Carahsoft Health & Welfare Benefit Guide 2022

2022 Carahsoft Health & Welfare Benefit Guide

CONNECTING YOUR BENEFITS

U n d e r st a n d ing your benefits pr ogr a m is e sse ntia l to ma ximiz ing the be ne f its p r o g r a m . T his guide is to help you unde r sta nd the most impor ta nt a spe c ts of th e b e ne f i t s p r ogram. T his guide w ill pr ovide a n ove r vie w of ke y pa rts of the be n e f its p r o g r a m p r ovided by C arahsoft.

A t Ca r a h so ft w e value your contributions to our suc c e ss a nd wa nt to pr ovide y o u w i t h a benefits package that pr ote c ts your he a lth a nd he lps your f ina nc i a l se c u r i t y, n o w and in the future. We c ontinua lly look f or va lua ble be ne f its th a t su p p o r t y o u r needs, w hether you a r e single , ma r r ie d, r a ising a f a mily, or thin k in g a he a d t o r e tirement. We are committe d to giving you the r e sour c e s you ne e d to u n d e r st a n d your options and ho w y our c hoic e s c ould a ff e c t you f ina nc ia lly.

T hi s g u i d e is an overview and d oe s not pr ovide a c omple te de sc ription of a l l b e ne f i t p r o visions. F or more deta ile d inf or ma tion, ple a se r e fe r to y our pla n b e ne f i t b o o klets or summary plan de sc r iptions ( SPDs) . The pla n be ne fit boo k le ts d e t e r m i n e how all benefits are paid.

A l i st o f p l a n contacts is included a t the ba c k of this guide .

Th e benef its in th i s s um mary are e ffe ct i v e : A p ril 1, 2022 - M ar c h 31, 2023

TABLE OF CONTENTS W h o Ca n Yo u Cover ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .............................................................................................

M e d i c a l . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...........................................................................................

1 2-3

G e tt i n g Ca re W h en You N eed It N ow . . . . . ............................................................................................

4

H ea l t h S av i n g s Accou nt ( H S A ) . . . . . . . . . . . . . . . ...........................................................................................

5

F l exi b l e S p e n d in g Accou nt ( FS A ) . . . . . . . . . . . . ............................................................................................

6

D e n t a l . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...........................................................................................

7

Vi s i o n . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...........................................................................................

8

Voluntary Disa bility Insura nce .....................................................................

9

Vo l u nt a r y L I fe Insu ran ce . . . . . . . . . . . . . . . . . . . . . . . . ...........................................................................................

10

O t h e r Vo l u n t ar y Ins u ran ces . . . . . . . . . . . . . . . . . . . ...........................................................................................

11

Co s t o f Cove ra g e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...........................................................................................

12-13

Fo r As s i s t a n ce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...........................................................................................

14

P l a n Co nt a c t s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..........................................................................................

15

Wo rd s Yo u N e ed to Kn ow . . . . . . . . . . . . . . . . . . . . . . . ............................................................................................

16

I mp o r t a n t P l a n N otices an d Doc u m ents .........................................................................................

17

M e d i c a re Pa r t D N otice . . . . . . . . . . . . . . . . . . . . . . . . . . . ..........................................................................................

18-19

Wo m en’ s Health a nd C a ncer R ights Act a nd N e wbo r ns' a nd Mo t he r s Ac t ................................ .

20

HIPAA No tic e of Specia l Enrollment R igh t s ................................................................................... .

21

Av ailability o f P riva y P ra ctices Notice ........................................................................................... .

22

C hildr en's Hea lth Insura nce P rogra m .... ......................................................................................... .

23 - 2 4

Medicare Par t D Notice: If you (an d/or your depen dents) have Medicare or will becom e eligible for Medicare in th e n ext 12 m onths, a federal law gives you m ore ch oices about your prescription drug covera ge. Please see th e Annual Notices in this booklet for m ore details.

WHO CAN YOU COVER?

HOW TO MAKE CHANGES?

WHO IS ELIGIBLE AND EFFECTIVE DATE?

U n l e ss y o u h a v e a q u a l i f i e d c h a n g e i n st a t u s , y o u cannot make changes to the benefits you elect except during open enrollment. Qualified changes i n st a t u s i n c l u d e , f o r e x a m p l e : m a r r i a g e , d i vo r c e , l e g a l se p a r a t i o n , b i r t h o r a d o p t i o n o f a c h i l d, c h a n g e i n c h i l d ’s d e p e n d e n t st a t u s, d e a t h o f a sp o u se , child or other qualified dependent, change in r e si d e n c e , c o m m e n c e m e n t o r t e r m i n a t i o n o f a d o p tio n p r o c e e d i n g s, c h a n g e i n e m p l o y m e n t st a t u s o r c h a n g e i n c o v e r a g e u n d e r a n o t h e r e m p l o y e r- sp o n so r e d p la n .

E n r o l l m e n t c h a n g e s m u st b e m a d e a n d c o m m u n ic a te d w i t h H u m a n Re so u r c e s w i t h i n 3 0 d a y s o f t h e qualifying event.

All full time employees, which are employees averaging 30 or more hours per week. Medical , Dental and Vision coverages for all plans begin t h e f irst of the m onth following your date of hire. F o r example, if you were hired on February 15th, y o u r coverages would be effective March 1st.

Transamerica Voluntary benefits are effective f i r st of the month following date of hire. In addition t o covering yourself, you may also elect coverage f o r y our spouse, and dependent children up to age 2 6 .

Enrollment selec tions must be made and communicated with Human Resources within 3 0 days of the qualifying event. Once you have ma d e your elections, you will not be able to change t h e m until next year ’s open enrollment period unles s y o u have a qualified change in status.

HOW TO ENROLL? To elect your He alth & Welfare benefits, pleas e l o g i n to ADP , which will require your username an d password. Link fo r ADP: https:// workforcenow.adp.com/workforcenow/login.ht m l .

The portal will g uide you through the benefits process. If you have any questions, please e-m a i l Benefits@C arahsoft.com.

P l e a se r e f e r t o t h e S u m m a r y P l a n D e sc r i p t io n f o r c o m p l e t e d e t a i l s o n h o w b e n e f i t s e l i g i b ility is determined.

1

MEDICAL

Me d i c a l c o v e r a g e p ro v id es y o u w ith b en efits tha t he lp ke e p you he a lthy, like pre ve ntive c a re s c re e nings and ac c e ss t o u rg e n t c a re . It als o p ro v id e s imp o r ta nt fina nc ia l prote c tion if you ha ve a s e rious me dic a l c ondi t i on.

HOW DOES IT WORK When you sign up for the health insurance policy, you may choose a doctor from a list of various participating providers included in the network to access medical care.

Benefits of Utilizing an In-Network Participating Provider: An in-network provider has agreed to provide care to members under the terms of a contract with the insurance carrier.

Base PPO

Buy Up PPO

I nsu ra n ce Carri e r :

Evolution Healthcare

Evolution Healthcare

Netwo rk:

Ci g n a P P O

Cigna PPO

Type o f P lan De s i g n :

PPO

PPO

Prim ar y Care Copay m e n t :

$3 0

$10

Sp ec ialist Copay m e n t :

$5 0

$20

Urg ent Care :

$75

$75

E m erg en cy R oom :

$200

$1 5 0

I n- Patient H os pi t al i z at i on :

20% a fte r d e d u c tib le

20 % a fte r d e d u c tib le

Ou t- Patien t Surg e r y :

20% a fte r d e d u c tib le

20 % a fte r d e d u c tib le

Presc ription Be n e f i t s :

$10/ $ 25 / $ 45 /

$ 1 0 / $ 25 / $ 45 /

Dedu c tib le :

$15 0 0/ $3 0 0 0

$ 5 0 0/ $1 0 0 0

Co - I nsu ra n ce :

20 %

20%

Ou t o f Po cke t Max i m um :

$ 450 0/ $9 0 0 0

$1 5 0 0/ $3 0 0 0

Ou t o f Network Cove ra g e

Yes

Ye s

2

MEDICAL CONTINUED

Me d i c a l c o v e r a g e p ro v id es y o u w ith b en efits tha t he lp ke e p you he a lthy, like pre ve ntive c a re s c re e nings and a c c e ss t o u rg e n t c a re . It als o p ro v id e s imp o r ta nt fina nc ia l prote c tion if you ha ve a s e rious me dic a l c ondi t i on.

HDHP I n s uran ce Carri e r :

Evolution Healthcare

N e twork :

Ci g n a P P O

Ty pe of P l an De s i g n :

H i g h Ded u ct i b l e Heal t h Pl an (H D H P )

Pri m ar y Care Copay m e nt:

20 % a fte r d e d u c tib le

Spe ci al i s t Copay m e n t :

20 % a fte r d e d u c tib le

U rg e n t Care :

20 % a fte r d e d u c tib le

E m e rg e n cy R oom :

20 % a fte r d e d u c tib le

I n - Pat i e n t H os pi t al i z at i o n:

20 % a fte r d e d u c tib le

Out- Pat i e n t Surg e r y :

20 % a fte r d e d u c tib le

Pre s cri pt i on Be n e f i t s :

$1 0/$ 25 /$ 45 a fte r d e d u c tib le

De d uc t i bl e :

$ 20 0 0/ $ 40 0 0

Co - I n s uran ce :

20%

Out of Pocke t Max i m u m :

$ 40 0 0/ $ 8 0 0 0

Out of N e twork Cove ra ge

Ye s

3

Getting Care When You Need It Now

WHEN TO USE THE ER

GET A VIDEO HOUSE CALL

The em er gen cy room shouldn’t be yo u r f ir s t choice unle ss the re ’s a n emerge n cy —a s er ious or life thre atening c ondit i o n t hat r equir es imme diate a ttention or t r eatm ent that is only availa ble at a hos pital.

E v o l u t i o n Heal t hcare m em b ers can v i d e o ch at wi t h a d o ct o r fro m t h e co m fo rt o f t h ei r o wn h o m es , wi t h o u t an ap p o i n t m en t . T el ado c p ro v i d es 2 4 /7 acces s t o U. S . bo ard -cert i fi ed p h y s i c i a n s , fo r t h e fract i o n of t h e co s t o f an o ff i c e v i s i t . P h y s i ci ans can t reat a h os t of co m m o n i l l n es s es q u i ck l y an d effe c t i v e l y t h ro u g h a real -t i m e v i d eo v i s i t . T h e y c a n ev en s en d p res cri p t i o n o rd ers t o y ou r l o cal p h arm acy. F o r m o re i n fo rm ati o n , v i s i t www. t el ad o c. co m .

WHEN TO USE URGENT CARE U rgent car e is for se rious symptoms, pain, or conditions tha t re quire i m mediate medic al a ttention but a re n o t s ever e or lif e-threa te ning a nd do not r equir e us e of a hospital or ER . Urgen t car e conditions inc lude , but are not l imited to: ea ra che, sore throat, rash es , s pr ains , f lu, a nd fever up to 104°.

PREVENTIVE OR DIAGNOSTIC? P rev en t i v e care i s i n t en d ed t o p reve n t o r d et ect i l l n es s befo re y o u n o t i ce any s y m p t o m s . Di ag n o s t i c care t reat s o r d i ag n o s es a p ro bl em aft er y o u h av e h a d symptoms.

WHEN YOU NEED CARE NOW

What do you do when you nee d ca re ri g h t aw a y, but it’s not a n emerge nc y?

B e s u re t o as k y o u r d o ct o r wh y a t e s t o r s erv i ce i s o rd ered . M an y p revent i v e s erv i ces are co vered at n o o u t -o f-p o c k e t co s t t o y o u . T h e s am e t es t o r s erv ic e c a n b e p rev en t i v e, di ag n o s t i c, o r ro u t i ne c a r e fo r a ch ro n i c h eal t h co n d i t i o n . Dep e nd i n g o n wh y i t ’s d o n e, y o u r s h are o f t h e c o s t m ay ch an g e.

Evolution H ealth M edical P lan Pa rtic ipants

• • •

Call Tela doc: 1-800-Te la doc ( 835- 2362) Find a P r ovider or Fac ility at w w w .m yevhc .c om Review our EVHC Use r Guide (pa g es 13- 14)

Wh at ev er t h e reas on , i t ’s i m p o rt ant t o k eep u p wi t h reco m m en d ed h eal t h s creen i n g s t o av o i d m o re s eri o u s a n d co s t l y h eal t h p robl em s d o wn t h e ro a d.

4

HEALTH SAVINGS ACCOUNT (HSA)

A He a l t h Sa v i n gs A cco u n t is a tax-adv an tag e d, porta ble (you ow n it!) s a vings a c c ount tha t is offe re d i f you en r o l l i n o u r E vo lu tio n H ealth care H D H P. He a lth Equity adminis te rs this pro g ra m.

Yo u c a n c o n t r i b u te p re-tax m o n ey to y o u r ac c ount to s a ve for out-of-poc ke t he a lthc a re e xpe ns e s . A ny m oney th a t y o u d o n ’ t s p en d g ro w s y ear after y ear a nd c a n be us e d in the future , e ve n a fte r you re tire .

ACCOUNT CONTRIBUTIONS Hea l t h Savin g s Accou nt

Yo u r Co st Pe r Paych e ck

Em p l oyee O nly

De te rm i n e d by Em pl oye e

Em p l oyee + S pouse

De te rm i n e d by Em pl oye e

Em p l oyee + Childre n

De te rm i n e d by Em pl oye e

Em p l oyee + Fa mily

De te rm i n e d by Em pl oye e

USING YOUR MONEY You can use you r account to pay for qualified m e d i c a l e x p e n se s t h a t a r e n o t p a i d f o r b y y o u r h i g h d e d u c t i b le h e a lth plan (HDHP). In general, your HSA can be use d f o r t h e se e x p e n se s: • • • • • •

Medically nece ssary expenses that are not co v e r e d b y y o u r h e a l t h p l a n i n c l u d i n g d e d u c t i b l e s a n d c o i n su r a n c e Dental care ser vices Vision care services P rescription drugs Over-the-counter (OTC) medications prescrib e d b y y o u r d o c t o r Certain medica l equipment

When possible, use your HSA debit card to pay f o r e x p e n se s. Ma k e su r e t h a t y o u k e e p r e c o r d s o f y o u r r e c eip ts a n d any OTC prescriptions in case the IRS requests t h e m .

ELIGIBILITY

Non-Qualified Expenses

You are not eligible to open or contribute to an H S A account if you are:

I f y o u u se H S A f u n d s f o r n o n - q u a l i f i e d e x p e n se s b e f o r e a g e 6 5 , y o u w i l l o w e a 2 0 % p e n a l t y t a x P LU S i n c o me t a x o n t h e w i t h d r a w a l . A f t e r a g e 6 5 , i f y o u u se H S A f u n d s f o r n o n - q u a l i f i e d e x p e n se s, y o u w i l l o w e in c o me t a x o n l y. Vi si t i r s. g o v / p u b l i c a t i o n s/ p 5 0 2 f o r d e ta ils .

• C overed by a non-high deductible health plan • Have a balance in a regular healthcare flexibl e spending account (you or your spouse count) • C overed under Medicare, Medicaid or Tricare • S omeone else’s tax dependent

5

Flexible Spending Account (FSA) A Fl e x i b l e Sp e n d in g A cco u n t lets y o u s et as ide mone y—be fore it’s ta xe d—through pa yroll de duc tions. The m o n e y c a n b e us ed fo r elig ib le h ealth care an d de pe nde nt da y c a re e xpe ns e s you a nd your fa mily e xpect t o h a v e o v e r t h e n ex t y ear. T h e m ain b en efit o f us ing a n FSA is tha t you re duc e your ta xa ble inc ome , w hi ch m e a n s y o u h a v e m o re m o n ey to s pen d . A n d re imburs e me nts from your FSA a c c ounts a re ta x-fre e . U p t o $ 5 5 0 o f u n u se d co n trib u tio n s can ro ll to th e ne xt pla n ye a r. You mus t re -e nroll in this progra m e a c h year .

He a l t h E q u i t y ad m in is ters th is p ro g ram.

TAX-FREE HEALTHCARE FSA

IMPORTANT CONSIDERATIONS •

There’s no “crossover” spending allowed b e t w e e n the healthcare and dependent care accoun t s.

•

Expenses must be incurred between 04/01/ 2 2 -0 3/31/23.

•

Elections cannot be changed during the p l a n y e a r , unless you have a qualified change in fami l y status (and the election change must be c o n si st e n t with the event).

•

$ 570 of unused contributions will roll into t h e n ext plan year, so it is very important tha t y o u plan carefully before making your electio n .

•

FSA funds can b e used for eligible expen se incurred by you, your spouse, and your ta x d ependents only. Your spouse or tax depe n d e n t children do not have to be covered on the Sample’s health plan.

•

Yo u cannot obtain reimbursement for eligi b l e expenses for a domestic partner or their c h i l d r e n , unless they qualify as your tax dependent s (Important: questions about the tax status o f y o u r dependents should be addressed with you r t a x advisor).

•

Keep your receipts as proof that your exp e n se s

E l i g i b l e e x p e n se s i n c l u d e m e d i c a l , d e n t a l , a n d vis io n c o st s i n c l u d i n g p l a n d e d u c t i b l e s, c o p a y s, c o i n su r a nc e a m o u n t s, a n d o t h e r n o n - c o v e r e d h e a l t h c a r e c o st s f or y o u a n d y o u r t a x d e p e n d e n t s. Yo u m a y a c c e ss yo u r e n t i r e a n n u a l e l e c t i o n f r o m t h e f i r st d a y o f t h e p la n y e a r a n d y o u c a n se t a si d e u p t o $ 2, 8 5 0 p e r y e ar . I f y o u a r e e n r o l l e d i n t h e H i g h D e d u c t i b l e H e a l t h P l a n He a lth S a v i n g s A c c o u n t , y o u c a n n o t p a r t i c i pa t e i n o u r Healthcare FSA.

TAX-FREE DEPENDENT CARE FSA E l i g i b l e e x p e n se s m a y i n c l u d e d a y c a r e c e n t e r s, in h o me c hi l d c a r e , a n d b e f o r e o r a f t e r sc h o o l c a r e f o r y o u r d e p e n d e n t c h i l d r e n u n d e r a g e 1 3 . O t h e r i n d i v i d u a ls ma y q u a l i f y i f t h e y a r e y o u r t a x d e p e n d e n t a n d a r e i n c a pa b le o f se l f - c a r e . I t i s i m p o r t a n t t o n ot e t h a t y o u c a n a c c e s s m o n e y o n l y a f t e r i t i s p l a c e d i nt o y o u r d e p e n d e n t c a r e FSA account.

A l l c a r e g i v e r s m ust h a v e a t a x I D o r S o c i a l S e c u r ity n u m b e r. Th i s i n f o r m a t i o n m u st b e i n c l u de d o n y o u r f e d e r a l t a x r e t u r n. I f y o u u se t h e d e p e n d e n t c a r e r e i m b u r se m e n t a c c ou n t , t h e I RS w i l l n o t a l l o w y o u to c l a i m a d e p e n d e n t c a r e c r e d i t f or r e i m b u r se d e xp e n s e s .

Co n su l t y o u r t a x a d v i so r t o d e t e r m i n e w h e t h e r yo u sh o u l d e n r o l l i n t h i s p l a n . You c a n se t a si d e u p to $5 , 0 0 0 p e r h o u se ho l d f o r e l i g i b l e d e pe n d e n t c a r e e x p e n se s f o r t h e ye a r.

were eligib le for IRS purposes.

6

DENTAL

R e g u l a r v i si t s t o y o u r d en tis ts can p ro tect m ore tha n your s mile ; the y c a n he lp prote c t your he a lth. Recent st u d i e s h a v e l i n k ed g u m d is eas e to d amag e e ls e w he re in the body a nd de ntis ts a re a ble to s c re e n for or al sy m p t o m s o f m an y o th er d is eas es in clu d in g c a nc e r, dia be te s , a nd he a rt dis e a s e . C a ra hs oft provide s you wi t h c o m p r e h e n s iv e co v erag e th ro u g h D elta D e nta l of V irginia .

Plan Summary

Low Option

High Option

I nsu ra n ce Ca rri e r :

De lt a De nt al

De lt a De nt al

N etwo rk:

PPO p l us Pre mi e r

PPO p l us Pre mi e r

Prevent ive S e r vi ce s :

100%

100%

B a sic S er v i ce s :

8 0%

90%

M a jo r S er vi ce s :

N/A

5 0%

O r t h o do n t i a S e r vi ce :

N/A

5 0%

E n do / Peri o S e r vi ce s C l a s s i f i e d :

8 0%

90%

D edu c t ibl e :

$5 0

$5 0

A nnu a l Ma x i m u m :

$125 0

$125 0

O u t o f N e twork Cove ra g e :

YES

YES

7

VISION

R o u t i n e v i si o n exam s can n o t o n ly co rrect v is ion, but a ls o de te c t more s e rious he a lth c onditions . We o f f e r y o u a v i si o n p lan th ro u g h A v es is .

Plan Summary-Exam Only I n s u ra n ce Ca rri e r :

A ve s is

Netwo rk :

A ve s is

Freq u en cy ( Exa m / Le n s e s / Fra m e s) :

1*Eve ry 12 months /N /A /N /A

Co pay ( Exa m / Le n s e s / Fra m e s ):

$10/N /A /N /A

Out o f Ne twork A l l owa n ce s Prov ide d:

Ye s

Plan Summary-Exam with Materials I n s u ra n ce Ca rri e r :

A ve s is

Netwo rk :

A ve s is

Freq u en cy ( Exa m / Le n s e s / Fra m e s) :

1* Eve ry 12 months /12 months /24 months

Co pay ( Exa m / Le n s e s / Fra m e s ):

$10/$25

Out o f Ne twork A l l owa n ce s Prov ide d:

Yes

8

VOLUNTARY DISABILITY INSURANCE

If y o u b e c o m e d is ab led an d cann o t w o rk , y our fina nc ia l s e c urity ma y be a t ris k. Prote c ting your inc o m e s t r e a m c a n p r o v id e y o u an d y o u r fam ily w ith pe a c e of mind.

VOLUNTARY SHORT-TERM DISABILITY INSURANCE: Short-Te rm D is abi l i t y

(S T D) c o v e r a g e p ay s y o u a b enefit if y o u te mpora rily c a n’t w ork be c a us e of a n injury, illne s s , or ma t er ni t y le a v e . B e n e f i t s m ay b e red u ced b y in co m e from othe r inc ome s ourc e s s uc h a s pa id time off. Your doct or and th e i n su r a n c e c omp an y w ill w o rk to g eth er to de te rmine how long be ne fits a re pa ya ble , ba s e d on your co n d i t i o n . C o v e rag e is p ro v id ed b y T ran s am e ric a , Inc . a nd ple a s e re vie w the Tra ns a me ric a V olunta ry B e n e f i t Gu i d e fo r y o u r in fo rmatio n .

Selected by employee

M onthly Benefit Amount:

$5,000.00

Maximum Monthly Benefit: Benefits Begin After:

Accid e n t : Sickne ss:

7 d a y s o f d i sa b i l i t y 7 d a y s o f d i sa b i l i t y 24 weeks

Maximum Benefit Period:

9

VOLUNTARY UNIVERSAL LIFE INSURANCE

If y o u h a v e l o v ed o n es w h o d ep en d o n y o u r inc ome for s upport, ha ving life a nd a c c ide nta l de a th ins ur ance ca n h e l p p r o t e c t y o u r family ’s fin an cial s ecurity a nd pa y for la rge e xpe ns e s s uc h a s hous ing a nd e ducat i on, as we l l a s d a y - t o -d ay liv in g ex p ens es .

VOLUNTARY LIFE Vo l u n t a r y Un i veral L ife In s u ran ce allo w s y o u to purc ha s e life ins ura nc e to prote c t your fa mily’s financi al se c u r i t y a n d b uild s g u aran teed cas h v alu e. C ove ra ge is provide d by Tra ns a me ric a a nd ple a s e re vie w the T r a n sa m e r i c a V o lu n tary B en efit G u id e fo r m ore informa tion.

Em p l oye e Volunt a r y Life Am oun t

M i n / Ma x F a c e A m o u n t : $ 1 5 , 0 0 0 - $ 5 0 0 , 0 0 0 G u a r a n t e e d I ssu e : $ 1 2 5 , 0 0 0

Sp o use Volu nt a r y L ife Am ou n t

M i n / Ma x F a c e A m o u n t : $ 1 0 , 0 0 0 - $ 1 0 0 , 0 0 0 G u a r a n t e e d I ssu e : $ 1 5 , 0 0 0

Chi l d( re n) Volu nt a r y L ife Am ou n t

Mi n / M a x F a c e A m o u n t : $ 2 5 , 0 0 0 G u a r a n t e e d I ssu e : $ 2 5 , 0 0 0

Sta te me nt of H e a lth: If you s e le c t a c ove ra ge am ount a bove a c e rta in limit, you w ill ne e d to s ubmi t a Sta te me nt of H e a lth form w ith a dditiona l infor m at i on a bout your he a lth in orde r for the ins ura nc e com pany to a pprove this highe r a mount of c ove ra ge .

10

OTHER VOLUNTARY BENEFITS

ACCIDENT INSURANCE

HOSPITAL INDEMNITY

I f an accident occurs, you may be surprised at ho w t h e expenses can add up. Accident Insurance is des i gn e d t o help you pay for unexpected costs that resul t f r om an accidental injury. Accident Insurance include s benefits for a wide range of common injuries s u c h as fractures, dislocations, burns, emergency ro om o r urgent care visit, and physical therapy.

I f you or a cover ed family member suffers an accident, this pl an will pay you a lump-sum, ta x- f r e e benefit. The am ount of money you receive depe n d s o n t he type and sev erity of your injury and can be u se d a ny way you choose. Transamerica, Inc. provid e s coverage for this program and please review th e Transm erica Benefit Guide for your information .

T h i s p o l i c y p a y s a sp e c i f i e d a m o u n t f o r e a c h d a y a n i n su r e d p e r so n i s c o n f i n e d t o t h e h o sp i t a l , a n d t h e b e n e f i t p a y m e n t s g o st r a i g h t t o t h e e m p l o y e e u nle s s t h e y a r e a ssi g ne d t o h e a l t h c a r e p r o v i d e r s.

Tr a n sa m e r i c a , I n c . p r o v i d e s c o v e r a g e f o r t h i s p r o g r a m a n d p l e a se r e v i e w t h e Tr a n sa m e r i c a Be n e f i t G u i d e f o r m o r e i n f o r m a t i o n .

T h e f o l l o w i n g b e ne f i t s a r e i n c l u d e d i n y o u r p l an : D a i l y I n - H o sp i t a l I n d e m n i t y Be n e f i t : •P a y s e a c h d a y a n i n su r e d p e r so n i s c o n f i n e d t o a h o sp i t a l ( b u t no t a n e m e r g e n c y r o o m , o u t p a t i e nt s ta y o r st a y i n a n o b se r v a t i o n u n i t ) a s t h e r e su l t o f a c o v e r e d a c c i d e nt o r si c k n e ss.

•$ 1 0 0 . 0 0 / d a y •M a x i m u m : $ 5 , 0 0 0. 0 0 / p e r c a l e n d a r y e a r I n t e n si v e Ca r e I nd e m n i t y Be n e f i t : •P a y s e a c h d a y a n i n su r e d p e r so n i s c o n f i n e d t o a n i n t e n si v e c a r e u n i t a s t h e r e su l t o f a c o v e r e d a c c i d e n t o r si c k n e ss.

•$ 2 0 0 . 0 0 / d a y •M a x i m u m : 1 0 d a ys/ p e r c a l e n d a r y e a r

CRITICAL ILLNESS INSURANCE:

H o sp i t a l Co n f i n e m e n t I n d e m n i t y Be n e f i t : C ritical Illness Insurance can help fill a financ i a l g a p i f you experienc e a serious illness such as canc e r , heart attack or s troke. Upon diagnosis of a cov e r e d i llness, a lum p-sum, tax-free benefit is immedia t e l y paid to you. After the first occurrence critical il l ne ss diagnosis, the insured person wi ll receive a lump su m percentage of the elected benefit amount, ($5,000 i ncrements to $30,000 of coverage). The diagno si s must be made after the effective date of the certi f i c a t e of coverage. Benefits can be used to help cover o u t of-pocket medical costs like your plan deductib l e , copays, or related expenses like transportation t o a nd f r om the h ospital, child care, lost income from w o r k or costs associat ed with adjusting to life follow i ng a covered critical illness.

Yo u choose a benefit amount that fits your payc h e c k. and can cover yourself and your family membe r s, i f needed. Trans america, Inc. provides coverag e f o r t his program and please review the Transameri c a Benefit Guide for more information.

•P a y s e a c h d a y a n i n su r e d p e r so n i s c o n f i n e d t o a h o sp i t a l ( b u t no t a n e m e r g e n c y r o o m , o u t p a t i e nt s ta y o r st a y i n a n O b se r v a t i o n u n i t ) a s t h e r e su l t o f a n a c c i d e n t a l i n j u r y o r si c k n e ss l a st i n g a m i n i m u m o f 2 4 c o n t i n u o u s h o u r s f r o m t i m e o f a d m i ssi o n .

•$ 1 0 0 0 . 0 0 •M a x i m u m : 1 d a y p e r c o n f i n e m e n t / 1 d a y p e r calendar year

11

COST OF COVERAGE

I n general, you pay for health cov erage before f e d e r a l , st a t e , a nd so c i a l se c u r i t y t a x e s a r e w i t h h e l d, so y o u p a y l e ss in taxes. P lease note that u nless your dom e st i c p a r t n e r i s y o u r t a x d e p e n d e nt a s d e f i n e d b y t h e I RS , c o n tr ibu t ions for dom estic partner coverage must be ma d e a f t e r- t a x . S i m i l a r l y, t h e c o m p a n y c o n t r i b u t i o n t o w a r d c ov e r a g e f o r your dom estic partner and his/her dependen t s w i l l b e r e p o r t e d a s t a x a b l e i n c o m e o n y o u r W - 2 . Co n t a c t y o u r t a x a dvisor for more details on how this tax tre a t m e nt a p p l i e s t o yo u . N o t i f y Ca r a h so f t i f y o u r d o m e st i c p a r tn e r is your tax dependent.

Evolution Healthcare Base PPO - Medical

Yo u r Co st Pe r Paych e ck

Emp l oyee O nly

$63.23

Emp l oyee + S pouse

$129.75

Emp l oyee + Childre n

$104.81

Emp l oyee + Fa mily

$182.63

Evolution Healthcare Buy-Up PPO - Medical

Yo u r Co st Pe r Paych e ck

Emp l oyee O nly

$104.28

Emp l oyee + S pouse

$216.10

Emp l oyee + Childre n

$175.49

Emp l oyee + Fa mily

$306.52

Evolution Healthcare HDHP - Medical

Yo u r Co st Pe r Paych e ck

Emp l oyee O nly

$40.00

E mp l oyee + S pouse

$100.00

E mp l oyee + Childre n

$90.00

E mp l oyee + Fa mily

$150.00

12

COST OF COVERAGE CONTINUED Delta Dental - Low Option

Yo u r Co st Pe r Paych e ck

Emp l oyee O nly

$3.02

Emp l oyee + S pou se

$6.03

Emp l oyee + Childre n

$6.37

Emp l oyee + Fa mily

$9.99

Delta Dental - High Option

Yo u r Co st Pe r Paych e ck

Emp l oyee O nly

$15.08

Emp l oyee + S pouse

$30.13

Emp l oyee + Childre n

$32.69

Emp l oyee + Fa mily

$54.16

Avesis Exam Only - Vision

Yo u r Co st Pe r Paych e ck

Emp l oyee O nly

$0.00

E m p l oyee + S pouse

$0.00

E m p l oyee + Childre n

$0.00

E m p l oyee + Fa mily

$0.00

Avesis Exam plus Materials - Vision

Yo u r Co st Pe r Paych e ck

Emp l oyee O nly

$2.56

Emp l oyee + S pouse

$4.84

Emp l oyee + Childre n

$5.68

Emp l oyee + Fa mily

$7.99

Voluntary Benefits

Yo u r Co st Pe r Paych e ck

Emp l oyee O nly

Em pl oye e S pe ci f i c

Emp l oyee + S pou se

Em pl oye e S pe ci f i c

Emp l oyee + Childre n

Em pl oye e S pe ci f i c

Emp l oyee + Fa mily

Em pl oye e S pe ci f i c

13

FOR ASSISTANCE

YOUR BENEFIT ADVOCATE

Synergy Group Benefits, Inc.employees are hig h l y t r a i ne d p r o f e ssi o n a l s w i t h e x t e n si v e i n su r a n c e i n d u st r y experience. T hey are your benefit advocates an d a r e a v a i l a b l e t o a ssi st y o u w i t h y ou r b e n e f i t n e e d s.

Call your B enefit Advocate for:

• • • • • • •

Insurance claim questions Denied claims app eals B enefit questions or clarification Prescription problems Flexible Spending Account questions COBRA inquiries General question

Benefit Advocate Contact information: Carahsof t Technology, Corp. contact:Jillian Szczepanek phone: (70 3) 871-8614 e-mail:jillian.szczepanek@carahsoft.com/ benefits@car ahsof t.com B enefits Broker Conta ct information: Synerg y Group Be nefits, In c. cont act: Ro bert Hay ward phone: (70 3) 932-2915 e-mail: rha yward@ssgofva.com

14

PLAN CONTACTS :

Plan Type

Provider Contact

Ph o n e N u mb e r

W e b si t e / Em a i l

Medical, Base PPO, Buy-Up PPO, HDHP PPO

Evolution Healthcare ( 8 0 0 ) 3 1 1 - 3 8 4 2

Den tal

Delta Dental

(800) 237-6060

Vision

Avesis

(855) 214-6777

Volu ntary B enefits

Transamerica Voluntary Benefits

(888) 763-7474

t r a n sa me r i c a e mp l o y e e b e n e f i t s. c o m

Corp orate Contact

Carahsoft

(703) 871-8614

Be n e f i t s@C a r a h so f t . c o m

B enefits Brok er

Synegy Group Benefits, Inc.

(703) 932-2915

r h a y w a r d @ssg o f v a . c o m

Flexib le Spending Accou nt ( FS A)

HealthEquity

(877) 924-3967

H ealth Savings Accou nt ( H SA)

HealthEquity

(877) 924-3967

15

myevhc.com

deltadentalva.com

a v e si s. c o m

h e a l t h e q u i t y . c o m/ wageworks h e a l t h e q u i t y . c o m/ wageworks

WORDS YOU NEED TO KNOW Health insurance seems to have its own langua g e . Yo u w i l l g e t m o r e o u t o f y o u r p l a n s i f u n d e r st a n d t h e m o s t c o m mon terms, explained below in plain English.

MEDICAL

PRESCRIPTION DRUG

OUT-OF-POCKET COST

BRAND NAME

DEDUCTIBLE

GENERIC DRUG

A healthcare exp ense you are responsible for pa yi ng with your own money, whether from your bank account, credit card, or from a health account su c h a s an HSA, FSA or HRA.

A d r u g so l d u n d e r i t s t r a d e m a r k e d n a m e . F o r e x a m p le , L i p i t o r i s t h e b r a n d n a m e o f a c o m m o n c h o l e st e r o l m e d i c i n e . Yo u g e n e r a l l y p a y a h i g h e r c o p a y f o r b r a n d n a m e d r u g s.

The amount of healthcare expenses you have to pa y f o r with your own money before your health pl a n w i l l p ay. The deductible do es not apply to preventi v e c a r e and certain other services.

A d r u g t h a t h a s t h e sa m e a c t i v e i n g r e d i e n t s a s a b r a n d n a m e d r u g , b u t i s so l d u n d e r a d i ff e r e n t n a m e .

F o r e x a m p l e , A t o r v a st a t i n i s t h e g e n e r i c n a m e f o r m e d i c i n e s w i t h t h e sa m e f o r m u l a a s Li p i t o r. Yo u g e n e r a l l y p a y a l o w e r c o p a y f o r g e n e r i c d r u g s.

COINSURANCE - After you meet the deduct i b l e

amount, you and your health plan share the cost o f covered expenses. Coinsurance is always a per c e nt a g e t o taling 100%. For example, if the p lan pays 80 % coinsurance, you are responsible for paying you r coinsurance share, 20% of the cost.

PREFERRED DRUG

E a c h h e a l t h p l a n h a s a l i st o f p r e sc r i p t i o n m e d ic in e s t h a t a r e p r e f e r r e d b a se d o n a n e v a l u a t i o n o f e ff e c t i v e n e ss a n d c o st . A n o t h e r n a m e f o r t h i s l is t is a “ f o r m u l a r y. ” T h e p l a n m a y c h a rg e m o r e f o r n o n preferred drugs or for brand name drugs that have g e n e r i c v e r si o n s. D r u g s t h a t a r e n o t o n t h e p r e f e r r e d d r u g l i st m a y n o t b e c o v e r e d .

COPAY

A set fee you pay whenever you use a particula r healthcare service, for example, when you see y o u r doctor or fill a prescription. After you pay the c o p a y a mount, your health plan pays the rest of the b i l l f o r t hat service.

DENTAL BASIC SERVICES

IN-NETWORK / OUT-OF-NETWORK

D e n t a l se r v i c e s su c h a s f i l l i n g s, r o u t i n e e x t r a c tio n s a n d so m e o r a l su rg e r y p r o c e d u r e s.

Network provide rs (doctors, hospitals, labs, et c . ) a r e contracted with your health plan and have agre e d t o charge lower fee s to plan members, as negotiat e d i n t h eir contract with the health plan. Services fro m out-of-network providers can cost you more be c a u se t he providers are under no obligation to limit th e i r maximum fees. With some plans, such as HMO s a n d EPOs, services fro m out-of-network providers a r e n o t covered at all.

DIAGNOSTIC AND PREVENTIVE SERVICES

G e n e r a l l y i n c l u d e r o u t i n e c l e a n i n g s, o r a l e x a m s , x r a y s, a n d f l u o r i d e t r e a t m e n t s. Mo st p l a n s l i m i t p r e v e n t i v e e x a m s a n d c l e a n i n g s t o t w o t i m e s a ye a r.

MAJOR SERVICES

C o m p l e x o r r e st o r a t i v e d e n t a l w o r k su c h a s c r o w n s , b r i d g e s, d e n t u r e s, i n l a y s a n d o n l a y s.

OUT-OF-POCKET MAXIMUM

The most you would pay from your own money f o r covered healthcare expenses in one year. Once y o u r e ach your plan’s out-of-pocket maximum dolla r amount (by paying your deductible, coinsuranc e a n d copays), the plan pays for all eligible expenses f or t h e r e st of the plan year.

16

Important Plan Notices & Documents CURRENT HEALTH PLAN NOTICES

CURRENT PLAN DOCUMENTS Important documents for our health plan and r e t i r e m e n t p l a n a r e a v a i l a b l e o n o u r b e n e f i t s w e b s ite and include:

Notices must be provided to plan participants o n a n annual basis and are available in this packet of o p e n enrollment materials and include:

•

Medicare Part D Notice Describes options to access prescription drug coverage for Med i c a r e eligible individuals.

•

Women’s Health and Cancer Rights Act De sc r i b e s benefits available to those that will or have undergone a mastectomy.

•

Newborns’ a nd Mothers’ Health Protection A c t Describes the rights of mother and newbor n t o stay in the hospital 48-96 hours after deliv e r y.

•

HIPAA Notice of Special Enrollment Righ t s Describes when you can enroll yourself an d / o r dependents in health coverage outside of op e n enrollment.

•

HIPAA Notice of Privacy Practices Describ e s h o w health information about you may be used a n d disclosed.

•

Premium Assistance Under Medicaid and t h e Children’s Health Insurance Program (CHI P ) Describes availability of premium assistan c e f o r Medicaid eligible dependents.

Summary Plan Descriptions A S u m m a r y P l a n D e sc r i p t i o n ( S P D ) i s t h e l e g a l d o c u m e n t f o r d e sc r i b i n g b e n e f i t s p r o v i d e d u n d e r the plan as well as plan rights and obligations t o p a r t i c i p a n t s a n d b e n e f i c i a r i e s. T h e f o l l o w i n g S u m m a r y P l a n d e sc r i p t i o n s i s a v a i l a b l e :

•

Em p l o y e e Be n e f i t s P l a n

Summary of Benefits and Coverage A S u m m a r y o f Be n e f i t s a n d Co v e r a g e ( S BC) i s a d o c u m e n t r e q u i r e d b y t h e A ff o r d a b l e Ca r e A c t ( A C A ) t h a t p r e se n t s b e n e f i t p l a n f e a t u r e s i n a st a n d a r d iz e d f o r m a t . Th e f o l l o w i n g S B C s a r e a v a i l a b l e o n t h e Alliant benefits portal:

•

Ev o l u t i o n H e a l t h – H D H P, P P O P a p e r c o p i e s o f t h e se d o c u m e nt s a n d n o t i c e s a r e a v a i l a b l e if r e q u e st e d . I f y o u w o u l d l i k e a p a p e r c o p y , ple a s e c o n t a c t H u m a n Re so u r c e s.

COBRA COVERAGE You and/or your dependents may have the righ t t o continue coverage after you lose eligibility un d e r t h e t e rms of our hea lth plan.

Statement of Material Modifications T h i s e n r o l l m e n t g u i d e c o n st i t u t e s a S u mma r y o f M a t e r i a l Mo d i f i c a t i o n s ( S MM ) t o t h e S a m p l e E m p l o y e e B e n e f i t s P l a n . I t i s m e a n t to su p p l e m e n t a n d / o r r e p l a c e c e r t a i n i n f o r m a tio n i n t h e S P D , so r e t a i n i t f o r f u t u r e r e f e r e n c e a l o n g w i t h y o u r S P D . P l e a se sh a r e t h e se materials with your covered family members.

17

MEDICARE PART D NOTICE Important Notice from Sample about Your Prescription Drug Coverage and Medicare P lease read this notice carefully and keep it wh e r e y o u c a n f i n d i t . Th i s n o t i c e h a s i n f o r m a t i o n a bo u t y o u r c u r r e n t prescription drug coverage with Carahsoft and a b o u t y o u r o p t i o n s u n d e r Me d i c a r e ’ s p r e sc r i p t i o n dr u g c o v er a g e .

This inform ation can help you decide whether o r n o t y o u w a n t t o j oi n a M e d i c a r e d r u g p l a n . I f y o u a r e c o n s id e r in g j o ining, you sho uld compare your current cove r a g e , i n c l u d i n g w h i c h d r u g s a r e c o v e r e d a t w h a t c o st , w i t h t h e coverage and costs of the plans offering Medic a r e p r e sc r i p t i o n d r ug c o v e r a g e i n you r a r e a . I n f o r m a t i o n a b o u t w h e r e you can get help to make decisions about your p r e sc r i p t i o n d r u g c ov e r a g e i s a t t he e n d o f t h i s n o t i c e .

There are two important things you need to kno w a b o u t y o u r c u r r e n t c o v e r a g e a n d M e di c a r e ’s p r e sc r i p t i o n d r u g coverage:

1.

Medicare prescription drug coverage becam e a v a i l a bl e i n 2 0 0 6 t o e v e r y o n e w i t h Me d i c a r e . Yo u c a n g e t th is coverage if you join a Medicare Prescripti o n D r u g P l a n o r j o i n a Me d i c a r e A d v a n t a ge P l a n ( l i k e a n H M O or PPO) that offers prescription drug cover a g e . A l l Me d i c a r e d r u g p l a n s p r o v i d e a t l e a st a st a n d a r d l e v e l o f coverage set by Medicare. Some plans may a l so o f f e r m o r e c o v e r a g e f o r a h i g h e r m o n t h l y p r e m i u m .

2.

Carahsoft has determined that the prescrip t i o n d r ug c o v e r a g e o f f e r e d b y t h e h e a l t h p l a n i s, o n a v e r a g e f o r a ll plan participants, expected to pay out as m u c h a s st a n d a r d Me d i c a r e p r e sc r i p t i o n d r u g c o v e r a g e p a ys a n d is therefore considered Creditable Coverage. Be c a u se y o u r e x i st i n g c o v e r a g e i s Cr e d i t a b l e Co v e r a g e , y o u c a n k e e p this coverage and not pay a higher premium ( a p e na l t y ) i f y o u l a t e r d e c i d e t o j o i n a Me d i c a r e d r u g p l a n.

When Can You Join A Medicare Drug Plan?

Yo u can join a M edicare drug plan when you fir st b e c o m e e l i g i b l e f o r Me d i c a r e a n d e a c h y e a r f r o m O c t o b e r 1 5 th to Decem ber 7th. However, if you lose your curr e n t c r e d i t a b l e p r e sc r i p t i o n d r u g c o ve r a g e , t h r o u g h no f a u l t o f y o u r own, you will also be eligible for a two (2) mo n t h S p e c i a l En r o l l m e n t P e r i o d ( S EP ) t o j o i n a M e d i c a r e d r u g p la n .

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?

I f you decide to join a Medicare drug plan, you r Ca r a h so f t c o v e r a ge w i l l n o t b e a f f e c t e d . S e e b e l o w f o r m o r e i n form ation about what happens to your curren t c ov e r a g e i f y o u j o i n a M e d i c a r e d r u g p l a n . S i n c e t h e e x i stin g prescription drug coverage under Carhsoft's Emp l o y e e Be n e f i t s P l a n i s c r e d i t a b l e ( e . g . , a s g o o d a s M e d i c a r e coverage), you c an retain your existing prescrip t i o n d r u g c o v e r a g e a n d c h o o se n o t t o e n r o l l i n a P a r t D p l a n ; o r yo u can enroll in a Part D plan as a supplement to, o r i n l i e u o f , y o u r e x i st i n g p r e sc r i p t i o n d r u g c o v e r a g e . I f y o u do decide to join a Medicare drug plan and drop y o u r Ca r a h so f t p r e sc r i p t i o n d r u g c o v e r a g e , b e a w a r e t ha t y o u a n d your dependents can only get this coverage bac k a t o p e n e n r o l l m e n t o r i f y o u e x p e r i e n c e a n e v e n t t h a t g i v es r is e to a HIPAA S pecial Enrollment Right. When Will Yo u P a y A H i g h e r P r e m i u m ( P e n a l t y ) T o Jo i n A Me d i c a r e D r u g Plan?

18

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?

Yo u should also know that if you drop or lose y o u r c u r r e n t c o v e r a g e w i t h Ca r a h so f t a nd d o n ’ t j o i n a Me d i c a r e drug plan within 63 continuous days after your c u r r e n t c o v e r a g e e n d s, y o u m a y p a y a h i g h e r p r e m i u m ( a p e n a lty ) t o join a Medicare drug plan later. If you go 6 3 c o n t i n u o u s d a y s o r l o n g e r w i t h o u t c r e d i t a b l e p r e sc r i p t i o n d r u g coverage, y our monthly premium may go up by a t l e a st 1 % o f t h e Me d i c a r e b a se b e n e f i c i a r y p r e m i u m p e r m o n th f o r every m onth that you did not have that cov e r a g e . F o r e x a m p l e , i f y o u g o n i n e t e e n m o n t h s w i t h o u t c r e d i ta b le coverage, your premium may consistently be at l e a st 1 9 % h i g h e r t ha n t h e M e d i c a r e b a se b e n e f i c i a r y p r e m i u m. Yo u may have to pay this higher premium (a penalt y ) a s l o n g a s y o u h a v e Me d i c a r e p r e sc r i p t i o n d r u g c o v e r a g e . I n addition, you m ay have to wait until the follow i n g O c t o b e r t o j o i n .

For More Information About This Notice Or Your Current Prescription Drug Coverage…

Contact the person listed below for further info r m a t i o n [ o r e - m a i l H u m a n Re so u r c e s a t Be n e f i t s@Ca r h so f t . c o m.

NOTE: Yo u’ll get this notice each year. You w i l l a l so g e t i t b e f o r e t h e ne x t p e r i o d y o u c a n j o i n a Me d i c a r e d r u g plan, and if this coverage through Carahsoft ch a n g e s. Yo u a l so m a y r e q u e st a c o p y o f t h i s n o t i c e a t a n y t i me .

For More Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plan s t h a t o ff e r p r e sc r i p t i o n d r u g c o v e r a g e i s i n t h e “ M e d i c a r e & Yo u ” handbook. Yo u’ll get a copy of the handbook in t h e m a i l e v e r y y e a r f r o m M e d i c a r e . Yo u m a y a l so b e c o n t a c te d directly by Medicare drug plans.

For more information about Medicare prescript i o n d r u g c o v e r a g e :

• •

Visit medicare.gov

•

Call 800-MEDICARE (800-633-4227). TTY u se r s sh o u l d c a l l 8 7 7 - 4 8 6 - 2 0 4 8 .

Call your State Health Insurance Assistanc e P r o g r a m ( se e t h e i n si d e b a c k c o v e r o f y o u r c o p y o f t h e “ M e d ic a r e & You” handbook for their telephone numb e r ) f o r p e r so n a l i z e d h e l p

I f you have limited income and resources, extr a h e l p p a y i n g f o r M e d i c a r e p r e sc r i p t i o n d r u g c o v e r a g e i s a v a ila b le .

F or information about this extra help, visit S ocial Security on the web at socialsecur i t y. g o v or call them at 8 00-772-1213 (TTY 800-325-07 7 8 ) .

R em emb e r : Ke e p t h i s C re d i t a b l e Cove ra ge n o tice . If yo u de cide to j o in o n e o f th e M ed ica re dr u g p l a n s , you m ay b e re q u ire d to p rovide a co py o f th is n o tice w h en yo u jo in to s h ow w h e t h e r or n ot yo u h ave m ain tain e d cre ditab le cove ra ge an d , th erefo re, w h e t h e r or n ot you a re re q u ire d to pay a h igh e r p re m iu m (a p e n al ty ).

Date: 04 /01/2022 N am e of Entity/Sender:Carahsoft C ontact-Position/Office: Human Resources Address: 11493 Su n set Hills Rd Suite 100 Resto n , VA 20 1 9 0 Phone Number:(703) 871-8614

19

WOMEN’S HEALTH & CANCER RIGHTS ACT

NEWBORNS’ & MOTHERS’ HEALTH PROTECTION ACT

I f you have had or are going to have a mastecto m y, you may be entitled to certain benefits under t h e Women’s Health and Cancer Rights Act of 199 8 ( W HCRA). F or individuals receiving mastectom y r e lated benefits, coverage will be provided in a manner determined in consultation with the att e n d i n g physician and the patient, for:

•

All stages of reconstruction of the breast o n which the mastectomy was performed;

•

Surgery and reconstruction of the other br e a st t o produce a symmetrical appearance;

• •

Prostheses; and

G r o u p h e a l t h p l a ns a n d h e a l t h i n sur a n c e i ssu e r s g e n e r a l l y m a y n o t , u n d e r F e d e r a l l a w, r e st r i c t be ne f its f o r a n y h o sp i t a l l e n g t h o f st a y i n c o n n e c t i o n w i th c h i l d b i r t h f o r t h e m o t h e r o r n e w bo r n c h i l d t o l e s s t h a n 4 8 h o u r s f o l l o w i n g a v a g i n a l d e l i v e r y, o r l e s s t h a n 9 6 h o u r s f o l l o w i n g a c e sa r e a n se c t i o n . H o we v e r, F e d e r a l l a w g e n e r a l l y d o e s n o t p r o h i b i t t h e m o t h e r ’s o r n e w b o r n ’s a t t e n d i n g p r o v i d e r, a f t e r c o n su l t i ng w i t h t h e m o t h e r, f r o m d i sc h a rg i n g t h e m o t h e r or her newborn earlier than 48 hours (or 96 hours as a p p l i c a b l e ) . I n a n y c a se , p l a n s a nd i ssu e r s m a y n o t, u n d e r F e d e r a l l a w, r e q u i r e t h a t a p r o v i d e r o b t a i n a u t h o r i z a t i o n f r o m t h e p l a n o r t h e i n su r a n c e i ss u e r f o r p r e sc r i b i n g a l e ng t h o f st a y n o t i n e x c e ss o f 4 8 h o u r s ( o r 9 6 h o u r s) . I f y o u w o u l d l i k e m o r e i n f o r m a t io n o n m a t e r n i t y b e n e f i t s, c a l l y o u r p l a n a d m i n i st r a t o r a t

Treatment of physical complications of the mastectomy, including lymphedema.

703-932-2915

These benefits w ill be provided subject to the sa m e deductibles and coinsurance applicable to othe r medical and surgical benefits provided under t h i s p lan. Therefore, the plan deductibles and coins u r a nc e a pply. If you would like more information on W H CRA benefits, call y our plan administrator

703-932-2915

20

HIPAA Notice of Special Enrollment Rights I f you decline enrollment in Carahsoft’s health p l a n f o r y o u o r y o u r d e p e n d e n t s ( i n c l u d i n g y o u r sp o u se ) b e c a u s e of other health insurance or group health plan c o v e r a g e , y o u o r y o u r d e p e n d e n t s m a y b e a b l e t o e n r ol l i n Carahsoft's health plan without waiting for the n e x t o p e n e n r o l l m e nt p e r i o d i f y o u :

•

Lose other health insurance or group healt h p l a n c o v e r a g e . Yo u m u st r e q u e st e n r o l l m e n t w i t h i n 3 0 d a y s a f te r the loss of other coverage.

•

Gain a new dependent as a result of marria g e , b i r t h , a d o p t i o n , o r p l a c e m e n t f o r a d o p t i o n . Yo u m u st r e qu e s t health plan enrollment within 30 days afte r t h e m a r r i a g e , b i r t h , a d o p t i o n , o r p l a c e m e n t f o r a d o p t i o n .

•

Lose Medicaid or Children’s Health Insura n c e P r o g r a m ( CH I P ) c o v e r a g e b e c a u se y o u a r e n o l o n g e r e l i g ib le .

You must re quest medical plan enrollment w i t h i n 6 0 d a y s a f t e r t h e l o ss o f su c h c o v e r a g e .

I f you request a change due to a special enrollme n t e v e n t w i t h i n t h e 3 0 d a y t i m e f r a m e c o v e r a g e w i l l b e e f f e c tiv e t h e date of birth, adoption or placement for ad o p t i o n . F o r a l l o t he r e v e n t s, c o v e r a g e w i l l b e e f f e c t i v e t h e f ir s t o f t h e m onth following your request for enrollme n t . I n a d d i t i o n , y o u m a y e n r o l l i n Ca r a h so f t ' s h e a l t h p l a n i f y o u become eligible for a state premium assistance p r ogr a m u n d e r M e d i c a i d o r CH I P. Yo u m ust r e q u e st e n r ol l me n t within 60 days after you gain eligibility for me d i c a l p l a n c o v e r a ge . I f y o u r e q u e st t h i s c h a n g e , c ov e r a g e w ill b e effective the first of the month following your r e qu e st f o r e n r o l l m e n t . S p e c i f i c r e st r i c t i o n s m a y a p p l y , d e p e n d in g o n federal and state law.

Note: If your dependent becomes eligible for a spe c i a l e n r o l l m e n t r i g h t , y o u m a y a d d t h e d e p e n d e nt t o y o ur c u r r e n t coverage or change to another health plan.

AVAILABILITY OF PRIVACY PRACTICES NOTICE We maintain the HIPAA Notice of Privacy Prac t i c e s f or Ca r a h so f t d e sc r i b i n g h o w h e a l t h i n f o r m a t i on a b o u t y o u may be used and disclosed. You may obtain a c opy o f t h e N o t i c e o f P r i v a c y P r a c t i c e s b y c o n t a c t i n g t h e H u m a n Resources Department.

21

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) I f you or your ch ildren are eligible for Medica i d o r C H I P a n d y o u ’ r e e l i g i b l e f o r h e a l t h c o v e r a g e f r o m y o u r employer, your state may have a premium assis t a n c e p r o g r a m t h a t c a n h e l p p a y f o r c o v e r a g e , u si n g f u n d s f r o m th e ir Medicaid or CHIP programs. If you or your ch i l d r e n a r e n ’t e l i g i b l e f o r M e d i c a i d o r CH I P, y o u w o n ’t b e e lig ib le f o r t h ese premium a ssistance programs but you ma y b e a b l e t o b u y i n d i v i d u a l i n su r a n c e c o v e r a g e t h r o u g h t h e H e a lth I n surance Marke tplace. For more information, v i si t w w w. h e a l t h c a r e . g o v .

I f you or your de pendents are already enrolled i n M e d i c a i d o r CH I P a n d y o u l i v e i n a S t a t e l i st e d b e l o w, c o n ta c t your State Medicaid or CHIP office to find out i f p r e m i u m a ssi st a n c e i s a v a i l a b l e .

I f you or your de pendents are NOT currently e n r o l l e d i n M e d i c a i d o r CH I P, a n d y o u t h i n k y o u o r a n y o f y o u r dependents might be eligible for either of thes e p r o g r a m s, c o n t a c t y o u r S t a t e Me d i c a i d o r C H I P o ff i c e o r d ia l 1-877-KIDS NOW or www.insurekidsnow.gov t o f i n d o u t h o w t o a p p l y. I f y o u q u a l i f y, a sk y o u r st a t e i f i t h a s a program that might help you pay the premiums f o r a n e m p l o y e r sp o n so r e d p l a n . I f y o u o r y o u r d e p e n d e nts are eligible for premium assistance under Medi c a i d o r CH I P, a s w e l l a s e l i g i b l e u n d e r y o u r e m p l o y e r p l a n , y o u r employer must allow you to enroll in your emp l o y e r p l a n i f y o u a r e n ’t a l r e a d y e n r o l l e d . Th i s i s c a l l e d a “ s p e c ia l enrollment” opportunity, and you must request c o v e r a g e w i t h i n 6 0 d a y s o f b e i n g d e t e r m i n e d e l i g i b l e f o r p r e miu m assistance. If you have questions about enrolli n g i n y o u r e m p l o y e r p l a n , c o n t a c t t h e D e p a r t m e n t o f L a b o r a t www.askebsa.do l.gov or call 1-866-444-EBSA ( 3 2 7 2 ) .

I f you live in on e of the following states, you m a y b e e l i g i b l e f o r a ssi st a n c e p a y i n g y o u r e m p l o y e r h e a l t h pla n premiums. The following list of states is curre n t a s o f Ju l y 3 1 , 2 0 1 8 . Co n t a c t y o u r S t a t e f o r m o r e i n f o r m a t i o n o n eligibility –

AL ABAMA - Me dica id

FLO R IDA - Me d i cai d

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

We b si t e : h t t p : / / f l m e d i c a i d t p l r e c o v e r y. c o m / h i p p / Phone: 1-877-357-3268

AL ASKA - Me dica id

G EO R G IA - Me d i cai d

The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@ MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/def a u l t . a sp x

We b si t e : h t t p : / / d c h . g e o rg i a . g o v / m e d i c a i d - Cl i c k o n H e a l t h I n su r a n c e P r e m i u m P a y m e n t ( H I P P ) Phone: 404-656-4507

AKANSAS - Me dica id

IN DIAN A - Me d i cai d

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

H e a l t h y I n d i a n a P l a n f o r l o w - i n c o m e a d u l t s 1 9 - 64 We b si t e : h t t p : / / w w w. i n . g o v / f ssa / h i p / Phone: 1-877-438-4479 All other Medicaid We b si t e : h t t p : / / w w w. i n d i a n a m e d i c a i d . c o m Phone 1-800-403-0864

COLO R ADO – Hea l t h First Colora d o ( Co l o ra do ’s Me dica id Prog ra m) & Ch i l d Hea l t h Pla n Plu s (CHP+)

IOWA – Me d i cai d

Health First Colorado Website: https://www.he althfirstcolorado.com/ Health First Colorado Member Contact Center : 1-800-221-3943/ State Relay 711 CHP+ : Colorado.gov/HCPF/Child-Health-Plan - P l u s CHP+ Customer Service: 1-800-359-1991/ State Relay 711

We b si t e : h t t p s: / / d h s. i o w a . g o v / h a w k - i Phone: 1-800-257-8563

22

KANSAS – Me dica id

N EW H AMP S H IR E – M e d i cai d

Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512

We b si t e : h t t p s: / / w w w. d h h s. n h . g o v / o m b p / n h h p p / P h o n e : 6 0 3 - 2 7 1 - 5 2 1 8 H o t l i n e : N H Me d i c a i d S e r v ic e Center at 1-888-901-4999

KE NTUCKY – Me dica id

N EW J ER S EY – M e d i cai d an d CH IP

Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

Me d i c a i d We b si t e : h t t p : / / w w w. st a t e . n j . u s/ h u m a n se r v i c e s/ d m a h s/ c l i e n t s/ m e d i c a i d / Me d i c a i d P h o n e : 6 0 9 - 6 3 1 - 2 3 9 2 C H I P We b si t e : h t t p : / / w w w. n j f a m i l y c a r e . o rg / i n d e x . h tml CHIP Phone: 1-800-701-0710

LOUISIANA – Me dica id

N EW YO R K – M e d i cai d

Website: http://dhh.louisiana.gov/index.cfm/su b home/1/n/331 Phone: 1-888-695-2447

We b si t e : h t t p s: / / w w w. h e a l t h . n y. g o v / h e a l t h _ c a r e / m e d ic aid/ Phone: 1-800-541-2831

MAINE – Me dica id

N O RT H CAR O LIN A – M e d i cai d

Website: http://www.maine.gov/dhhs/ofi/publi c a ssi stance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711

We b si t e : h t t p s: / / d m a . n c d h h s. g o v / Phone: 919-855-4100

MA SSAC HUSE T TS – Me dica id a n d CH IP

N O RT H DAKOTA – M e d i cai d

Website: http://www.mass.gov/eohhs/gov/depa r t m e n t s/ masshealt h/ Phone: 1-800-862-4840

We b si t e : h t t p : / / w w w. n d . g o v / d h s/ se r v i c e s/ m e d i c a ls e r v / medicaid/ Phone: 1-844-854-4825

MINNE SOTA – Me dica id

O KL AH O M A – Me d i cai d an d CH IP

Website: http://mn.gov/dhs/people-weserve/se n i o r s/ We b si t e : h t t p : / / w w w. i n su r e o k l a h o m a . o rg health-care/health-careprograms/programs-and - se r v i c e s/ P h o n e : 1 - 8 8 8 - 3 6 5 - 3 7 4 2 medical-assistance.jsp Phone: 1-800-657-3739 MISSOURI – Me dica id

O R EG O N – Me d i cai d

Website: http://www.dss.mo.gov/mhd/particip a n t s/ p a g es/hipp.ht m Phone: 573-751-2005

We b si t e : h t t p : / / h e a l t h c a r e . o r e g o n . g o v / P a g e s/ i n de x . a s p x h t t p : / / w w w. o r e g o n h e a l t h c a r e . g o v / i n d e x - e s. h t m l Phone: 1-800-699-9075

MONTANA – Me dica id

PEN N SYLVAN IA – Me d i cai d

Website: http://dphhs.mt.gov/MontanaHealthc a r e P r o grams/HIPP Phone: 1-800-694-3084

We b si t e : h t t p : / / w w w. d h s. p a . g o v / p r o v i d e r / m e d i c a la s s is t a n c e / h e a l t h i n su r a n c e p r e m i u m p a y m e n t h i p p p r o g r a m/ index.htm Phone: 1-800-692-7462

NE BRASKA – Me dica id

R H O DE IS L AN D – M e d i cai d

Website: http://www.ACCESSNebraska.ne.go v Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-11 7 8

We b si t e : h t t p : / / w w w. e o h h s. r i . g o v / Phone: 855-697-4347

NEVADA – Me dica id

S O UT H CAR O LIN A – Me d i cai d

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

We b si t e : h t t p s: / / w w w. sc d h h s. g o v Phone: 1-888-549-0820

SOUTH DAKOTA - Me dica id

WAS H IN G TO N – Me d i cai d

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

We b si t e : h t t p : / / w w w. h c a . w a . g o v / f r e e - o r- l o w - c o s th e a l t h - c a r e / p r o g r a m - a d m i n i st r a t i o n / p r e m i u m - p a y ment-program Phone: 1-800-562-3022 ext. 15473

T EXAS – Me dica id

WEST VIR G IN IA – M e d i cai d

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

We b si t e : h t t p : / / m y w v h i p p . c o m / To l l - f r e e p h o n e : 1 - 8 5 5 - My W V H I P P ( 1 - 8 5 5 - 6 9 9 - 8 4 4 7 )

23

UTAH – Me dica id a n d CHIP

WIS CO N S IN – M e d i cai d an d CH IP

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

We b si t e : h t t p s: / / w w w. d h s. w i sc o n si n . g o v / p u b l i c a tio n s / p1/p10095.pdf Phone: 1-800-362-3002

VE RMONT – Me dica id

WYO MIN G – Me d i cai d

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

We b si t e : h t t p s: / / w y e q u a l i t y c a r e . a c s- i n c . c o m / Phone: 307-777-7531

VI RG INIA – Me dica id a n d CHIP Medicaid Website: http://www.coverva.org/pro g r a m s_ premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/progra m s_ p r e mium_assistance.cfm CHIP Phone: 1-855-242-8282

To see if any other states have added a premium a ssi st a n c e p r o g r a m si n c e Ju l y 3 1 , 2 0 1 8 , o r f o r m o r e i n f o r ma tio n o n special enrollment rights, contact either: U. S . Depar tm e nt of L a bor

U. S . De par t m e n t o f H eal t h an d H u m an S e r vi ces

Employee Benefits Security Administration www.dol.gov/ag encies/ebsa 1-866-444-EBSA (3272)

Ce n t e r s f o r Me d i c a r e & Me d i c a i d S e r v i c e s w w w. c m s. h h s. g o v 1 - 8 7 7 - 2 6 7 - 2 3 2 3 , Me n u O p t i o n 4 , E x t . 6 1 5 6 5

Pap er wo rk Redu c t ion Ac t St a te m e nt According to the Paperwork Reduction Act of 19 9 5 ( P u b . L . 1 0 4 - 1 3 ) ( P RA ) , n o p e r so n s a r e r e q u i r e d t o r e s p o n d to a collection of information unless such collect i o n d i sp l a y s a v a l i d O ff i c e o f Ma n a g e m e n t a n d Bu d g e t ( O MB ) c o n tr o l number. The De partment notes that a Federal a g e n c y c a n n o t c o n d u c t o r sp o n so r a c o l l e c t i o n o f i n f o r m a t i o n u n le s s i t is approved by OMB under the PRA, and disp l a y s a c u r r e n t l y v a l i d O M B c o n t r o l n u m b e r, a n d t h e p u b l i c is n o t r e quired to respo nd to a collection of informat i o n u n l e ss i t d i sp l a y s a c u r r e n t l y v a l i d O M B c o n t r o l n u m b e r. S e e 4 4 U.S.C. 3507. Also, notwithstanding any other p r o v i si o n s o f l a w, n o p e r so n sh a l l b e su b j e c t t o p e n a l t y f o r f a ilin g t o comply with a collection of information if th e c o l l e c t i o n o f i n f o r m a t i o n d o e s n o t d i sp l a y a c u r r e n t l y v a l id O M B control number. See 44 U.S.C. 3512.

The public reporting burden for this collection o f i n f o r m a t i o n i s e st i m a t e d t o a v e r a g e a p p r o x i m a t e l y se v e n m in u te s per respondent. Interested parties are encoura g e d t o se n d c o m m e n t s r e g a r d i n g t h e b u r d e n e st i m a t e o r a n y o th e r aspect of this collection of information, includ i n g su g g e st i o n s f o r r e d u c i n g t h i s b u r d e n , t o t h e U . S . D e p a r t me n t o f Labor, Employee Benefits Security Administra t i o n , O ff i c e o f P o l i c y a n d Re se a r c h , A t t e n t i o n : P RA C l e a r a n c e O ff icer, 200 Constitu tion Avenue, N.W., Room N-5 7 1 8 , Wa sh i n g t o n , D C 2 0 2 1 0 o r e m a i l e b sa . o p r @d o l . g o v a n d r e f e r e n c e t h e OMB Control Number 1210-0137.

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