2024-2025 Midwest Mole, Inc. Benefits Guide

Welcometothe2024-2025MidwestMoleEmployee BenefitsGuide.Thisguideoffersyouandyourfamily membersalookintoyourcomprehensivebenefits program.Weencourageyoutotakethetimeto educateyourselfaboutyouroptionsandchoosethe bestcoverageoptionsforyouandyourfamily.We haveincludedbriefdescriptionsofourbenefit offeringsandthecost.Ifyouhaveanyquestions, pleasecontactMidwestMole’sHumanResources Department.

Benefitsfor2024-2025Introduction

AsanemployeeofMidwestMole,enjoyingyourworkandmakingvaluablecontributionsto businessareequallyvital.Thehealth,satisfactionandsecurityofyouandyourfamilyare important,notonlytoyourwell-being,butultimately,intermsofachievingthegoalsofour organization.

Forthe2024-2025planyear,MidwestMolehasworkedhardtoofferacompetitivetotal rewardspackagethatincludesvaluableandcompetitivebenefitsplans.Theseprograms reflectourcommitmenttokeepingourstaffhealthyandsecure.Weunderstandthatyour situationisunique,andMidwestMoleisofferinganoverallbenefitspackagethatcanbe shapedandmoldedbyyoutofityourneeds.

ThisbenefitsbookletisasummarydescriptionofyourMidwestMolebenefitplans.Ifthereis adiscrepancybetweenthesesummariesandthewrittenlegalplandocuments,theplan documentsshallprevail.Thisbookletandplansummariesdonotconstituteacontractof employment.

Wehopethisbenefitsbooklet,alongwithouradditionalcommunicationanddecisionmakingtools,willhelpyoumakethebesthealthcarechoicesforyouandyourfamily.

UpdateOnHealthCareReform

EffectiveJanuary1,2019theTaxCutsandJobsAct(TJCA) repealedtheindividualmandatetomaintainhealth insuranceorberesponsiblefora“sharedresponsibility payment”.Wehopetokeepofferingthesebenefitsasa valuablepartofyourtotalcompensationinthefuture. However,becauseweofferyoucoveragethatsatisfiesall thehealthreformrequirements,youwillnotqualifyforany federalassistancetopurchaseanindividualorfamilypolicy ontheopenmarket(the“marketplace”).

2024-2025Overview

MidwestMoleprovidesanarrayofbenefitsthatcanhelpyouenjoyincreasedwell-being, dealwithanunexpectedillnessoraccident,buildandprotectyourfinancialsecurity, balanceyourpersonalandprofessionallifeandmeeteverydayneeds.Thesebenefitsare affordable,comprehensiveandcompetitive.

Thetablebelowsummarizesthebenefitsavailabletoeligiblestaffandtheirdependents.

Regularfull-timeemployeesworking30ormorehoursperweekareeligibletoenrollin benefits.

Youmayalsoenrollthefollowingfamilymembers:

•Yourlegalspouse

•Yourchildrenunderage26

•Yourunmarriedchildrenwhoareage26orolderandmentallyorphysicallydisabled

Childrenincludeyournaturalchildren,adoptedchildren,step-childrenwhoyousupport, andchildrencoveredunderachildsupportorder.

2024-2025Overview(continued)

ChangesandQualifyingEvents

WhenCoverageBegins

Anewlyhiredemployeemaychoosebenefitplansthatwillbeeffectiveonthe1st ofthemonthfollowing30daysofemployment.Failuretoelectbenefitswithin30 daysofbecomingeligiblewillresultinforfeitureofcoverageandyouwillnot haveanotheropportunitytoenrolluntiltheannualenrollment,unlessyou experienceaQualifyingEvent.

QualifyingEvents

Eligibleemployeesmayenrollormakechangestotheirbenefitselectionsduring theannualopenenrollmentperiod.Aswithmostbenefits,onceyouelectan optionyouareboundtothatchoicefortheentireplanyearunlessyou experiencea“QualifyingEvent”.Thesemayinclude,butarenotlimitedto:

Changesinemploymentstatus

Changesinlegalmaritalstatus

Changesinnumberofdependents

Takinganunpaidleaveofabsence

Dependentsatisfiesorceasestosatisfyeligibilityrequirement

FamilyMedicalLeaveAct(FMLA)leave.

ACOBRA-qualifyingevent

EntitlementtoMedicareorMedicaid

Achangeintheplaceofresidenceoftheemployee,resultinginthe currentcarriernotbeingavailable

MedicalBenefits

HealthSavingsAccount(HSA)

ThisishowanHSAworks:

Ahealthsavingsaccount(HSA)isahealthcareaccountandsavingsaccountinone.Themain purposeofthisaccountistooffsetthecostofaqualifyinghighdeductiblehealthplan(HDHP)and providesavingsforyourout-of-pocketeligiblehealthcareexpenses–thoseyouandyourtax dependentsmayhavenow,inthefuture,andduringyourretirement.

Thisisa“portable”account.YouownyourHSA!It’sincludedinyouremployeebenefitspackage,but afteryousetupyouraccount,it’syourstokeep,evenifyouchangejobsorretire.

OnceyourHSAisestablished,moneyiscontributedtoyouraccountbyyou,friendsand/orfamily, andyoucanthenuseyourHSAdollarstax-freetopayforeligiblehealthcareexpenses.Yousave moneyonexpensesyou’realreadypayingfor,likedoctors’officevisits,prescriptiondrugs,and muchmore.Bestofall,youdecidehowandwhentouseyourHSAdollars.

AnnualContributionLimit:

Forthe2024planyeartheIRShassetthemaximumHSAcontributionforasingleat$4,150and familyat$8,300.Forthoseage55+,theIRSallowsanadditional$1,000“catch-up”contribution.

WhyisitagoodideatohaveanHSA?

HSAsbenefiteveryonewhoiseligibletohavethisaccount–singleindividuals,families,andsoonto-beretirees.Yousavemoneyontaxesinthreeways:

•Tax-freedeposits–ThemoneyyoucontributetoyourHSAisn’ttaxed(uptotheIRSannuallimit).

•Tax-freeearnings–Yourinterestandanyinvestmentearningsgrowtax-free.

•Tax-freewithdrawals–Themoneyusedtowardeligiblehealthcareexpensesisn’ttaxed–nowor inthefuture.

•Settingasidepre-taxdollarsintoyourHSAmeansyoupayfewertaxesandincreaseyourtakehomepaybyyourtaxsavings.Yousavemoneyoneligibleexpensesthatyouarepayingforoutof yourpocket.Theamountyousavedependsonyourtaxbracket.Forexample,ifyouareinthe30 percenttaxbracket,youcansave$30onevery$100spentoneligiblehealthcareexpenses.

HSAfundsrolloverfromyeartoyearandaccumulateinyouraccount.Thereisno“use-it-or-lose-it” rulewithHSAs,andyoudecidehowandwhentouseyourHSAfunds,whichcanbeusedfor eligibleexpensesyouhavenow,inthefuture,orduringretirement.Andwhenyouhaveacertain balanceinyourHSA,investmentopportunitiesareavailable.

PrescriptionDrugChanges

InmovingourmedicalandpharmacycoveragetoAnthemthefollowing medicationswillchangetiers.Ifyoutakeanyofthesemedications,you’llwant tobepreparedforthesechangeseffectiveJuly1,2024.Ifthemedicationisin green,itisatalowercosttoyou,ifitisred,youwillexperienceapossible increaseincost.

TheValueofPreventativeCare

Understandingthefullvalueofcoveredbenefitsallowsyoutotakeresponsibilityfor maintaininggoodhealthandincorporatinghealthyhabitsintoyourlifestyle.Some examplesincludegettingregularphysicalexaminations,mammogramsand immunizations.

ThroughtheplansofferedbyMidwestMole,allcoveredindividualsandfamilymembersare eligibletoreceiveroutinewellnessserviceslikethese,atnocost;allcopays,coinsurance,and deductiblesarewaived.

WhichPreventiveCareServicesAreCovered?

TheUSPreventiveServicesTaskForcemaintainsaregularlistofrecommendedservices thatallACA-compliantinsuranceplansshouldcoverat100%within-networkproviders. Belowisalistofcommonservicesthatareincludedintheplansofferedthisyear:

RoutinePhysicalExam

WellBabyandChildCare

WellWomanVisits

Immunizations

RoutineBoneDensityTest

RoutineBreastExam

RoutineGynecologicalExam

ScreeningforGestational Diabetes

ObesityScreeningand Counseling

RoutineDigitalRectalExam

RoutineColonoscopy

RoutineColorectalCancerScreening

RoutineProstateTest

RoutineLabProcedures

RoutineMammograms

RoutinePapSmear

SmokingCessationPrograms

HealthEducation/CounselingServices

HealthCounselingforSTDsandHIV

TestingforHPVandHIV

ScreeningandCounselingforDomestic Violence

SupplementalInsurance

Principal CriticalIllness

CriticalIllnessinsuranceismeanttopayyouacashbenefitbasedontheselectedamount ofcoveragechosenduringenrollmentshouldyouoracoveredfamilymemberdevelops certainillnesses.Examplesofcertaincoveredillnessesarelistedbelow.

Childrenareautomaticallycoveredfor25%ofanemployee’sbenefitatnocosttoyou GuaranteeIssueisthemaximumscheduledbenefitavailableduringtheinitial enrollmentperiodwithnoproofofgoodhealthrequired.

Principal

BasicLife/AD&D

LifeInsuranceisanimportantpartofyourfinancialwell-being,especiallyifothersdepend onyouforsupport.MidwestMoleprovidesBasicTermLifeandAD&Dinsuranceatno costtoyou.

ShortTermDisability

MidwestMoleprovidesshorttermdisabilitycoveragetohelpprovidepaycheckreplacement moniesintheeventyouaredisabled.Thisinsuranceisprovidedatnocosttoyou.

DentalCoverage

Principal

DentalcoverageisofferedthroughPrincipalandutilizesthePrincipalDPPO network.ToFindaProviderinyourarea,pleasevisitwww.principal.com/dentist

VisionCoverage VSP(throughPrincipal)

VisioncoverageisofferedthroughPrincipalandutilizestheVSP(VisionServicePlan) network.ToFindaProviderinyourarea,pleasevisitwww.vsp.com

VoluntaryLifeInsurance

VoluntaryGroupTermLife

MidwestMolealsoprovidesyouwiththeopportunitytopurchaseadditionallifeinsurance throughPrincipal.Premiumsarebasedonageandamountofinsurance.

$110,000Employee/$30,000spouse

AvailableinIncrementsof$5,000 Employeemustelectcoveragetocovera spouse

$100,000(NottoExceed100%ofEE election)

$5,000or$10,000 Employeemustelectcoveragetocover dependentchildren

VoluntaryLifeInsurance

Note:Proofofgoodhealth/evidenceof insurabilityisrequiredtoapplyforbenefit amountsgreaterthanthosehighlightedhere.

Ifyouragechangestoadifferentrateband duringtheguaranteeperiod,yourpremium willchangetoreflectthenewrateband effectiveofonthenextpolicyanniversary date.

Thissummaryisnotacompletestatement oftherights,benefits,limitationsand exclusionsofthecoveragedescribedhere. Forcostandcoveragedetails,contact PrincipalLifeInsuranceCompany.

PrincipalisissuedbyPrincipalLife InsuranceCompany,711HighSt,Des Moines,IA50392

Age-BasedReductions

VoluntaryLifeInsurance

Note:Proofofgoodhealth/evidenceof insurabilityisrequiredtoapplyforbenefit amountsgreaterthanthosehighlightedhere.

Ifyouragechangestoadifferentrateband duringtheguaranteeperiod,yourpremium willchangetoreflectthenewrateband effectiveofonthenextpolicyanniversary date.

Thissummaryisnotacompletestatement oftherights,benefits,limitationsand exclusionsofthecoveragedescribedhere. Forcostandcoveragedetails,contact PrincipalLifeInsuranceCompany.

PrincipalisissuedbyPrincipalLife InsuranceCompany,711HighSt,Des Moines,IA50392

Age-BasedReductions

MidwestMoleofferseligibleemployeesandthefamilymemberslivingintheirhouseholdsan EmployeeAssistanceProgramwithNewAvenues,Inc.

NewAvenuesoffersconfidentialcounselingthroughanetworkoflicensedclinicianslocated closetoyourhomeorworkplace.Thesetrainedprofessionalsarereadytohelpyoudealwith familyorwork/lifeissuesthatmaybecausingyourlifetofeeloutofbalance.

Allservicesarestrictlyconfidentialandatnocosttotheemployeeorfamilymembers.

CommonQuestions…

WHOISELIGIBLE?

•Allfull-timeandpart-timeemployeesandthefamilymemberslivingintheirhouseholds.

•Dependentsuptoage26,notlivinginthehomeoftheemployee,areeligibleifonthe employee’shealthinsurance.

•PerDiem,temporaryemployees,volunteers,andstudent/internsareexcluded.

•Startsfirstdateofactiveemployment.

•Eligibilityrunsthroughthelastdayofemployment.

•ServiceswillonlybecoverediftheemployeecallsNewAvenuesforauthorizationpriortotheir firstsession.

WITHWHATTYPESOFPROBLEMSCANNEWAVENUESCOUNSELORSHELP?

•StressAnxietyWorkplaceIssues

•Marriage/Family/Relationshipproblems

•PersonalConcernsSubstanceAbuseGrief

HOWMANYCOUNSELINGSESSIONSDOIHAVE?

Thereare3Face-to-FaceEAPsessionsperemployeefamilypercontractyear. ThecontractyearrunsfromApril1stthroughMarch31st.

WHATIFINEEDMORETHAN3SESSIONS?

OnceyouhaveusedyourEAPsessions,youareresponsibleforfeesincurredforadditional sessions.Youmaychoosetocontinueservicesunderthetermsofyourhealthplanbenefit. (SeeyourhealthplanSPDforadescriptionofcoveredservices).NewAvenuesmakesevery attempttoarrangeyourEAPsessionswithacounselorwhoisinyourhealthplannetworkso youmaycontinuewiththesameperson.

HOWDOIACCESSMYFACE-TO-FACEEAPSESSIONS?

JustcallNewAvenuesat:800-731-6501or574-232-2131.Selectoption#2.Servicesarestrictly confidentialandthereisnoout-of-pocketcosttoyouortoyourfamilymembers.

Inadditiontoface-to-facecounseling,NewAvenuesofferstelephoniccounseling(855-492-3625) aswellasanarrayofonlinesupportservicesavailable24/7.

YoumayalsodownloadtheiCONNECTYOUAppfromtheAppStore(iphone)orGooglePlay (android)andregisterusingthepasscode34952tohave24/7accesstomentalhealth professionals.

Aweb-basedinformationcentercontainingawealthofarticles,usefultips,interactivetoolsand linksaswellasaccesstoStructuredTelephonicCounseling(855-492-3625)offeringlivecounselors thatcanbeaccessed24/7fromthecomfortofyourhome.

NEWAVENUESPROVIDERDIRECTORY:

AlistingoflicensedandcredentialedcounselorsandtherapistsintheNewAvenuesEAPNetwork.

ComplianceNotices

NoticeofSpecialEnrollmentRights

Ifyouaredecliningenrollmentforyourselforyourdependents(includingyourspouse)becauseofotherhealthinsuranceor grouphealthplancoverage,youmaybeabletoenrollyourselfandyourdependentsinthisplanifyouoryourdependents loseeligibilityforthatothercoverage(oriftheemployerstopscontributingtowardyouroryourdependents’othercoverage). However,youmustrequestenrollmentwithin30daysafteryouroryourdependents’othercoverageends(orafterthe employerstopscontributingtowardtheothercoverage).Inaddition,ifyouhaveanewdependentasaresultofmarriage, birth,adoption,orplacementforadoption,youmaybeabletoenrollyourselfandyourdependents.However,youmust requestenrollmentwithin30daysafterthemarriage,birth,adoption,orplacementforadoption.

Ifyouaredecliningenrollmentforyourselforyourdependents(includingyourspouse)whilecoverageunderMedicaidora stateChildren’sHealthInsuranceProgram(CHIP)isineffect,youmaybeabletoenrollyourselfandyourdependentsin thisplanifyouoryourdependentsloseeligibilityforthatothercoverage.However,youmustrequestenrollmentwithin60 daysafteryouroryourdependents’MedicaidorCHIPcoverageends.Ifyouoryourdependents(includingyourspouse) becomeeligibleforastatepremiumassistancesubsidyfromMedicaidoraCHIPprogramwithrespecttocoverageunder thisplan,youmaybeabletoenrollyourselfandyourdependents(includingyourspouse)inthisplan.However,youmust requestenrollmentwithin60daysafteryouoryourdependentsbecomeeligibleforthepremiumassistance.

NoticeofPatientProtection

Ifyourhealthplangenerallyrequiresthedesignationofaprimarycareprovider,youhavetherighttodesignateanyprimary careproviderwhoparticipatesinournetworkandwhoisavailabletoacceptyouoryourfamilymembers.Forchildren,you maydesignateapediatricianastheprimarycareprovider.Untilyoumakethisdesignation,thehealthplangenerallymay designateoneforyou.Forinformationonhowtoselectaprimarycareprovider,andforalistoftheparticipatingprimary careproviders,contactyourplanadministratororyourHumanResourcesDepartment.

Youdonotneedpriorauthorizationfromthehealthplanorfromanyotherperson(includingaprimarycareprovider)in ordertoobtainaccesstoobstetricalorgynecologicalcarefromahealthcareprofessionalinournetworkwhospecializesin obstetricsorgynecology.Thehealthcareprofessional,however,mayberequiredtocomplywithcertainprocedures, includingobtainingpriorauthorizationforcertainservices,followingapre-approvedtreatmentplan,orproceduresfor makingreferrals.Foralistofparticipatinghealthcareprofessionalswhospecializeinobstetricsorgynecology,contactyour planadministratororHumanResourcesDepartment.

Women’sHealthandCancerRightsActNotice

Ifyouhavehadoraregoingtohaveamastectomy,youmaybeentitledtocertainbenefitsundertheWomen’sHealthand CancerRightsActof1998(WHCRA).Forindividualsreceivingmastectomy-relatedbenefits,coveragewillbeprovidedina mannerdeterminedinconsultationwiththeattendingphysicianandthepatient,for:

•Allstagesofreconstructionofthebreastonwhichthemastectomywasperformed;

•Surgeryandreconstructionoftheotherbreasttoproduceasymmetricalappearance;

•Prostheses;and

•Treatmentofphysicalcomplicationsofthemastectomy,includinglymphedema.

Thesebenefitswillbeprovidedsubjecttothesamedeductiblesandcoinsuranceapplicabletoothermedicalandsurgical benefitsprovidedunderthisplan.IfyouwouldlikemoreinformationonWHCRAbenefits,contactthePlanAdministrator.

Newborns’andMothers’HealthProtectionActNotice

Grouphealthplansandhealthinsuranceissuersgenerallymaynot,underFederallaw,restrictbenefitsforanyhospital lengthofstayinconnectionwithchildbirthforthemotherornewbornchildtolessthan48hoursfollowingavaginaldelivery, orlessthan96hoursfollowingacesareansection.However,Federallawgenerallydoesnotprohibitthemother'sor newborn'sattendingprovider,afterconsultingwiththemother,fromdischargingthemotherorhernewbornearlierthan48

27 ComplianceNotices

hours(or96hoursasapplicable).Inanycase,plansandissuersmaynot,underFederallaw,requirethataproviderobtain authorizationfromtheplanortheinsuranceissuerforprescribingalengthofstaynotinexcessof48hours(or96hours).

Michelle’sLawNotice

Michelle’sLawwassignedintolaweffectiveJanuary1,2010.Thislawgenerallyallowsseriouslyillorinjuredfulltime collegestudents,whoarecoveredundertheirparent’shealthinsuranceplan,totakeuptooneyearofmedicallynecessary leaveofabsenceiftheleavenormallywouldcausethedependentchildtoloseeligibilityforcoverageundertheplandueto lossofstudentstatus.FortheMichelle’sLawextensionofeligibilitytoapply,adependentchild’streatingphysicianmust providewrittencertificationofmedicalnecessity(i.e.,certificationthatthedependentchildsuffersfromaseriousillnessor injurythatnecessitatestheleaveofabsenceorotherenrollmentchangethatwouldotherwisecauselossofeligibility).

*UnderthePatientProtectionandAffordableCareAct,grouphealthplansarerequiredtooffercoveragetodependent childrenuptoage26,regardlessofstudentstatus.

HIPAANoticeofPrivacyPractices

TheHealthInsurancePortabilityandAccountabilityActof1996("HIPAA")requiresthatwemaintaintheprivacyofprotected healthinformation,givenoticeofourlegaldutiesandprivacypracticesregardinghealthinformationaboutyouandfollowthe termsofournoticecurrentlyineffect.Participantsininsuredgrouphealthplansmayalsoreceiveanoticeofprivacy practicesfromthoseplans.YoumayrequestacopyofthecurrentPrivacyPractices,explaininghowmedicalinformation aboutyoumaybeusedanddisclosedandhowyoucangetaccesstothisinformation.

AsRequiredbyLaw.WewilldiscloseHealthInformationwhenrequiredtodosobyinternational,federal,stateorlocallaw. Youhavetherighttoinspectandcopy,righttoanelectroniccopyofelectronicmedicalrecords,righttogetnoticeofa breach,righttoamend,righttoanaccountingofdisclosures,righttorequestrestrictions,righttorequestconfidential communications,righttoapapercopyofthisnoticeandtherighttofileacomplaintifyoubelieveyourprivacyrightshave beenviolated.

GeneticInformationNondiscriminationActof2008(GINA)

TheGeneticInformationNondiscriminationActof2008(“GINA”)prohibitsthePlanfromdiscriminatingagainstindividualson thebasisofgeneticinformationinprovidinganythebenefitsunderincludedbenefitplans.GINAgenerally:

•ProhibitsthePlanfromadjustingpremiumorcontributionamountsforagrouponthebasisofgeneticinformation;

•ProhibitsthePlanfromrequestingormandatingthatanindividualorfamilymemberofanindividualundergoagenetic test,providedthatsuchprohibitiondoesnotlimittheauthorityofahealthcareprofessionaltorequestanindividualto undergoagenetictest,orprecludeagrouphealthplanfromobtainingorusingtheresultsofagenetictestinmakinga determinationregardingpayment;

•AllowsthePlantorequest,butnotmandate,thataparticipantorbeneficiaryundergoagenetictestforresearch purposesifthePlandoesnotusetheinformationforunderwritingpurposesandmeetscertaindisclosurerequirements; and

•ProhibitsthePlanfromrequesting,requiring,orpurchasinggeneticinformationforunderwritingpurposes,orwithrespect toanyindividualinadvanceoforinconnectionwithsuchindividual’senrollment.

MentalHealthParityActNotice

TheMentalHealthParityAct(“MHPA”)requiresthattheannualorlifetimedollarlimitsonmentalhealthbenefitsmaynotbe lowerthananysuchdollarlimitsforhealthandsurgicalbenefitsofferedbyagrouphealthplanorhealthinsuranceissuer offeringcoverageinconnectionwithagrouphealthplan.ThelifetimelimitceasedtoapplyeffectiveJanuary1,2011andthe annuallimitceasedtoapplyeffectiveJanuary1,2014.Beginningwiththe2010planyear,federallawalsowillrequirethat plansprovidingbothhealth/surgicalandmentalhealthbenefitsmaynotimposemorerestrictivefinancialrequirements(such asdeductiblesandcopayments)andtreatmentlimitations(suchaslimitsondaysofcoverage)onmentalhealthbenefits thanareimposedonhealth/surgicalbenefits.

ComplianceNotices

AQualifiedMedicalChildSupportOrder(QMCSO)isacourtorderoranorderissuedbyastateadministrativeagencyin accordancewithfederalandstatelawsthatrequiresanalternatebeneficiary(forexample,achildorstepchild)tobe coveredbyaplanparticipant’sgrouphealthplan.ThePlanhonorsQMCSOsthatmeetthelegalrequirementsforsuch orders.ItisimportanttonotethataQMCSOcannotrequireaplantoprovideatypeorformofbenefit,oranoption,thatis notcurrentlyavailablefromtheplantowhichtheorderisdirected,unlessreceivingthisbenefitoroptionisnecessaryto meettherequirementsoftheSocialSecurityAct,whichrelatestotheenforcementofstatechildsupportlawsand reimbursementofMedicaid.AQMCSOmustbeprovidedtothePlanAdministratortodetermineifitmeetsthelegal requirementsforaQMCSO.Ifitdoes,thealternatebeneficiaryisconsideredabeneficiaryforthepurposesofERISAandis enrolledasadependentoftheemployeeparticipant.IfthePlanAdministratorreceivesamedicalchildsupportorderthat relatestoyou,youwillbenotifiedandtheninformedofthedecisionastowhethertheorderisqualified.

UniformedServicesEmploymentandReemploymentRightsAct(USERRA)

Continuationandreinstatementrightsmayalsobeavailableifyouareabsentfromemploymentduetoserviceinthe uniformedservicespursuanttotheUniformedServicesEmploymentandReemploymentRightsActof1994(USERRA).If youtakeleaveunderUSERRA,totheextentrequiredbyUSERRA,yourEmployermaycontinuetomaintainyourbenefits onthesametermsandconditionsasifyouwerestillanactiveemployee.

EmployeesgoingintoorreturningfromserviceintheuniformedservicesmayhavePlanrightsmandatedbyUSERRA. TheserightsapplyonlytoemployeesandtheirdependentscoveredunderthePlanbeforetheemployeeleftformilitary service.TobeentitledtoUSERRArights,theemployeemustgivetheemployeradvancednoticeoftheemployee’sabsence fromemploymentforuniformedservice,unlessprecludedbymilitarynecessityorifitisotherwiseimpossibleor unreasonableunderallthecircumstances.Additionally,subjecttocertainexceptions,theemployee’sabsencefromwork maynotexceedfiveyears.

USERRArightsincludeupto24monthsofcontinuedhealthcarecoverage.Forperiodsofleavelessthan31days,the employeeonlyneedstopayhisorhernormalportionofthepremium.Forperiodsofleave31daysormore,coveragewill onlybeextendeduponpaymentoftheentirecostofcoverageplusareasonableadministrativefee.

IfyoucomplywithUSERRAuponreturningtoactiveemploymentaftermilitaryservice,youmayre-enrollyourselfandyour eligibledependentsinhealthcoverageimmediatelyuponreturningtoactiveemployment,evenifyouandyoureligible dependentsdidnotelectUSERRAcontinuationcoverageduringyourmilitaryservice.Reinstatementwilloccurwithoutany waitingperiodsorpre-existingconditionexclusions,exceptforillnessesorinjuriesconnectedtothemilitaryservice.

USERRArightsterminateiftheemployee’sdischargefromtheuniformedservicewasaresultof“dishonorable”orother undesirableconduct,theemployeefailstoreportbacktoworkorapplyforreemploymentwithinthetimeperiodrequired underUSERRA,oriftheemployeefailstopaycoveragepremiums.

ThetimeperiodswithinwhichtoelectandpayforUSERRAcontinuationofcoverageshallbethesametimeperiodswithin whichtoelectandpayforCOBRAcoverageunderthePlan.IfbothUSERRAandCOBRAapply,anelectionfor continuationcoveragewillbeanelectiontotakeconcurrentCOBRA/USERRAcoverage.Notealsothatstatelawmay providecontinuationand/orconversioncoverage.

ComplianceNotices

PremiumAssistanceUnderMedicaidandtheChildren’sHealthInsuranceProgram(CHIP) IfyouoryourchildrenareeligibleforMedicaidorCHIPandyou’reeligibleforhealthcoveragefromyouremployer,your statemayhaveapremiumassistanceprogramthatcanhelppayforcoverage,usingfundsfromtheirMedicaidorCHIP programs.Ifyouoryourchildrenaren’teligibleforMedicaidorCHIP,youwon’tbeeligibleforthesepremiumassistance programsbutyoumaybeabletobuyindividualinsurancecoveragethroughtheHealthInsuranceMarketplace.Formore information,visitwww.healthcare.gov.

IfyouoryourdependentsarealreadyenrolledinMedicaidorCHIPandyouliveinaStatelistedbelow,contactyourState MedicaidorCHIPofficetofindoutifpremiumassistanceisavailable.

IfyouoryourdependentsareNOTcurrentlyenrolledinMedicaidorCHIP,andyouthinkyouoranyofyourdependents mightbeeligibleforeitheroftheseprograms,contactyourStateMedicaidorCHIPofficeordial1-877-KIDSNOWor www.insurekidsnow.govtofindouthowtoapply.Ifyouqualify,askyourstateifithasaprogramthatmighthelpyoupay thepremiumsforanemployer-sponsoredplan.

IfyouoryourdependentsareeligibleforpremiumassistanceunderMedicaidorCHIP,aswellaseligibleunderyour employerplan,youremployermustallowyoutoenrollinyouremployerplanifyouaren’talreadyenrolled.Thisiscalleda “specialenrollment”opportunity,andyoumustrequestcoveragewithin60daysofbeingdeterminedeligiblefor premiumassistance.Ifyouhavequestionsaboutenrollinginyouremployerplan,contacttheDepartmentofLaborat www.askebsa.dol.govorcall1-866-444-EBSA(3272).

Ifyouliveinoneofthefollowingstates,youmaybeeligibleforassistancepayingyouremployerhealthplan premiums.ThefollowinglistofstatesiscurrentasofJanuary31,2024.ContactyourStateformore informationoneligibility.

ALABAMA-Medicaid

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

ARKANSAS–Medicaid

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

COLORADO–HealthFirstColorado(Colorado’s MedicaidProgram)&ChildHealthPlanPlus(CHP+)

HealthFirstColoradoWebsite: https://www.healthfirstcolorado.com/ HealthFirstColoradoMemberContactCenter: 1-800-221-3943/StateRelay711 CHP+:https://hcpf.colorado.gov/child-health-plan-plus CHP+CustomerService:1-800-359-1991/StateRelay711 HealthInsuranceBuy-InProgram (HIBI):https://www.mycohibi.com/ HIBICustomerService:1-855-692-6442

ALASKA-Medicaid

TheAKHealthInsurancePremiumPaymentProgram Website:http://myakhipp.com/ Phone:1-866-251-4861

Email:CustomerService@MyAKHIPP.com MedicaidEligibility: https://health.alaska.gov/dpa/Pages/default.aspx

CALIFORNIA–Medicaid

HealthInsurancePremiumPayment(HIPP)Program Website:http://dhcs.ca.gov/hipp Phone:916-445-8322

Fax:916-440-5676

Email:hipp@dhcs.ca.gov

FLORIDA–Medicaid

Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery. com/hipp/index.html Phone:1-877-357-3268

ComplianceNotices

GEORGIA–Medicaid

GAHIPPWebsite:https://medicaid.georgia.gov/healthinsurance-premium-payment-program-hipp

Phone:678-564-1162,Press1

GACHIPRAWebsite:

https://medicaid.georgia.gov/programs/third-partyliability/childrens-health-insurance-program-reauthorization-act2009-chipra

Phone:(678)564-1162,Press2

IOWA–MedicaidandCHIP(Hawki)

MedicaidWebsite:

https://dhs.iowa.gov/ime/members

MedicaidPhone:1-800-338-8366

HawkiWebsite:http://dhs.iowa.gov/Hawki HawkiPhone:1-800-257-8563

HIPPWebsite:https://dhs.iowa.gov/ime/members/medicaid-ato-z/hipp

HIPPPhone:1-888-346-9562

KENTUCKY–Medicaid

KentuckyIntegratedHealthInsurancePremiumPayment Program(KI-HIPP)Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone:1-855-459-6328

Email:KIHIPP.PROGRAM@ky.gov

KCHIPWebsite:https://kidshealth.ky.gov/Pages/index.aspx Phone:1-877-524-4718

KentuckyMedicaidWebsite:https://chfs.ky.gov/agencies/dms

MAINE–Medicaid

EnrollmentWebsite: https://www.mymaineconnection.gov/benefits/s/?language=en_ US

Phone:1-800-442-6003;TTY:Mainerelay711 PrivateHealthInsurancePremiumWebpage: https://www.maine.gov/dhhs/ofi/applications-forms Phone:1-800-977-6740;TTY:Mainerelay711

MINNESOTA–Medicaid

Website: https://mn.gov/dhs/people-we-serve/children-andfamilies/health-care/health-care-programs/programs-andservices/other-insurance.jsp

Phone:1-800-657-3739

INDIANA–Medicaid

HealthyIndianaPlanforlow-incomeadults19-64 Website:http://www.in.gov/fssa/hip/ Phone:1-877-438-4479

AllotherMedicaid

Website:https://www.in.gov/medicaid/ Phone1-800-457-4584

KANSAS–Medicaid

Website:https://www.kancare.ks.gov/ Phone:1-800-792-4884

HIPPPhone:1-800-967-4660

LOUISIANA–Medicaid

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

MASSACHUSETTS–MedicaidandCHIP

Website:https://www.mass.gov/masshealth/pa Phone:1-800-862-4840

TTY:711

Email:masspremassistance@accenture.com

MISSOURI–Medicaid

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

NEBRASKA–Medicaid MONTANA–Medicaid

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

Email:HHSHIPPProgram@mt.gov

Website:http://www.ACCESSNebraska.ne.gov

Phone:1-855-632-7633

Lincoln:402-473-7000

Omaha:402-595-1178

NEWHAMPSHIRE–Medicaid NEVADA–Medicaid

MedicaidWebsite:http://dhcfp.nv.gov

MedicaidPhone:1-800-992-0900

Website:https://www.dhhs.nh.gov/programsservices/medicaid/health-insurance-premium-program Phone:603-271-5218

TollfreenumberfortheHIPPprogram:1-800-852-3345, ext.5218

ComplianceNotices

NEWJERSEY–MedicaidandCHIP

MedicaidWebsite:

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

CHIPWebsite:http://www.njfamilycare.org/index.html CHIPPhone:1-800-701-0710

NORTHCAROLINA–Medicaid

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

OKLAHOMA–MedicaidandCHIP

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

PENNSYLVANIA–MedicaidandCHIP

Website:https://www.dhs.pa.gov/Services/Assistance/Pages/H IPP-Program.aspx

Phone:1-800-692-7462

CHIPWebsite:Children'sHealthInsuranceProgram(CHIP) (pa.gov)

CHIPPhone:1-800-986-KIDS(5437)

SOUTHCAROLINA–Medicaid

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

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

VERMONT–Medicaid

Website:HealthInsurancePremiumPayment(HIPP)Program |DepartmentofVermontHealthAccess Phone:1-800-250-8427

WASHINGTON–Medicaid

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

WISCONSIN–MedicaidandCHIP

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

NEWYORK–Medicaid

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

NORTHDAKOTA–Medicaid

Website:https://www.hhs.nd.gov/healthcare Phone:1-844-854-4825

OREGON–Medicaid

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

RHODEISLAND–MedicaidandCHIP

Website:http://www.eohhs.ri.gov/ Phone:1-855-697-4347,or 401-462-0311(DirectRIteShareLine)

SOUTHDAKOTA-Medicaid

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

MedicaidWebsite:https://medicaid.utah.gov/ CHIPWebsite:http://health.utah.gov/chip Phone:1-877-543-7669

VIRGINIA–MedicaidandCHIP

Website:https://coverva.dmas.virginia.gov/learn/premiumassistance/famis-select

https://coverva.dmas.virginia.gov/learn/premiumassistance/health-insurance-premium-payment-hippprograms Medicaid/CHIPPhone:1-800-432-5924

WESTVIRGINIA–MedicaidandCHIP

Website:https://dhhr.wv.gov/bms/ http://mywvhipp.com/ MedicaidPhone:304-558-1700

CHIPToll-freephone:1-855-MyWVHIPP(1-855-699-8447)

WYOMING–Medicaid

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

ToseeifanyotherstateshaveaddedapremiumassistanceprogramsinceJanuary31,2024,orformoreinformationon specialenrollmentrights,contacteither:

U.S.DepartmentofLabor EmployeeBenefitsSecurityAdministration www.dol.gov/agencies/ebsa 1-866-444-EBSA(3272)

U.S.DepartmentofHealthandHumanServices CentersforMedicare&MedicaidServices www.cms.hhs.gov 1-877-267-2323,MenuOption4,Ext.61565

32 ComplianceNotices

YourRightsandProtectionsAgainstSurpriseMedicalBills

Whenyougetemergencycareoraretreatedbyanout-of-networkprovideratanin-networkhospitalorambulatorysurgical center,youareprotectedfrombalancebilling.Inthesecases,youshouldn’tbechargedmorethanyourplan’scopayments, coinsuranceand/ordeductible.

Whatis“balancebilling”(sometimescalled“surprisebilling”)?

Whenyouseeadoctororotherhealthcareprovider,youmayowecertainout-of-pocket-costs,likeasuchasacopayment, coinsurance,ordeductible.Youmayhaveadditionalcostsorhavetopaytheentirebillifyouseeaproviderorvisitahealth carefacilitythatisn’tinyourhealthplan’snetwork.

“Out-of-network”meansprovidersandfacilitiesthathaven’tsignedacontractwithyourhealthplantoprovideservices.Outof-networkprovidersmaybepermittedtobillyouforthedifferencebetweenwhatyourplanpaysandthefullamount chargedforaservice.Thisiscalled“balancebilling.”Thisamountislikelymorethanin-networkcostsforthesameservice andmightnotcounttowardyourplan’sdeductibleorannualout-of-pocketlimit.

“Surprisebilling”isanunexpectedbalancebill.Thiscanhappenwhenyoucan’tcontrolwhoisinvolvedinyourcare—like whenyouhaveanemergencyorwhenyouscheduleavisitatanin-networkfacilitybutareunexpectedlytreatedbyanoutof-networkprovider.Surprisemedicalbillscouldcostthousandsofdollarsdependingontheprocedureorservice.

Youareprotectedfrombalancebillingfor: Emergencyservices

Ifyouhaveanemergencymedicalconditionandgetemergencyservicesfromanout-of-networkproviderorfacility,the mosttheycanbillyouisyourplan’sin-networkcost-sharingamount(suchascopayments,coinsurance,anddeductibles). Youcan’tbebalancebilledfortheseemergencyservices.Thisincludesservicesyoumaygetafteryou’reinstable condition,unlessyougivewrittenconsentandgiveupyourprotectionsnottobebalancedbilledforthesepost-stabilization services.

Certainservicesatanin-networkhospitalorambulatorysurgicalcenter

Whenyougetservicesfromanin-networkhospitalorambulatorysurgicalcenter,certainproviderstheremaybeout-ofnetwork.Inthesecases,themostthoseproviderscanbillyouisyourplan’sin-networkcost-sharingamount.Thisappliesto emergencymedicine,anesthesia,pathology,radiology,laboratory,neonatology,assistantsurgeon,hospitalist,orintensivist services.Theseproviderscan’tbalancebillyouandmaynotaskyoutogiveupyourprotectionsnottobebalancebilled.

Ifyougetothertypesofservicesatthesein-networkfacilities,out-of-networkproviderscan’tbalancebillyou,unlessyou givewrittenconsentandgiveupyourprotections.

You’reneverrequiredtogiveupyourprotectionsfrombalancebilling.Youalsoaren’trequiredtogetout-ofnetworkcare.Youcanchooseaproviderorfacilityinyourplan’snetwork.

Whenbalancebillingisn’tallowed,youalsohavethefollowingprotections:

•You’reonlyresponsibleforpayingyourshareofthecost(likethecopayments,coinsurance,anddeductiblethatyouwould payiftheproviderorfacilitywasin-network).Yourhealthplanwillpayanyadditionalcoststoout-of-networkprovidersand facilitiesdirectly.

•Generally,yourhealthplanmust:

oCoveremergencyserviceswithoutrequiringyoutogetapprovalforservicesinadvance(alsoknownas“prior authorization”).

oCoveremergencyservicesbyout-of-networkproviders.

oBasewhatyouowetheproviderorfacility(cost-sharing)onwhatitwouldpayanin-networkproviderorfacilityand showthatamountinyourexplanationofbenefits.

oCountanyamountyoupayforemergencyservicesorout-of-networkservicestowardyourin-networkdeductibleand out-of-pocketlimit.

Ifyoubelieveyou’vebeenwronglybilled,contactthefederalNoSurprisesHelpDeskat1-800-985-3059.Visit www.cms.gov/nosurprises/consumersformoreinformationaboutyourrightsunderfederallaw.

33 ComplianceNotices

FamilyandMedicalLeaveAct(FMLA)

LeaveEntitlements.Eligibleemployeeswhoworkforacoveredemployercantakeupto12weeksofunpaid,job-protected leaveina12-monthperiodforthefollowingreasons:

•Thebirthofachildorplacementofachildforadoptionorfostercare;

•Tobondwithachild(leavemustbetakenwithinoneyearofthechild’sbirthorplacement);

•Tocarefortheemployee’sspouse,child,orparentwhohasaqualifyingserioushealthcondition;

•Fortheemployee’sownqualifyingserioushealthconditionthatmakestheemployeeunabletoperformtheemployee’s job;

•Forqualifyingexigenciesrelatedtotheforeigndeploymentofamilitarymemberwhoistheemployee’sspouse,child,or parent.

Aneligibleemployeewhoisacoveredservicemember’sspouse,child,parent,ornextofkinmayalsotakeupto26weeks ofFMLAleaveinasingle12-monthperiodtocarefortheservicememberwithaseriousinjuryorillness.Anemployeedoes notneedtouseleaveinoneblock.Whenitismedicallynecessaryorotherwisepermitted,employeesmaytakeleave intermittentlyoronareducedschedule.

Employeesmaychoose,oranemployermayrequire,useofaccruedpaidleavewhiletakingFMLAleave.Ifanemployee substitutesaccruedpaidleaveforFMLAleave,theemployeemustcomplywiththeemployer’snormalpaidleavepolicies.

BenefitsandProtections.WhileemployeesareonFMLAleave,employersmustcontinuehealthinsurancecoverageasif theemployeeswerenotonleave.UponreturnfromFMLAleave,mostemployeesmustberestoredtothesamejoborone nearlyidenticaltoitwithequivalentpay,benefits,andotheremploymenttermsandconditions.Anemployermaynot interferewithanindividual’sFMLArightsorretaliateagainstsomeoneforusingortryingtouseFMLAleave,opposingany practicemadeunlawfulbytheFMLA,orbeinginvolvedinanyproceedingunderorrelatedtotheFMLA.

EligibilityRequirements.Anemployeewhoworksforacoveredemployermustmeetthreecriteriainordertobeeligiblefor FMLAleave.Theemployeemust:

•Haveworkedfortheemployerforatleast12months;

•Haveatleast1,250hoursofserviceinthe12monthsbeforetakingleave;*and

•Workatalocationwheretheemployerhasatleast50employeeswithin75milesoftheemployee’sworksite.*Special “hoursofservice”requirementsapplytoairlineflightcrewemployees.

RequestingLeave.Generally,employeesmustgive30-days’advancenoticeoftheneedforFMLAleave.Ifitisnotpossible togive30-days’notice,anemployeemustnotifytheemployerassoonaspossibleand,generally,followtheemployer’s usualprocedures.Employeesdonothavetoshareamedicaldiagnosisbutmustprovideenoughinformationtothe employersoitcandetermineiftheleavequalifiesforFMLAprotection.Sufficientinformationcouldincludeinformingan employerthattheemployeeisorwillbeunabletoperformhisorherjobfunctions,thatafamilymembercannotperform dailyactivities,orthathospitalizationorcontinuingmedicaltreatmentisnecessary.Employeesmustinformtheemployerif theneedforleaveisforareasonforwhichFMLAleavewaspreviouslytakenorcertified.Employerscanrequirea certificationorperiodicrecertificationsupportingtheneedforleave.Iftheemployerdeterminesthatthecertificationis incomplete,itmustprovideawrittennoticeindicatingwhatadditionalinformationisrequired.

EmployerResponsibilities.Onceanemployerbecomesawarethatanemployee’sneedforleaveisforareasonthatmay qualifyundertheFMLA,theemployermustnotifytheemployeeifheorsheiseligibleforFMLAleaveand,ifeligible,must alsoprovideanoticeofrightsandresponsibilitiesundertheFMLA.Iftheemployeeisnoteligible,theemployermust provideareasonforineligibility.EmployersmustnotifyitsemployeesifleavewillbedesignatedasFMLAleave,andifso, howmuchleavewillbedesignatedasFMLAleave.

Enforcement.EmployeesmayfileacomplaintwiththeU.S.DepartmentofLabor,WageandHourDivision,ormaybringa privatelawsuitagainstanemployer.TheFMLAdoesnotaffectanyfederalorstatelawprohibitingdiscriminationor supersedeanystateorlocallaworcollectivebargainingagreementthatprovidesgreaterfamilyormedicalleaverights.

ComplianceNotices

Pleasereadthisnoticecarefullyandkeepitwhereyoucanfindit.Thisnoticehasinformationaboutyourcurrent prescriptiondrugcoveragewithMidwestMoleGroupHealthPlanandaboutyouroptionsunderMedicare’s prescriptiondrugcoverage.ThisinformationcanhelpyoudecidewhetherornotyouwanttojoinaMedicare drugplan.Ifyouareconsideringjoining,youshouldcompareyourcurrentcoverage,includingwhichdrugsare coveredatwhatcost,withthecoverageandcostsoftheplansofferingMedicareprescriptiondrugcoveragein yourarea.Informationaboutwhereyoucangethelptomakedecisionsaboutyourprescriptiondrugcoverageis attheendofthisnotice.

TherearetwoimportantthingsyouneedtoknowaboutyourcurrentcoverageandMedicare’sprescriptiondrug coverage:

1.Medicareprescriptiondrugcoveragebecameavailablein2006toeveryonewithMedicare.Youcangetthis coverageifyoujoinaMedicarePrescriptionDrugPlanorjoinaMedicareAdvantagePlan(likeanHMOor PPO)thatoffersprescriptiondrugcoverage.AllMedicaredrugplansprovideatleastastandardlevelof coveragesetbyMedicare.Someplansmayalsooffermorecoverageforahighermonthlypremium.

2.MidwestMolehasdeterminedthattheprescriptiondrugcoverageofferedbytheMidwestMoleGroupHealth Planis,onaverageforallplanparticipants,expectedtopayoutasmuchasstandardMedicareprescription drugcoveragepaysandisthereforeconsideredCreditableCoverage.Becauseyourexistingcoverageis CreditableCoverage,youcankeepthiscoverageandnotpayahigherpremium(apenalty)ifyoulaterdecide tojoinaMedicaredrugplan.

WhenCanYouJoinAMedicareDrugPlan?

YoucanjoinaMedicaredrugplanwhenyoufirstbecomeeligibleforMedicareandeachyearfromOctober15th toDecember7th

However,ifyouloseyourcurrentcreditableprescriptiondrugcoverage,throughnofaultofyourown,youwill alsobeeligibleforatwo(2)monthSpecialEnrollmentPeriod(SEP)tojoinaMedicaredrugplan.

WhatHappensToYourCurrentCoverageIfYouDecidetoJoinAMedicareDrugPlan?

IfyoudecidetojoinaMedicaredrugplan,yourcurrentMidwestMoleGroupHealthPlancoveragewillnotbe affected.IfyoukeepyourcurrentcoverageandelectMedicarePartD,yourMidwestMoleGroupHealthPlan coveragemaycoordinatewithyourMedicarePartDcoverage.IfyoudodecidetojoinaMedicaredrugplanand dropyourcurrentMidwestMoleGroupHealthPlancoverage,beawarethatyouandyourdependentswillnot beabletogetthiscoverageback,unlessyouhaveaqualifyinglifeeventoruntilthenextopenenrollment.

WhenWillYouPayAHigherPremium(Penalty)ToJoinAMedicareDrugPlan?

YoushouldalsoknowthatifyoudroporloseyourcurrentcoveragewithMidwestMoleanddon’tjoina Medicaredrugplanwithin63continuousdaysafteryourcurrentcoverageends,youmaypayahigherpremium (apenalty)tojoinaMedicaredrugplanlater.

Ifyougo63continuousdaysorlongerwithoutcreditableprescriptiondrugcoverage,yourmonthlypremiummay goupbyatleast1%oftheMedicarebasebeneficiarypremiumpermonthforeverymonththatyoudidnothave

ComplianceNotices

thatcoverage.Forexample,ifyougonineteenmonthswithoutcreditablecoverage,yourpremiummay consistentlybeatleast19%higherthantheMedicarebasebeneficiarypremium.Youmayhavetopaythis higherpremium(apenalty)aslongasyouhaveMedicareprescriptiondrugcoverage.Inaddition,youmayhave towaituntilthefollowingOctobertojoin.

ForMoreInformationAboutThisNoticeOrYourCurrentPrescriptionDrugCoverage Contactthepersonlistedbelowforfurtherinformation.

NOTE:You’llgetthisnoticeeachyear.YouwillalsogetitbeforethenextperiodyoucanjoinaMedicaredrug plan,andifthiscoveragethroughMidwestMolechanges.Youalsomayrequestacopyofthisnoticeatany time.

ForMoreInformationAboutYourOptionsUnderMedicarePrescriptionDrugCoverage

MoredetailedinformationaboutMedicareplansthatofferprescriptiondrugcoverageisinthe“Medicare&You” handbook.You’llgetacopyofthehandbookinthemaileveryyearfromMedicare.Youmayalsobecontacted directlybyMedicaredrugplans.

FormoreinformationaboutMedicareprescriptiondrugcoverage:

•Visitwww.medicare.gov

•CallyourStateHealthInsuranceAssistanceProgram(seetheinsidebackcoverofyourcopyofthe “Medicare&You”handbookfortheirtelephonenumber)forpersonalizedhelp

•Call1-800-MEDICARE(1-800-633-4227).TTYusersshouldcall1-877-486-2048.

Ifyouhavelimitedincomeandresources,extrahelppayingforMedicareprescriptiondrugcoverageis available.Forinformationaboutthisextrahelp,visitSocialSecurityonthewebatwww.socialsecurity.gov,or callthemat1-800-772-1213(TTY1-800-325-0778).

Remember:KeepthisCreditableCoveragenotice.IfyoudecidetojoinoneoftheMedicaredrug plans,youmayberequiredtoprovideacopyofthisnoticewhenyoujointoshowwhetherornot youhavemaintainedcreditablecoverageand,therefore,whetherornotyouarerequiredtopaya higherpremium(apenalty).

EffectiveDate:07/01/2024

NameofEntity/Sender:MidwestMole

Contact--Position/Office:MaxPhillips,HumanResourcesManager

Address:6814W350North,GreenfieldIN46140

PhoneNumber:317-545-1335ext.119

https://www.midwestmole.com