom
20
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Reston Association provides generous paid time off benefits to accommodate the diverse needs of staff and to provide a positive worklife balance The amount of paid time off you earn per year is based on your years of service In addition Reston Association observes 9 paid holidays and assigns one paid floating holiday per year For more information on paid time off benefits and how to request time off please refer to the Reston Association Employee Handbook
WorkLife Balance ndash Paid Time Off (PTO)
Teleworking
The medical leave bank is available to help employees in extenuating circumstances protect their incomes by receiving paid leave once their personal PTO is used up A maximum of six (6) workweeks may be granted for each Medical Leave Bank request If additional time is necessary a new request must be made For program eligibility and criteria go to CommonHumResBenefits
Medical Leave Bank
Volunteer Release Time
On a per position basis employees may be allowed to telework for part of their workweek or in certain circumstances Such arrangements must be in compliance with the written administrative procedure including being approved in advance by the department director
Employees are encouraged to become involved in their communities lending their voluntary support to programs that enrich the quality of life and opportunities for all citizens This benefit allows employees to take paid-time off during a work day to participate in a volunteer activity that benefits the community at large Such activities are typically sponsored by a charitable or service organization or work with one or more individuals in need of assistance or special service
21
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Training amp Career Development
Reston Association offers two types of learning opportunities for employees mdashinformal and formalmdashto foster individual development and training and career planning
I Informal Learning Opportunities (individual development amp training)
Focus on individual acquiring or enhancing specific task andor process skills to perform his or her current job better Typically this type of learning is not ldquodegree- orientedrdquo
Participants may or may not receive attendance or achievement certificate
Conferences workshops seminars webinars online courses etc typically lasting a few hours to one week
Requests for this type of training should be made to your supervisor or department head
II Formal Learning Opportunities (career planning)
Professional DevelopmentCareer Planning
Formalstructured learning geared toward improving and maintaining professional competence enhancing career progression staying abreast of new technologies and best practices developing process skills andor compliance with professional regulations
Future but not degree-oriented CEUs may be earned
May lead to qualification or credential required to obtain or retain specific certification
Opportunity may range from semester-long academic course to 24 month program with wide range of content and learning experience
Tuition Reimbursement Program
Supports formal education goals (AA bachelors masters) of individual to enhance knowledge and skills in specific areaindustry
Learning must be job-related and accomplished at or through accredited learning institution or e-learning platform connected with the institution
Requests for this type of training should be made to Human Resources as soon as foreseeable to ensure best availability of funds to support reimbursement
22
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
23
Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan Individuals have 30 days from the date of this notice to request enrollment For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card
Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members Until you make this designation the medical carrier designates one for you For information on how to select a primary care provider and for a list of the participating primary care providers contact the medical insurance carrier at the number listed on your identification card
For children you may designate a pediatrician as the primary care provider You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology The health care professional however may be required to comply with certain procedures including obtaining prior authorization for certain services following a pre-approved treatment plan or procedures for making referrals For a list of participating health care professionals who specialize in obstetrics or gynecology contact the medical insurance carrier at the number listed on your identification card
OTC Drug Reimbursements for FSAsHRAsHSAs Under the new Health Care Reform law (PPACA) the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained The change does not affect insulin even if purchased without a prescription or other health care expenses such as medical devices eyeglasses contact lenses co-pays and deductibles The new standard applies only to purchases made on or after January 1 2011
A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs)
The IRS has also posted a questions and answers section on its website httpwwwirsgovnewsroomarticle0id=22730800html concerning these provisions
Patient Protection and Affordable Care Act (PPACA) Mandatory Notices
The text below is an annual open enrollment required notice
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
24
Notice of Privacy Practices
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
Our Pledge to You
This notice is intended to inform you of the privacy practices followed by the Reston Associationrsquos Employee Benefit Plan (the Plan) and the Planrsquos legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The notice also explains the privacy rights you and your family members have as participants of the Plan It is effective on April 14 2011
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy Reston Association requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule Generally protected health information is information that identifies an individual created or received by a health care provider health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions provision of health care or payment for health care whether past present or future
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule we may use or disclose your protected health information for certain purposes without your permission This section describes the ways we can use and disclose your protected health information
bull Payment We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits seek reimbursement from a third party or coordinate benefits with another health plan under which you are covered For example a health care provider that provided treatment to you will provide us with your health information We use that information in order to determine whether those services are eligible for payment under our group health plan
bull Health Care Operations We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities resolution of internal grievances and evaluating plan performance For example we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs
bull Treatment Although the law allows use and disclosure of your protected health information for purposes of treatment as a health plan we generally do not need to disclose your information for treatment purposes Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment payment and health care operations
bull As permitted or required by law We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law We are permitted by law to share information subject to certain requirements in order to communicate information on health-related benefits or services that may be of interest to you respond to a court order or provide information to further public health activities (eg preventing the spread of disease) without your written authorization We are also permitted to share protected health information during a corporate restructuring such as a merger sale or acquisition We will also disclose health information about you when required by law for example in order to prevent serious harm to you or others
The text below is an annual open enrollment required notice
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
25
Notice of Privacy Practices
bull Pursuant to your Authorization When required by law we will ask for your written authorization before using or disclosing your protected health information If you choose to sign an authorization to disclose information you can later revoke that authorization to prevent any future uses or disclosures
bull To Business Associates We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information For example we may disclose your protected health information to a Business Associate to administer claims Business Associates are also required by law to protect protected health information
bull To the Plan Sponsor We may disclose protected health information to certain employees of Reston Association for the purpose of administering the Plan These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA unless you have authorized additional disclosures Your protected health information cannot be used for employment purposes without your specific authorization
Your Rights bull Right to Inspect and Copy In most cases you have the right to inspect and copy the protected health
information we maintain about you If you request copies we will charge you a reasonable fee to cover the costs of copying mailing or other expenses associated with your request Your request to inspect or review your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to inspect and copy your health information To the extent your information is held in an electronic health record you may be able to receive the information in an electronic format
bull Right to Amend If you believe that information within your records is incorrect or if important information is missing you have the right to request that we correct the existing information or add the missing information Your request to amend your health information must be submitted in writing to the person listed below In some circumstances we may deny your request to amend your health information If we deny your request you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information
bull Right to an Accounting of Disclosures You have the right to receive an accounting of certain disclosures of your protected health information The accounting will not include disclosures that were made (1) for purposes of treatment payment or health care operations (2) to you (3) pursuant to your authorization (4) to your friends or family in your presence or because of an emergency (5) for national security purposes or (6) incidental to otherwise permissible disclosures
Your request to for an accounting must be submitted in writing to the person listed below You may request an accounting of disclosures made within the last six years You may request one accounting free of charge within a 12-month period
The text below is an annual open enrollment required notice
25
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
26
The information provided herein is intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriersadministrators For more detailed information pertaining to your employee benefit plans including limitations and exclusions
please refer to the plan documents andor evidence of coverage provided by the carriersadministrators
Womenrsquos Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womenrsquos Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for
bull All stages of reconstruction of the breast on which the mastectomy was performed bull Surgery and reconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment of physical complications of the mastectomy including lymphedema
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits call your plan administrator
CHIP-Childrens Health Insurance Program (CHIP) Reauthorization Act of 2009
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their health premiums
If you or your dependents are already enrolled in Medicaid or CHIP you can contact your state Medicaid or CHIP office to find out if premium assistance is available For a list of the contacts in each State go to wwwdolgovebsachipmodelnoticedoc
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can then contact the State to find out if it has a program that might help you pay the premiums for an employer-sponsored plan
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
The text below is an annual open enrollment required notice
26
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
27
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP you wonrsquot
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 wwwhealthcaregov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below
contact your State Medicaid or CHIP office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your
dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or wwwinsurekidsnowgov 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 arenrsquot already
enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov 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 July 31 2019 Contact your State for
more information on eligibility ndash
ALABAMA ndash Medicaid FLORIDA ndash Medicaid Website httpmyalhippcom
Phone 1-855-692-5447
Website httpflmedicaidtplrecoverycomhipp
Phone 1-877-357-3268
ALASKA ndash Medicaid GEORGIA ndash Medicaid The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website httpsmedicaidgeorgiagovhealth-
insurance-premium-payment-program-hipp
Phone 678-564-1162 ext 2131
ARKANSAS ndash Medicaid INDIANA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid
Website httpwwwindianamedicaidcom
Phone 1-800-403-0864
COLORADO ndash Health First Colorado
(Coloradorsquos Medicaid Program) amp Child Health
Plan Plus (CHP+)
IOWA ndash Medicaid
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay
711
Website
httpdhsiowagovHawki
Phone 1-800-257-8563
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
28
KANSAS ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website httpwwwkdheksgovhcf
Phone 1-785-296-3512
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345 ext 5218
KENTUCKY ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpschfskygov
Phone 1-800-635-2570
Medicaid Website
httpwwwstatenjushumanservices
dmahsclientsmedicaid
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
LOUISIANA ndash Medicaid NEW YORK ndash Medicaid
Website httpdhhlouisianagovindexcfmsubhome1n331
Phone 1-888-695-2447
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MAINE ndash Medicaid NORTH CAROLINA ndash Medicaid
Website httpwwwmainegovdhhsofipublic-assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MASSACHUSETTS ndash Medicaid and CHIP NORTH DAKOTA ndash Medicaid
Website httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
MINNESOTA ndash Medicaid OKLAHOMA ndash Medicaid and CHIP
Website
httpsmngovdhspeople-we-serveseniorshealth-carehealth-care-
programsprograms-and-servicesother-insurancejsp
Phone 1-800-657-3739
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
MISSOURI ndash Medicaid OREGON ndash Medicaid
Website httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
MONTANA ndash Medicaid PENNSYLVANIA ndash Medicaid
Website httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
Website
httpwwwdhspagovprovidermedicalassistancehealthinsuranc
epremiumpaymenthippprogramindexhtm
Phone 1-800-692-7462
NEBRASKA ndash Medicaid RHODE ISLAND ndash Medicaid and CHIP
Website httpwwwACCESSNebraskanegov
Phone (855) 632-7633
Lincoln (402) 473-7000
Omaha (402) 595-1178
Website httpwwweohhsrigov
Phone 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
29
NEVADA ndash Medicaid SOUTH CAROLINA ndash Medicaid
Medicaid Website httpsdhcfpnvgov
Medicaid Phone 1-800-992-0900
Website httpswwwscdhhsgov
Phone 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON ndash Medicaid
Website httpdsssdgov
Phone 1-888-828-0059
Website httpswwwhcawagov
Phone 1-800-562-3022 ext 15473
TEXAS ndash Medicaid WEST VIRGINIA ndash Medicaid Website httpgethipptexascom
Phone 1-800-440-0493
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
UTAH ndash Medicaid and CHIP WISCONSIN ndash Medicaid and CHIP Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
Website
httpswwwdhswisconsingovpublicationsp1p10095p
df
Phone 1-800-362-3002
VERMONTndash Medicaid WYOMING ndash Medicaid Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
VIRGINIA ndash Medicaid and CHIP Medicaid Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
Medicaid Phone 1-800-432-5924
CHIP Website
httpwwwcovervaorgprograms_premium_assistan
cecfm
CHIP Phone 1-855-242-8282
To see if any other states have added a premium assistance program since July 31 2019 or for more
information on special enrollment rights contact either
US Department of Labor US Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare amp Medicaid Services
wwwdolgovagenciesebsa wwwcmshhsgov
1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are required to respond
to a collection of information unless such collection displays a valid Office of Management and Budget (OMB)
control number The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA and displays a currently valid OMB control number and
the public is not required to respond to a collection of information unless it displays a currently valid OMB control
number See 44 USC 3507 Also notwithstanding any other provisions of law no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number See 44 USC 3512
The public reporting burden for this collection of information is estimated to average approximately seven minutes
per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US Department of
Labor Employee Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email ebsaoprdolgov and
reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 12312019)
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Notes
30
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Notes
31
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc
Prepared by
Please contact Reston Associationrsquos Human Resources Department at 703-435-7990 or hrrestonorg with any
questions related to your Total Rewards Guide
copy 2019 McGriff Insurance Services Inc