2024 Open Enrollment & Benefits Guide - Staff & Administration

2024 Open Enrollment & Benefits Guide Staff & Administration Photo by Sara Tetro, System Office

CCSNH Open Enrollment and Employee Benefits Guide – Staff & Administration Plan Year 2024

TABLE OF CONTENTS Highlights for 2024, Virtual Informational Meetings

4

Useful Contacts

5

Medical Plan Options (Anthem)

6

Medical Plan Comparison

10

Medical Plan Buy-Out Program

12

Resources to Help You Compare & Save

13

Wellness @ CCSNH

16

Dental Plan (Delta Dental)

17

Life, AD&D, LTD (Hartford)

19

Voluntary Benefits - Vision, FSAs, Supplemental Life

20

Employee Assistance Program

22

Additional Notices

23

To Do List

29

Open Enrollment for Plan Year 2024 is 11/01/23 through 11/17/23

CCSNH Open Enrollment and Employee Benefits Guide – Staff & Administration Plan Year 2024

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Highlights for 2024

Same Plans and Generous Funding

We are pleased to report that the benefits within our three medical plans remain unchanged for 2024.

CCSNH presently pays approximately 94% of plan premiums in addition to funding a Health Reimbursement Account to pay 50% of in-network plan deductibles.

Virtual Informational Meetings Friday, 11/3/2023 at 11:00 am Meeting ID: https://aleragroup.zoom.us/j/97036764144 Phone: +1 253 205 0468

Wednesday, 11/8/2023 at 2:00 pm Meeting ID: https://aleragroup.zoom.us/j/97036764144 Phone: +1 253 205 0468

CCSNH Open Enrollment and Employee Benefits Guide – Faculty Plan Year 2024

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USEFUL CONTACTS

GBCC

Diane Carroll

x7603

dscarroll@ccsnh.edu

LRCC

Karen Schaffner

x6730

kschaffner@ccsnh.edu

MCC

Jeannie DiBella

x8006

jdibella@ccsnh.edu

NCC

Cathy Barry

x1766

cbarry@ccsnh.edu

NHTI

Kirsty Hart

x4122

khart@ccsnh.edu

RVCC

Jill Spurr

x5323

jspurr@ccsnh.edu

WMCC Gretchen Taillon

x3003

gtaillon@ccsnh.edu

System Kathleen Medaglia

x7050

kmedaglia@ccsnh.edu

System Sara Sawyer

x7003

ssawyer@ccsnh.edu

A

S

D

Anthem BCBS 800.870.3122 anthem.com

SmartShopper 800.824.9127 smartshopper.com

Delta Dental 800.832.5700 nedelta.com

K

H

KGA 800.648.9557 (Employee Assistance Program)

The Hartford Group 860.547.5000 (Long-Term Disability & Life Insurance)

C

D

csONE Delta Vision 888.227.9745 x2040 866.723.0513 combinedservices.com eyemedvisioncare.com (Flexible Spending Accounts)

CCSNH Open Enrollment and Employee Benefits Guide – Staff & Administration Plan Year 2024

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MEDICAL BENEFITS CCSNH will continue to offer three medical plan options through Anthem BCBS to its benefits-eligible, full-time employees. Each health plan has a $4,000/individual and $8,000/family in-network deductible, and CCSNH provides a Health Reimbursement Account for the purpose of funding 50% of the in-network annual deductible costs. In all three plans, you benefit from your active engagement in managing your personal health, and how you access your health services. To that end, we strongly encourage you to review each plan as further described in the subsequent pages and engage in a dialogue with a member of your HR staff, our benefit plan consultant, or a representative from Anthem to ensure that you completely understand the medical benefits and the tools, resources, and support provided.

One important resource to you is anthem.com. Besides serving as a 24x7 resource to answer questions about your plan, on the website subscribers can also: • Order and print out a temporary member ID card if you lose yours • Check the status of a claim • Search for a doctor, specialist, or hospital • Learn about hundreds of health and wellness topics

Cost The medical plan rates for employees are listed on page 11. Note that employee contribution rates for the White and Purple Plan are identical, while the Green Plan (National PPO) also includes the employer premium difference between the Green Plan and the White Plan.

Eligibility Full-time staff and administrators are eligible to participate in a CCSNH medical plan the first day of the month following 30 days of full-time employment. They can enroll themselves, their spouse (and their eligible dependents) and their dependent children to age 26.

CCSNH Open Enrollment and Employee Benefits Guide – Staff & Admin, Plan Year 2024

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MEDICAL PLAN-WHITE OPTION The White Plan is a Point-of-Service Plan, meaning that it offers both in-network and out-of-network benefits, but benefits are richer when accessing in-network providers. It has a $4,000 individual deductible and an $8,000 family deductible for in-network providers; the first 50% of which is covered by CCSNH through a Health Reimbursement Account (HRA). Below is a high-level overview of the plan; a more comprehensive Summary of Benefits and Coverage is available on myCCSNH. – (CDHP Lumenos BlueChoice New England with HRA) Within the White Plan, you are 100% covered for Preventative Care. This includes: Child Preventative Care

*Office Visits for preventative services *Screening Tests for vision, hearing and lead exposure. Also includes pelvic exam and Pap tests for females who are 18, or have been sexually active * Immunizations (Hep A, Hep B, Diphtheria [Tetanus, Pertussis/DtaP],Chicken Pox, Influenza, Pneumonia, HPV-cervical cancer, H. Influenza Type B, Polio, Measles, Mumps, and Rubella (MMR))

Adult Preventative Care

*Office Visits for preventative services *Screening Tests (cholesterol and lipid level tests, colorectal cancer, prostate cancer, diabetes, and osteoporosis). Also, includes mammograms, as well as pelvic exams and Pap test. *Immunizations (Hep A, Hep B, Diphtheria [Tetanus, Pertussis/DtaP], Chicken Pox, Influenza, Pneumonia, HPV-cervical cancer)

For Other Care

First - You will use your CCSNH HRA allocation ($2,000 towards Individual Coverage, $4,000 toward Family Coverage) to pay towards covered expenses (see below).

Covered Expenses include, but are not limited to: -Physician Office Visits -Maternity Care

-Outpatient Hospital Services -Prescription Drugs -Durable Medical Equipment -Emergency Hospital Services -Inpatient and Outpatient Mental Health and Substance Abuse Services

-Inpatient Hospital Services -Diagnostic X-rays/Lab Tests -Physical, Speech, & Occupational Therapy

-Chiropractic Care -Home Health Care -Hospice Care

*Some covered services have limitations or other restrictions. Please refer to full Summary of Benefits and Coverage.

Then - If you use all the money in your HRA, you will pay out of pocket until you meet your annual deductible.

Annual Deductible

(in-network and out-of-network deductibles do not cross accumulate)

In Network $4,000 for Single $8,000 for Family

Out of Network $8,000 for Single $16,000 for Family

After - You meet your annual deductible, the plan pays 100% for network providers and 70% for out-of-network providers and your prescription costs will now be co-pays.

Prescriptions

Rx Retail: $10/$35/$50/30% coinsurance to $250 max Rx Mail (90 day fill): $20/$70/$150/limited mail order

Additional Cost Protections for You The total amount you spend out-of-pocket in this plan is limited. Once you spend that amount, the plan pays 100% of the cost of covered services for the remainder of the benefit year. Your Annual Out-of-Pocket Maximum consists of funds you spend from your HRA, your deductible responsibility, and your Rx-CoPay and/or Co-Insurance Amounts.

Annual Out-of-Pocket Maximums

In Network $6,850 Individual Coverage $13,700 Family Coverage

Out of Network $16,000 Individual $24,000 Family

The benefit summary shown above does not replace the official plan documents or contracts that govern your eligibility to participate in these plans or the amount of benefits you may receive. If there is a discrepancy between the official plan documents and this summary, your actual benefits will always be governed by the plan documents. Some of the above services may require precertification. Please confirm with Anthem.

CCSNH Open Enrollment and Employee Benefits Guide – Staff & Admin, Plan Year 2024

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MEDICAL PLAN-GREEN OPTION The Green Plan has a plan design and benefits very similar to the White Plan. The main distinction is that the Green Plan uses the broader “National” network of providers, instead of the New England network used in the White and Purple Plans. This buy-up plan (the employee contributions are higher, see rates on page 11) may be suited for those who regularly access non-emergency care outside of New England. Below is a high-level overview of the plan; a more comprehensive Summary of Benefits and Coverage is available on myCCSNH.

GREEN Plan – (CDHP Lumenos National PPO Health Plan, with HRA) Within the Green Plan, you are 100% covered for Preventative Care. This includes: Child Preventative Care

*Office Visits for preventative services *Screening Tests for vision, hearing and lead exposure. Also includes pelvic exam and Pap tests for females who are 18, or have been sexually active * Immunizations (Hep A, Hep B, Diphtheria [Tetanus, Pertussis/DtaP],Chicken Pox, Influenza, Pneumonia, HPV-cervical cancer, H. Influenza Type B, Polio, Measles, Mumps, and Rubella (MMR))

Adult Preventative Care

*Office Visits for preventative services *Screening Tests (cholesterol and lipid level tests, colorectal cancer, prostate cancer, diabetes, and osteoporosis). Also, includes mammograms, as well as pelvic exams and Pap test. *Immunizations (Hep A, Hep B, Diphtheria [Tetanus, Pertussis/DtaP], Chicken Pox, Influenza, Pneumonia, HPV-cervical cancer)

For Other Care

First - You will use your CCSNH HRA allocation ($2,000 towards Individual Coverage, $4,000 toward Family Coverage) to pay towards covered expenses (see below).

Covered Expenses include, but are not limited to: -Physician Office Visits -Maternity Care

-Outpatient Hospital Services -Prescription Drugs -Durable Medical Equipment -Emergency Hospital Services -Inpatient and Outpatient Mental Health and Substance Abuse Services

-Inpatient Hospital Services -Diagnostic X-rays/Lab Tests -Physical, Speech, & Occupational Therapy

-Chiropractic Care -Home Health Care -Hospice Care

*Some covered services have limitations or other restrictions. Please refer to full Summary of Benefits and Coverage.

Then - If you use all the money in your HRA, you will pay out of pocket until you meet your annual deductible.

Annual Deductible (in-network and out-of-

network deductibles do not cross accumulate)

In Network $4,000 for Single $8,000 for Family

Out of Network $8,000 for Single $16,000 for Family

After - You meet your annual deductible, the plan pays 100% for network providers and 70% for out-of-network providers.

Additional Cost Protections for You The total amount you spend out-of-pocket in this plan is limited. Once you spend that amount, the plan pays 100% of the cost of covered services for the remainder of the benefit year. Your Annual Out-of-Pocket Maximums consists of funds you spend from your HRA, your deductible responsibility and your Co-Insurance Amounts.

Annual Out-of-Pocket Maximums

In Network $6,850 Individual Coverage $13,700 Family Coverage

Out of Network $16,000 Individual $24,000 Family

The benefit summary shown above does not replace the official plan documents or contracts that govern your eligibility to participate in these plans or the amount of benefits you may receive. If there is a discrepancy between the official plan documents and this summary, your actual benefits will always be governed by the plan documents. Some of the above services may require precertification. Please confirm with Anthem.

CCSNH Open Enrollment and Employee Benefits Guide – Staff & Admin, Plan Year 2024

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MEDICAL PLAN-PURPLE OPTION The Purple Plan is an Access Blue New England HMO Site of Service Plan, which is a health plan designed to reward members for using lower cost health care providers (e.g., independent labs are no cost to plan members). It requires up front copayments for doctor visits, specialty care, outpatient surgical (approved facilities), and prescriptions. However, none of these expenses are applied to your deductible, meaning that the funding by CCSNH for your HRA is preserved for other medical expenses that are subject to your plan deductible. Below is a high-level overview of the plan; a more comprehensive Summary of Benefits and Coverage is available on myCCSNH.

PURPLE Plan (Access Blue New England HMO Site of Service, with HRA) Services Covered 100% for Preventative Care Child Preventative Care

*Office Visits for preventative services *Screening Tests for vision, hearing and lead exposure. Also includes pelvic exam and Pap tests for females who are 18, or have been sexually active * Immunizations (Hep A, Hep B, Diphtheria [Tetanus, Pertussis/DtaP],Chicken Pox, Influenza, Pneumonia, HPV-cervical cancer, H. Influenza Type B, Polio, Measles, Mumps, and Rubella (MMR))

Adult Preventative Care

*Office Visits for preventative services *Screening Tests (cholesterol and lipid level tests, colorectal cancer, prostate cancer, diabetes, and osteoporosis). Also, includes mammograms, as well as pelvic exams and Pap test. *Immunizations (Hep A, Hep B, Diphtheria [Tetanus, Pertussis/DtaP], Chicken Pox, Influenza, Pneumonia, HPV-cervical cancer)

Lab tests furnished by an independent laboratory provider

Services Subject to Co-Payment Only Medical exams, injections (including allergy injections), office surgery and anesthesia Surgery and anesthesia in an independent ambulatory surgery center Physical/Occupational/Speech therapy (up to 20 visits per therapy, per member, per calendar year) Urgent care facility charge Chiropractic visit (chiropractic x-ray subject to deductible) Prescriptions

$25 per visit to your PCP $50/Visit to Specialist or Network Walk-In Center $125 per admission $50 per visit $125 per visit $50 Rx Retail: $10/$35/$50/30% coinsurance to $250 max Rx Mail (90 day fill): $20/$70/$150/limited mail order

Services Subject to Deductible You will use your HRA allocation from CCSNH to pay towards deductible expenses (see below). If you use all the money in your HRA, you will pay out of pocket until you meet your annual deductible. $2,000 HRA towards Individual Coverage $4,000 towards Family Coverage Lab tests furnished by a non-independent lab provider

Deductible

Urgent Care physician fee, CT scan, MRI

Deductible

Inpatient and Outpatient Hospitalization Emergency Room Services

Deductible $250 co-pay plus Deductible

Other services in Certificate of Coverage Annual Deductible

Deductible In Network $4,000 for Single $8,000 for Family

After you meet your annual deductible, you will continue to be responsible for any applicable copayments until you meet the out-ofpocket maximum of $6,600 (single) / $13,200 (family)

The benefit summary shown above does not replace the official plan documents or contracts that govern your eligibility to participate in these plans or the amount of benefits you may receive. If there is a discrepancy between the official plan documents and this summary, your actual benefits will always be governed by the plan documents. Some of the above services may require precertification. Please confirm with Anthem.

CCSNH Open Enrollment and Employee Benefits Guide – Staff & Admin, Plan Year 2024

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MEDICAL PLAN COMPARISON Benefits

In Network Deductible(s) Plan Deductible Health Reimbursement Account Out of Pocket Maximum Physician Office Visits Primary Office Specialist Office Chiropractic Hospital Services Inpatient Hospitalization Outpatient Hospitalization Emergency Room Urgent Care Pharmacy Benefits Deductible Applies?

Tier 1: Generic Tier 2: Preferred Brand Name Tier 3: Brand Name Tier 4: Specialty Other Benefits Preventative Care Services Outpatient Surgery / Select Locations Independent Laboratory Services Hospital Laboratory Services X-Ray, MRI, CT Scan, PET Scan Vision Examination Durable Medical Equipment Non Network Benefits Deductible Coinsurance Out of Pocket Limit Network Network

High Deductible WHITE

High Deductible GREEN

Site of Service PURPLE

$4,000 (2x Family) $2,000 (2x Family) $6,850 (2x Family)

$4,000 (2x Family) $2,000 (2x Family) $6,600 (2x Family)

Deductible Deductible Deductible

$25 $50 $50 (unlimited)

Deductible Deductible Deductible Deductible

Deductible Deductible $250 Copay + Deductible $125 Copay + Deductible

YES $10 (2x Mail, 90 day) $35 (2x Mail, 90 day) $50 (3x Mail, 90 day) 30% coinsurance, $250 max. (limited mail order)

$0 $0 $0 $0

NO $10 (2x Mail, 90 day) $35 (2x Mail, 90 day) $50 (3x Mail, 90 day) 30% coinsurance, $250 max. (limited mail order)

100%

100%

Deductible

$125 Copay

Deductible Deductible Deductible $0 (every 2 years) Deductible

100% Deductible Deductible $0 (every 2 years) $100 Deductible then 20%

$8,000 (2 per family) 30% $16,000 single / $24,000 family

None None None

New England

National

CCSNH Open Enrollment and Employee Benefits Guide – Staff & Admin, Plan Year 2024

New England

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MEDICAL PLAN EMPLOYEE CONTRIBUTIONS Bi-Weekly, Pre-Tax Payroll Deductions (calculated based on 26 pay periods) Single Employee + Family Coverage 1 Coverage Coverage White Plan (CDHP Lumenos BlueChoice New England, with HRA)

$33.00

$55.00

$71.50

$114.05

$231.70

$305.26

$33.00

$55.00

$71.50

GREEN Plan * (CDHP Lumenos National PPO Health Plan, with HRA)

PURPLE Plan (Access Blue New England HMO Site of Service, with HRA)

Employee Premium Contributions for the White Plan and Purple Plan listed above became effective with the 1/27/2023 pay date. These employee contributions amounts may be subject to change pursuant to the in-force collective bargaining agreement or Board approval, as applicable. *Employee Premium Contributions for the Green Plan listed above reflect the monthly premium rate adjustment for the 2024 calendar year and will be effective with the 1/26/2024 pay date. These employee contributions amounts may be subject to change pursuant to the in-force collective bargaining agreement or Board approval, as applicable.

CCSNH Open Enrollment and Employee Benefits Guide – Staff & Admin, Plan Year 2024

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MEDICAL PLAN BUY-OUT PROGRAM CCSNH has a Medical Buy-Out Program that allows benefits-eligible full-time employees to receive a generous incentive payment for waiving your CCSNH health (medical and pharmacy) insurance benefits, should you elect available group coverage elsewhere. For a full-time employee who waives the medical benefit because they are either insured through a spouse’s or parent’s employer provided non-CCSNH group health plan, or through a group plan available through other employment, s/he will receive: • $2,000/annually, when Employee Only coverage is waived • $3,000/annually, when Employee + 1 coverage is waived • $4,000/annually, when Family coverage is waived Payments are made on a bi-weekly basis in your payroll check and are subject to the tax laws of the Internal Revenue Service (IRS) as they apply to taxable fringe benefits. Please see below for answers to Frequently Asked Questions about the program.

When can I enroll?

Now, because it is Open Enrollment, and during the plan year only if a Qualifying Event occurs. New employees may also enroll within 30 calendar days after being eligible to receive CCSNH health benefits coverage. Annual enrollment in the medical insurance buy-out program is required.

How do I do so?

To enroll in the program, an employee must complete the Medical Buy-Out Enrollment/Change Form and submit the completed form, along with proof of other medical coverage to Human Resources. An employee, including current participants, must also elect (or re-elect) this option on the CCSNH Employee Self Service Portal at https://my.adp.com by the Open Enrollment deadline of Friday, November 17, 2023. CCSNH medical coverage will not be terminated until other eligible coverage is in effect, appropriate documentation has been submitted, and such documentation has been approved by the CCSNH. Once I enroll, can I reinstate my CCSNH medical benefits?

Yes. As an active employee, you may withdraw from the buy-out program during Open Enrollment or during the plan year based on a Qualifying Event. To withdraw during the plan year, you must experience a Qualifying Event and provide proof of loss of coverage within 31 days after that loss.

Can I participate in the Medical Buy-Out Program and still elect the dental benefit?

Yes. CCSNH Open Enrollment and Employee Benefits Guide – Staff & Admin, Plan Year 2024

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LIVEHEALTH ONLINE Given the rapid growth of telemedicine, we are pleased to highlight a way for you to access convenient and affordable care through Anthem BCBS – LiveHealth Online.

Using LiveHealth Online, you can have a video visit with a doctor or therapist on your smartphone, tablet or computer with a webcam that includes: •

Immediate access to board-certified doctors 24/7. It’s a great option for care when your doctor isn’t available. Doctors using LiveHealth Online can provide medical care for common conditions, like the flu, colds, pink eye and more.

•

The ability to have prescriptions sent to the pharmacy of your choice. Doctors in NH have the ability to prescribe medicine, based on the online visit. And they’ll even send prescriptions to the pharmacy of your choice, if needed.

Employees enrolled in the White Plan (CDHP Lumenos BlueChoice New England), or Green Plan (CDHP Lumenos National PPO) will pay $55 at the time of service and can submit for reimbursement from their HRA afterward (contingent on available funds). Employees enrolled in the Purple Plan (Access Blue New England HMO Site of Service) will be charged only $10. Lastly, all other employees, full and part-time, that are not on our plans can also access the service for a flat fee of $55.

It’s quick and easy to sign up and get started. Just go to livehealthonline.com or download the mobile app.

CCSNH Open Enrollment and Employee Benefits Guide – Staff & Admin, Plan Year 2024

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SMARTSHOPPER If you are enrolled in a CCSNH Anthem plan, SmartShopper is a voluntary program to help you be a savvy medical consumer by reminding you that you have choices when it comes to your health care. If your doctor recommends a particular medical service, SmartShopper can tell you how much that test or procedure costs at different in-network facilities in your area. If you choose a cost-effective option, you can qualify for a cash reward.

SmartShopper is provided as part of your Anthem plan at no additional cost to you. Rewards range from $25 to $1,000, and reward checks are mailed within 45 to 60 days of claim payment.

All health centers suggested by SmartShopper are part of the Anthem network and have met strict quality standards. The locations are well-known and fully licensed to provide services.

Register at smartshopper.com or contact the SmartShopper Personal Assistant team at 1-800-824-9127 to learn

more about the dozens of services eligible for rewards.

CCSNH Open Enrollment and Employee Benefits Guide – Staff & Admin, Plan Year 2024

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OTHER RESOURCES TO HELP YOU COMPARE & SAVE As healthcare costs continue to rise, it is becoming more and more important for us to become educated consumers regarding our medical plan usage. This includes accessing tools that help us research cost and quality of healthcare and exploring alternatives to care. Below are a specific resources available to you through our health plan and other free resources dedicated to lowering your out-of-pocket costs.

NH HealthCost (nhhealthcost.nh.gov) was developed by the New Hampshire Insurance Department to improve the price transparency of health care services in New Hampshire. It allows you to compare the estimated cost of healthcare procedures by medical provider or facility and using claims data from the New Hampshire Comprehensive Health Information System database.

GoodRx (goodrx.com) was founded on the principle to enable smarter consumers to make better choices. It allows you to search by location to find out different prices of medications at local pharmacies and when discount coupons are available

Lastly, we are fortunate to have built a partnership with ConvenientMD (convenientmd.com), a New Hampshire-based company that provides timely treatment of non-life threatening injuries and illnesses at low-cost, walk-in urgent care centers. ConvenientMD has locations in Bedford, Belmont, Concord, Dover, Exeter/Stratham, Keene, Littleton, Londonderry, Manchester, Merrimack, Nashua, Portsmouth, and Windham/Greater Salem. As many of our employees are on the White plan whose services are initially funded 50% from an HRA, ConvenientMD has provided cards for these plan participants that ensure that our employees will never be charged up front. To pick up a card, stop by your HR office.

CCSNH Open Enrollment and Employee Benefits Guide – Staff & Admin, Plan Year 2024

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WELLNESS @ CCSNH As part of the CCSNH Community, you have access to a robust wellness program to improve your physical and mental well-being.

Fitness Reimbursement Programs Eligible CCSNH employees enrolled in an Anthem medical plan can take advantage of one of the following two fitness reimbursement programs each year.

Anthem Fitness Reimbursement Program Receive reimbursement of up to $450 per subscriber per calendar year (January 1-December 31) for membership dues at fitness clubs when they work out a minimum of eight times per month. A qualified fitness facility must include equipment for both cardiovascular and strength training and require a member to pay membership dues.

Anthem Home Exercise Equipment Reimbursement Program Receive reimbursement of up to $200 per subscriber per calendar year (January 1-December 31) for the purchase of home exercise equipment that provides a cardiovascular/muscular total-body workout.

Community Health Education Reimbursement Programs CCSNH Anthem subscribers are eligible for reimbursement of up to $150 per family per calendar year for fees related to classes or group therapy for Smoking Cession, Nutrition Education, Weight Management, Stress Management, Physical Activity, Childbirth Education, and Parenting Education.

Campus Wellness Committees Campuses and the system office have employee-driven wellness committees. Get involved! Activities range from fitness programs and competitions to guest speakers on wellness and nutrition.

Wellness Incentives for Anthem Subscribers Prevention, Wellness, and Condition Management Incentives – Engagement Package 700 Participate and complete a wide variety of condition management, preventative care, and wellness activities.

Earn Up to $700 in a Gift Card Rewards

CCSNH Open Enrollment and Employee Benefits Guide – Staff & Admin, Plan Year 2024

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DENTAL PLAN - DELTA DENTAL The Delta Dental plan offered through CCSNH features 100% coverage for diagnostic/preventive care, three cleanings per calendar year, 80% coverage for basic restorative care, and 50% coverage for major restorative care up to calendar year maximum of $2,000 per person (all services combined).

In addition, the plan offers 50% orthodontia coverage for both adults and eligible children, up to a $1,500 lifetime maximum.

Members are free to visit any dentist, though you’ll get your best value with less hassle when you receive care from a Delta Dental PPO or Delta Dental Premier participating dentist. This is because participating dentists have agreed upon Delta Dental’s approved amounts for service so there will be no balance billing, and Delta Dental pays the dentist directly so there are no claim forms. Find participating dentists, look up benefits and claims, or access your ID cards on nedelta.com or on the Delta Dental app.

The following page contains a summary of benefits but to best understand how to use the plan as well as the specific benefits and plan provisions, please refer to the Dental Plan Description booklet posted on myCCSNH. Cost (Bi-Weekly Pre-Tax Employee Payroll Deductions) Level Employee Employee + 1 Family

Rate* $3.50 $6.00 $9.50

*Effective with 1/27/23 pay date and subject to change pursuant to the in-force collective bargaining agreement or Board approval, as applicable.

Eligibility - Full-time staff and administrators are eligible to participate in a CCSNH dental plan the first day of the month following 30 days of full-time employment. They can enroll themselves, their spouse (and their eligible dependents) and their dependent children to age 26.

CCSNH Open Enrollment and Employee Benefits Guide – Staff & Admin, Plan Year 2024

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DENTAL PLAN - DELTA DENTAL Diagnostic/Preventative Coverage A Deductible: None

Basic Restorative Coverage B

*Covered at 100%

*Covered at 80%

Diagnostic: Evaluations, 2x/calendar yr.

Basic Restorative: Amalgam(silver) fillings; Composite (white) fillings (anterior teeth only)

X-rays

Major Restorative Coverage C Deductible: $25 per person/calendar yr.** *Covered at 50%

Orthodontics Coverage D Deductible: None

Major Restorative Removable and fixed partial dentures (bridge)

Orthodontics:

*Covered at 50%

Correction of (crooked) teeth for adults and eligible children.

Complete dentures

Complete series or panoramic film, once in a 5 yr. period; bitewings, 2x/calendar yr.; x-rays of individual teeth as needed.

Preventative Cleanings, 3x/calendar yr.

Fluoride, 1x/calendar yr. to age 18

Space maintainers 1x/lifetime to age 16

Sealant application to permanent molars, 1x/three yr. period per tooth to age 19

Oral Surgery: Surgical and routine extractions Endodontics: Root canal therapy

Restorative Crowns Onlays Implants

Emergency Palliative Treatment Periodontics: Treatment of gum disease Periodontal cleaning (maintenance procedures) Note: Cleanings are limited to three in a calendar year; these may be routine (Coverage A) or periodontal (Coverage B), or a combination of both.

Clinical crown lengthening - once per lifetime per site.

Denture Repair: Repair of a removable denture to its original condition Rebase and reline (dentures)

Calendar Yr. Maximum: $2,000 per person (Coverages A, B, and C combined)

Lifetime Max: $1,500

*Benefit percentages are based upon the actual charges submitted up to the Maximum Allowable Charge for participating providers or Northeast Delta Dental’s allowance for non-participating providers. **Any expense incurred during the last 3 months of a calendar year which is applied against an individual’s deductible will also reduce his/her deductible for the next calendar year.

CCSNH Open Enrollment and Employee Benefits Guide – Staff & Admin, Plan Year 2024

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BASIC TERM LIFE/AD&D AND LONG-TERM DISABILITY CCSNH provides Basic Life and Accidental Death and Dismemberment (AD&D) and Long Term Disability (LTD) insurance benefits through the Hartford Insurance Company.

Basic Life Insurance is equal to one time (1X) an employee's basic annual earnings to a maximum of $300,000; the minimum benefit is $25,000. Basic Life features include, but are not limited to: • Continuation of Life insurance while totally disabled (as defined by the Group Policy) • Accelerated Benefits Option • Conversion and Portability AD&D features include, but are not limited to: • 100% of the Basic Life Benefit • Continuation of Life insurance while totally disabled (as defined by the Group Policy) • Portability • Funeral planning and grief counseling services Note: There is an age reduction formula for Basic Life and AD&D of 50% at age 70.

In addition to the above, employees are automatically eligible for Travel Assistance services with Hartford’s AD&D coverage. Travel Assistance, administered by Generali Global Assistance, Inc., is a valuable benefit which offers employees and their dependents medical, travel, legal, financial and concierge services, 24 hours a day, 365 days a year while traveling internationally or domestically.

The Long-Term Disability Plan coverage provides income replacement equal to 60% of monthly earnings with a maximum monthly benefit of $6,000. The waiting period is 180 calendar days (6 months). Eligible employees are automatically enrolled in this 100% company-paid plan.

Hartford also offers additional disability plan benefits to help you return to work and financial incentives and assistance in obtaining Social Security Benefits to help you get the maximum benefits from your coverage.

Eligibility Active, eligible full-time employees are automatically enrolled in this 100% company-paid plan on the first of the month following 30 days of employment.

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VISION PLAN – DELTA VISION Delta Vision is a voluntary, 100% employee-paid comprehensive vision plan with a network of both independent providers and retail chains through the EyeMed Vision Care network. This represents almost 88,000 providers nationwide including the most popular optical retail outlets such as LensCrafters, Target Optical, Sears Optical, JCPenney Optical and many Pearle Vision locations.

Below is a high-level overview of the plan benefits. For a more detailed summary, visit myCCSNH. Services Every 12 Months

Network

Non-Network (Reimbursement)

Annual Vision Exam

$10 Copay

$35 allowance

Frames

$130 Allowance, then 20% off balance

$65 allowance

Standard Plastic Lens

$25 Copay

Single: $25 allowance Bi-focal: $40 allowance Tri-focal: $55 allowance

Contact Lenses (in place of frame lenses)

$130 Allowance, then 15% off balance

Conventional: $104 allowance Disposable: $104 allowance

Like your medical and dental contribution, your vision premiums will be deducted bi-weekly from your pay on a pre-tax basis. The premium rates remain the same for 2024.

Cost (Bi-Weekly Pre-Tax Employee Payroll Deductions) Level Employee Employee + 1 Family

Rate $3.57 $6.12 $10.96

Eligibility Full-time staff and administrators are eligible to participate in a CCSNH voluntary vision plan the first day of the month following 30 days of full-time employment. They can enroll themselves, their spouse (and their eligible dependents) and their dependent children to age 26.

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FLEXIBLE SPENDING ACCOUNTS CCSNH offers you the opportunity to participate in a Health Care Reimbursement Account and/or a Dependent Care Reimbursement Account through csONE Benefit Solutions (previously Combined Services). These flexible spending accounts provide you a way to pay for eligible out-of-pocket health care not covered by your health plan and/or dependent care expenses on a pre-tax basis through payroll deductions, up to the IRS allowable limits. This means that contributions to your FSA are deducted before taxes are calculated on your pay. Examples of expenses that can be covered by a Health Care FSA include co-payments and deductibles, vision care, acupuncture, non-covered dental and orthodontia care. Examples of expenses that can be covered by a Dependent Care FSA include licensed day care or nursery schools and dependent care in your home. Eligible dependents must be under the age of 13, or incapable of self-care.

Please note that any unused funds that remain at the end of the 2024 calendar year beyond a permissible $610 rollover for the health care FSA, are forfeited per IRS regulations. Keep track of your account by using the csONE app. This rollover may be subject to change pursuant to IRS regulations.

Health Care FSA Dependent Care FSA

Administration Fee, paid by employee $3.65/month $3.65/month

Minimum Annual Contribution $200 $200

Maximum Annual Contribution *$3,050 $5,000

Rollover $610* n/a

*Please note that the IRS may increase the maximum allowable annual contribution and rollover amount for 2024.

SUPPLEMENTAL LIFE INSURANCE During Open Enrollment, or anytime throughout the year, current employees can enroll in or increase their current supplemental life insurance policy, subject to evidence of insurability. Supplemental life insurance, offered through Hartford, provides you the peace of mind of knowing that your family or close friends can continue to lead the lifestyle you have provided them while not burdening them with any debts. Supplemental coverage is voluntary, 100% employee paid, and deducted from your paycheck on a post-tax basis. This coverage is in addition to basic Life and AD&D (accidental death and dismemberment) insurance, which the CCSNH provides for you at no cost equal to one time (1x) your basic annual earnings to a maximum of $300,000. All coverage has an evidence of insurability requirement.

If you purchase additional coverage for yourself, you can also purchase spousal coverage to a maximum of $100,000 and life insurance of $3,000 for your eligible children.

For more information on Supplemental Life and AD&D coverage and rates visit myCCSNH. CCSNH Open Enrollment and Employee Benefits Guide – Staff & Admin, Plan Year 2024

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EMPLOYEE ASSISTANCE PROGRAM CCSNH partners with KGA Employee Assistance and Work-Life Program to address the full range of personal or professional challenges employees may experience to include stress, life event changes, relationship issues, and health concerns.

KGA features: • Live 24/7 support • Face-to-face consultation sessions for employees and their household members • Legal and financial consultation • Childcare and eldercare information and resources • Crisis management services • An employee-accessible website with online resources, referral services and training

In addition, managers and supervisors can avail themselves of expert consultation regarding workforce performance and risk management issues.

Connect with a counselor by calling: 1.800.648.9557

Access resources online at: https://kgreer.com (company code: CCSNH)

Maintenance of confidentiality is one of the most important aspects of EAP. Asserting and maintaining the confidentiality of employees’ participation in the program is the cornerstone of professional ethics as well as federal and state regulations that apply to EAP's. Confidentiality in the EAP will be maintained within the rules established by federal and state law and professional ethical standards. Disclosure of information shared by the employee to any source without the prior written consent of that employee is prohibited. This means that the fact that an employee has consulted with EAP, as well the details of the conversation, are usually protected against disclosure.

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ADDITIONAL NOTICES Please note the following required notifications: • • • • • • • • • • • • • •

Summary of Benefits and Coverage Women’s Health and Cancer Rights Act Preventive Care Services Health Insurance Marketplace Coverage Notice Newborns’ and Mothers’ Health Protection Act COBRA Continuation Coverage Rights HIPAA Special Enrollment Rights Medicaid and the Children’s Health Insurance Program (CHIP) Medicare Part D Prescription Drug Coverage Michelle’s Law Notice Medical Loss Ratio (MLR) Rule HIPAA Privacy Practices Rights & Protections Against Surprise Medical Bills Wellness Program Notice For more information regarding your health plan please contact your CCSNH Benefits Administrator Sara Sawyer at (603) 230-3503 or via email at ssawyer@ccsnh.edu

---------------------------------------------------------------------------------------------------------------------------------------------Summary of Benefits & Coverage of Health Insurance Under the Affordable Care Act, health insurers and group health plans will provide the 180 million Americans who have private insurance with clear, consistent, and comparable information about their health plan benefits and coverage. Under the law, insurance companies and group health plans will provide consumers with a concise document detailing, in plain language, simple and consistent information about health plan benefits and coverage.

This summary of benefits and coverage document will help consumers better understand the coverage they have and, for the first time, allow them to easily compare different coverage options. It will summarize the key features of the plan or coverage, such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions.

An SBC must be provided to all “participants and beneficiaries” without charge regardless of group size and/or the employee’s intent to elect or waive benefits. Participants include employees or retirees who are, or may become, eligible for a benefit under the plan; beneficiaries include the participant’s dependents that may be entitled to coverage under the plan. SBCs should be provided at the following times: -Initial enrollment: An SBC for each benefit package option for which the participant becomes eligible (e.g., new hires, qualifying status changes) must be included in any distribution of enrollment materials. If written enrollment materials are not distributed, the SBC must be furnished no later than the first date the individual is eligible to enroll in coverage.

-Open enrollment: An SBC for the benefit package option in which the participant is enrolled must be CCSNH Open Enrollment and Employee Benefits Guide – Staff & Admin, Plan Year 2024

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included with other open enrollment materials and will be posted on myCCSNH. The regulations provide that if reenrollment is automatic, the SBC must be provided no later than 30 days before the beginning of the next plan year.

-HIPAA special enrollment: Generally, an SBC for the benefit package option in which a special enrollee enrolls must be provided no later than 90 days after enrollment (the same time frame for providing an SPD). However, individuals who have not yet enrolled may request an SBC for any benefit package option at any time. These SBCs must be furnished as described below.

-On request: An SBC must be provided as soon as practical (but no more than seven business days) after a request.

--------------------------------------------------------------------------------------------------------------------------------------------Women’s Health and Cancer Rights Act (WHCRA) If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: -All stages of reconstruction of the breast on which the mastectomy was performed; -Surgery and reconstruction of the other breast to produce a symmetrical appearance; -Prostheses; and Treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under a CCSNH medical plan. Refer to the Anthem Blue Cross Blue Shield SBC (Summary of Benefits and Coverage) for specific member cost share effective January 1, 2024, that is available at myCCSNH. --------------------------------------------------------------------------------------------------------------------------------------------Health Insurance Preventive Care Services Legislation The Affordable Care Act – the health insurance reform legislation passed by Congress and signed into law by President Obama on March 23, 2010 – helps make prevention affordable and accessible for all Americans by requiring health plans to cover preventive services and by eliminating cost sharing for those services.

Preventive services that have strong scientific evidence of their health benefits must be covered and plans can no longer charge a patient a copayment, coinsurance, or deductible for these services when they are delivered by a network provider. Details on the specific preventive care services included, at no cost to members, through your Anthem Blue Cross Blue Shield health insurance plan.

--------------------------------------------------------------------------------------------------------------------------------------------New Health Insurance Marketplace Coverage Notice The Marketplace is designed to help individuals find health insurance that meets their needs and budget. The Marketplace offers “one-stop shopping” to find and compare private health insurance options. For 2024, open enrollment for health insurance coverage through the Marketplace will be from November 1, 2023, through December 15, 2023, for coverage starting January 1, 2024.

The Marketplace can help you evaluate your coverage options, including eligibility for coverage and costs. Please visit www.healthcare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.

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-------------------------------------------------------------------------------------------------------------------------------------------Newborns’ and Mothers’ Health Protection Act (NMHPA) The Newborns’ and Mothers’ Health Protection Act of 1996 (the Newborns’ Act), signed into law on September 26, 1996, requires plans that offer maternity coverage to pay for at least a 48-hour hospital stay following a vaginal delivery or 96-hour stay following a cesarean section. This law was effective for group health plans for plan years beginning on or after January 1, 1998. On October 27, 1998, the Department of Labor, in conjunction with the Departments of the Treasury and Health and Human Services, published interim regulations clarifying issues arising under the Newborns’ Act. The changes made by the regulations are effective for group health plans for plan years beginning on or after January 1, 1999.

The Newborns’ Act and its regulations provide that health plans and insurance issuers may not restrict a mother’s or newborn’s benefits for a hospital length of stay that is connected to childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section. However, the attending provider (who may be a physician or nurse midwife) may decide, after consulting with the mother, to discharge the mother or newborn child earlier.

The Newborns’ Act, and its regulations, prohibits incentives (either positive or negative) that could encourage less than the minimum protections under the Act as described above. A mother cannot be encouraged to accept less than the minimum protections available to her under the Newborns’ Act and an attending provider cannot be induced to discharge a mother or newborn earlier than 48 or 96 hours after delivery. The type of coverage provided by the plan (insured or self-insured) and state law will determine whether the Newborns’ Act applies to a mother’s or newborn’s coverage.

-------------------------------------------------------------------------------------------------------------------------------------------Continuation Coverage Rights Under COBRA The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because a life event referred to as a “qualifying event.” COBRA continuation coverage can become available to you and other members of your family for a specified period of time, with such coverage paid for by the recipient. For additional information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the CCSNH Benefit Administrator.

-------------------------------------------------------------------------------------------------------------------------------------------HIPAA Special Enrollment Rights If you decline coverage for you or your dependents (including your spouse) because of other health insurance coverage, you may be eligible to enroll yourself and your dependents in a CCSNH health plan if you or your dependents lose eligibility for that other coverage. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be eligible to enroll yourself and your dependents. You must request enrollment within 30 days for the qualifying event.

If your or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or become eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll in a CCSNH health plan. You must request enrollment within 60 days of the loss of Medicaid or CHIP or the determination of eligibility for a premium assistance subsidy.

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-------------------------------------------------------------------------------------------------------------------------------------------Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) Maine, Massachusetts, Vermont and New Hampshire Offer Free or Low-Cost Health Coverage to Children and Families If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, but are unable to afford the premiums, 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 are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance programs, but you may be able to by individual insurance coverage through the Health Insurance Marketplace. For more information visit www.healthcare.gov.

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

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

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2023. You should contact your state for further information on eligibility.

MAINE - Medicaid Phone: 1-800-977-6740

VERMONT -Medicaid TTY: Maine relay 711

Phone: 1-800-250-8427

Website: www.maine.gov/dhhs/ofi/applications-forms

Website: www.dvha.vermont.gov/members/medicaid/hipp-program

MASSACHUSETTS - Medicaid and CHIP

NEW HAMPSHIRE – Medicaid

Phone: 1-800-862-4840

Phone: 603-271-5218 HIPP Toll Free: 1-800-852-3345, ext. 5218

TTY: MA relay 711

Website: www.mass.gov/masshealth/pa

Website: www.dhhs.nh.gov/programs-services/medicaid/healthinsurance-premium-program

*To view additional states that have added a premium assistance program since July 31, 2023, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 www.dol.gov/agencies/ebsa www.cms.hhs.gov ----------------------------------------------------------------------------------------------------------------------------------------------CCSNH Open Enrollment and Employee Benefits Guide – Staff & Admin, Plan Year 2024

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Prescription Drug Coverage and Medicare Employees, their spouses, and other dependents who will be or currently are 65 years old or older within the next year PLEASE READ If you or any of your dependents is Medicare Part D eligible and considering enrolling in the CCSNH Prescription Drug Coverage, please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the CCSNH and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1.

Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2.

CCSNH has determined that the prescription drug coverage offered by the CCSNH’s Group Health Plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

Joining a Medicare Drug Plan - You can join a Medicare drug plan when you first become eligible for Medicare and each year from OCTOBER 15th until DECEMBER 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

Your Current Coverage and a Medicare Drug Plan - If you decide to join a Medicare drug plan, your CCSNH coverage will not be affected. Please see your Anthem Blue Cross Blue Shield SBC (Summary of Benefits and Coverage) plan description for more detail to compare the plan provisions/options between your CCSNH plan and the Medicare Part D coverage. You may also contact the Human Resources Department for more information and answers to your questions.

If you decide to join a Medicare drug plan and drop your CCSNH coverage, be aware that you and your dependents may or may not be able to get this coverage back, see your Anthem Blue Cross Blue Shield SBC (Summary of Benefits and Coverage) plan description for verification or contact your Human Resources Department for more information.

When Will You Pay a Higher Premium (Penalty) To Join a Medicare Drug Plan? - You should also know that if you drop or lose your current coverage with CCSNH and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a Penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as CCSNH Open Enrollment and Employee Benefits Guide – Staff & Admin, Plan Year 2024

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you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For more detailed information about Medicare prescription drug coverage visit www.medicare.gov or call 1-800MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For more information about this extra help, visit Social Security on the web at www.socialsecurity.gov or call 1-800-772-1213 (TTY 1-800-325-0778).

----------------------------------------------------------------------------------------------------------------------------------------------Michelle’s Law Notice When a dependent child over the age of 26 loses student status under the eligibility policy of CCSNH group health plan coverage, as a result of a medically necessary leave of absence from a post-secondary educational institution, the CCSNH group health plan will continue to provide coverage during the leave of absence for the earlier end date of up to one year, or until coverage would otherwise terminate under the CCSNH group health plan.

To maintain eligibility, continue coverage as a dependent during such leave of absence: •

The CCSNH Group Health Plan must receive written confirmation by a treating physician of the dependent child which states that the child is suffering from a serious illness or injury and that the leave of absence (or other change of enrollment) is medically necessary; and

•

The dependent is established as a disabled dependent as defined by the medical carriers.

----------------------------------------------------------------------------------------------------------------------------------------------Medical Loss Ratio (MLR) Rule Notice The Affordable Care Act requires health insurers to spend at least 85% of the premiums received on health care services and activities to improve health care quality for large group markets. This referred to as the “Medical Loss Ratio” standard or the 85/15 rule, which is intended to ensure that consumers receive value for their health care dollars. The Medical Loss Ratio rule is calculated on a state-by-state basis. If a health insurer does not spend at least 85% of the premiums it receives on health care services and activities to improve health care, the insurer must rebate the difference to the employer.

---------------------------------------------------------------------------------------------------------------------------------------------HIPAA Privacy Practices Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) the CCSNH health plans have established privacy practices regarding your 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.

Under the HIPAA Privacy Rule, CCSNH health plans may use or disclose your protected health information for certain purposes without your permission. The ways we can use and disclose your protected health information in order to provide payment for health services; to perform administrative functions; to provide treatment; as permitted or required by law; to business associates; to the plan sponsor; or pursuant to your authorization.

Under the HIPAA Privacy Rule, you possess the right to inspect an copy the protected health information that health CCSNH Open Enrollment and Employee Benefits Guide – Staff & Admin, Plan Year 2024

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plan maintains about you; to request that incorrect information is corrected or that missing information is added to your record; to receive an accounting of certain disclosures; to request the information for treatment, payment, or other administrative purposes is not used or disclosed unless specifically authorized by you, when required by law, or in emergency circumstances; to receive confidential communications containing your health information; and to be notified in the event of a breach of our unsecured protected health information, which will be made in accordance with federal requirements.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your records you may contact Sara Sawyer, CCSNH Director of Human Resources. You may also send a written complaint to the US Department of Health and Human Services – Office of Civil Rights. For further information visit www.hhs.gov/ocr. You will not be penalized or retaliated against for filing a complaint.

---------------------------------------------------------------------------------------------------------------------------------------------Rights and Protections Against Surprise Medical Bills Included in the Consolidated Appropriations Act 2021 were requirements for health plans to provide protections against Surprise Medical Bills. These protections apply to services received on or after January 1, 2022.

“Out-of-network” describes providers and facilities that haven’t signed a contract with a CCSNH health plan. Out-ofnetwork providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount of the charged service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward you annual out-of-pocket.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care – like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

If you have an emergency medical condition and get emergency services from an out-of-network provider of facility, the most the provider or facility may bill you is your plan’s in-network cost sharing amount (such as copayments and coinsurance). You cannot be balance billed for these emergency services. This includes services you get after you are in a stable condition, unless you give written consent and give up your protections not to be balanced bill for the post stabilization services. If you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. The most these providers can bill you is your plan’s in-network cost-sharing amount.

These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you believe you have been wrongly billed, you may contact the U.S. Department of Health & Human Services at 1877-696-6775 or your State Insurance Commissioner.

---------------------------------------------------------------------------------------------------------------------------------------------Wellness Program Notice Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact Sara Sawyer, CCSNH Director of Human Resources, and CCSNH will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status.

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TO DO LIST: o Review this Benefits Guide and share it with your family. This Guide provides important information about your benefit options and their related costs. o If you are unclear about some of the terminology used, review this Glossary of Health Coverage and medical Terms. o

Attend one of the Open Enrollment presentations.

o If you are a current participant in the medical plan, use this once-a-year opportunity (outside of a qualified event) to transition to another plan, should you choose to do so. If you would like to make a change, you must select a new plan on the CCSNH Employee Self Service Portal at https://my.adp.com by the Open Enrollment deadline of Friday, November 17, 2023. If you would like to remain in the same medical plan with the same elections, your coverage will continue uninterrupted. o If you are a current participant in the Medical Buy Out Program or wish to enroll for the 2024 plan year, you must enroll/re-enroll by submitting a new Medical Insurance Buy-Out Enrollment/Change Form with proof of other non-CCSNH medical coverage. You will also need to elect this option on the CCSNH Employee Self Service Portal at https://my.adp.com by the Open Enrollment deadline of Friday, November 17, 2023. o If you are a current participant in Delta Vision Plan or Flexible Spending Account program or wish to enroll for the 2024 plan year , you must enroll/re-enroll on the CCSNH Employee Self Service Portal at https://my.adp.com by the Open Enrollment deadline of Friday, November 17, 2023. o If you are a current participant in the Delta Dental plan and/or Supplemental Life Insurance programs and wish to continue participation with no changes, you need not do anything as your coverage will continue uninterrupted. New enrollees or those interested in making changes must do so on the CCSNH Employee Self Service Portal. o Get additional information and download any necessary forms by logging on to myCCSNH. o Ask questions. If you have additional questions after reading this Benefits Guide, contact any member of the Human Resources staff. o Verify your elections. Don’t forget to carefully check your pay stub to make sure you are enrolled for the benefits you elected. If you have questions or believe there is an error, contact Human Resources immediately.

About this Benefits Guide This Benefits Guide is not intended to be, nor shall it be construed as, a contract of any type. It highlights features of CCSNH’s health plans, and it is not intended to cover the programs in detail. Every effort has been made to ensure the accuracy of the information presented however in the event of discrepancies, your coverage will be determined by the legal plan documents that govern the plan.

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