2025 2026
Total Rewards Guide
We are pleased to offer you a comprehensive total rewards program intended to protect your well-being and financial health. This guide is your opportunity to learn more about the benefits available to you and your eligible dependents beginning November 1, 2025 . Getting the most value from your benefits depends on how well you understand your plans and how you choose to use them. Please take the time to review this guide.
Availability of Summary Health Information
You have a choice between two medical plan networks. Both plans have the same in-network deductible, maximum out-of-pocket, and copays. One plan includes out-of-network benefits. A Summary of Benefits and Coverage (SBC) documents for each plan are available summarizing important information about your health coverage in a standard format. The SBCs are available at https://access.paylocity.com/ under Bswift Benefits from HR & Payroll on the top left of the Paylocity homepage.
If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, federal law gives you more choices about your
Please see page 29 for more details.
Important Contacts
Medical and Rx
24-Hour Nurseline
Aetna/#450513
Aetna
Health Advocacy/Virtual Care HealthJoy
Employee Assistance Program
Dental
Vision
Flexible Savings Accounts
Life and AD&D
Family and Medical Leave of Absence
Disability
Accident and Critical Illness
Legal Identity Theft
Pet Insurance
Aetna Resources for Living myStrength app/#632253
Aetna/#450513
Aetna/#450513
Higginbotham
New York Life Life: #FLX969571 AD&D: #0K971004
New York Life/Group Benefit Solutions (NYL GBS)/#FML-961102
New York Life
Short Term Disability: FLK-961102
Long Term Disability: FLK-961103
Allstate/#35611
LegalShield/#204125 IDShield/#204125
Nationwide/#N10342
Medical: 888-416-2277 Rx: 888-792-3862
800-556-1555
www.aetna.com
N/A
877-500-3212 support@healthjoy.com
888-238-6232
www.resourcesforliving.com Login: ACH Services Password: EAP
877-238-6200 www.aetna.com
877-973-3238 www.aetnavision.com
866-419-3519
800-362-4462 Fax: 877-300-6770
flexservices.higginbotham.net email: flexclaims@higginbotham.net
Claim Forms: www.nyl.com/customer-forms claims.pghlif2@newyorklife.com
888-842-4462 (English) 866-562-8421 (Spanish) www.mynylgbs.com
888-842-4462 Fax: 800-642-8553 gbsintakepaper@newyorklife.com
800-521-3535
888-807-0407
www.allstatebenefits.com/mybenefits
www.mylegalshield.com www.idshield.cloud/login
877-738-7874 www.petinsurance.com/ACHservices
https://ACH.BenefitHub.com customercare@benefithub.com 401(k) Empower/#5000348-01
866-664-4621
800-338-4015 https://participant.empower-retirement.com
To access the most recent electronic copy of the Total Rewards Guide, go to The Loop/HR/Benefits
Helpful Apps to Download
Aetna Health
HealthJoy
Description Link
Search for in-network providers and facilities and see what procedures may cost. See claims details and access your ID card, etc.
Access to telemedicine. Healthcare concierges who can advocate on your behalf for medical bills. Online medical consultations, recommendations, and prescription savings.
Apple App Store (iPhone/iPad): https://apps.apple.com/us/app/aetna-health/id1261033071
Google Play Store (Android): https://play.google.com/store/search?q=aetna&c=apps
Apple App Store (iPhone/iPad): https://apps.apple.com/us/app/healthjoy/id1104881108
Google Play Store (Android): https://play.google.com/store/search?q=healthjoy&c=apps myStrength
Emotional health support. Connect with a licensed therapist from the comfort of home. Get 24/7 access online or via the mobile app.
® Higginbotham FSA
Check your account summary, available balances, claims requiring receipts, statements, and notifications.
Guidance Resources (via NYL)
LegalShield
Employee assistance and wellness support during life’s challenges. Financial, legal, and estate support to help you navigate through stressful times.
Apple App Store (iPhone/iPad): https://apps.apple.com/us/app/mystrength-by-teladoc-health/ id1446491603
Google Play Store (Android): https://play.google.com/store/apps/details?id=com.mystrength.cross. MyStrength
Apple App Store (iPhone/iPad): https://apps.apple.com/us/app/higginbotham-fsa/id1558901680
Google Play Store (Android): https://play.google.com/store/search?q=higginbotham&c=apps
Apple App Store (iPhone/iPad): https://apps.apple.com/sr/app/guidanceresources-now/id556008763
Google Play Store (Android): https://play.google.com/store/apps/details?id=com.compsych. gro&hl=en_US&gl=US&pli=1
Legal support and answers to legal questions, help with estate planning, and will preparation.
Apple App Store (iPhone/iPad): https://apps.apple.com/us/app/legalshield-law-firms-on-call/ id924247236
Google Play Store (Android): https://play.google.com/store/search?q=legalshield&c=apps
IDShield
Identity theft protection and credit monitoring. Credit score tracker, alerts for fraudulent activity, and support for identity theft restoration.
Apple App Store (iPhone/iPad): https://apps.apple.com/us/app/%CE%B9dshield-protect-what-matters/ id1444809858
Google Play Store (Android): https://play.google.com/store/search?q=idshield&c=apps
Helpful Apps to Download
APP Description Link
Paylocity
Access personal HR and pay information through the Paylocity app. For benefits information, visit https://access.paylocity.com/. Click on the Bswift Benefits tab from HR & Payroll on the top left of the homepage.
Access your mileage and trip expenses. Create, delete, view, edit, and submit company trip and expense records.
Expense report tracking from the point of purchase to accounting.
EQ2
Empower 401(k)
Provides direct care staff with a diverse toolkit that reinforces the skills taught in the EQ2 program. Includes daily check-in and supportive messages.
Camp Gladiator offers outdoor and virtual boot camps led by certified trainers. Workouts are designed for all fitness levels, focusing on strength, endurance, agility, and flexibility in a motivating community.
As a part of your plan, your account dashboard gives you a real time view of spending, saving, debt and more so you can track, manage and plan all your financial priorities in one place.
Apple App Store (iPhone/iPad): https://apps.apple.com/us/app/paylocity-mobile/id652438572
Google Play Store (Android): https://play.google.com/store/apps/details?id=com.paylocity. paylocitymobile&hl=en_US&gl=US
Apple App Store (iPhone/iPad): https://apps.apple.com/us/app/suremobile/id656746421
Google Play Store (Android): https://play.google.com/store/search?q=suremobile&c=apps
Apple App Store (iPhone/iPad): https://apps.apple.com/us/app/sap-concur/id335023774
Google Play Store (Android): https://play.google.com/store/apps/details?id=com.concur. breeze&hl=en_US
Apple App Store (iPhone/iPad): https://apps.apple.com/us/app/eq2-staff-support/id1618835187
Google Play Store (Android): https://play.google.com/store/apps/details?id=com.eq2.app
Apple App Store (iPhone/iPad): https://apps.apple.com/us/app/camp-gladiator/id648465971
Google Play Store (Android): https://play.google.com/store/search?q=camp%20gladiator&c=apps
Apple App Store (iPhone/iPad): https://apps.apple.com/us/app/empower/id1001257338
Google Play Store (Android): https://play.google.com/store/apps/details?id=com. participantmobileapp&hl=en_US
SureMobile
Concur
Camp Gladiator
Eligibility
You are eligible for benefits if you are a regular, full-time employee working an average of 30 hours per week*. Your coverage is effective the first of the month following your date of hire or change to full-time status.
You may enroll eligible dependents for benefits coverage. Eligible dependents include:
• Your legal spouse
• Children under the age of 26 regardless of student, dependency, or marital status
• Children over the age of 26 who are fully dependent on you for support due to a mental or physical disability, and who are indicated as such on your federal tax return (documentation may be required)
* Part-time employees are eligible for the following benefits: HealthJoy, Aetna’s Resource for Living, Employee Assistance Program (EAP), BenefitHub, and 401(k).
Enrollment
OPEN ENROLLMENT
Open Enrollment (OE) is your opportunity to choose benefits for the upcoming plan year (November 1, 2025 - October 31, 2026). You must enroll in benefits to have coverage effective November 1, 2025. If you wish to participate in the Flexible Spending Accounts (FSAs) program, you must determine your contribution and make that election.
New Hires
You should make your benefit elections as soon as possible. You have 30 days from your date of hire to enroll; however, if you do not complete your enrollment before the first day of the month following your date of hire, you may receive a double payroll deduction on your paycheck. If you do not make any elections, you will not have benefits coverage (except for company-paid benefits), and you will have to wait until the next OE period to enroll unless you experience a Qualifying Life Event (QLE) during the plan year.
Enrolling for Benefits
To make your benefit elections, including new hire enrollment or a QLE, log on to https://access.paylocity.com and select Bswift Benefits from HR & Payroll on the top left of the homepage.
Qualifying Life Events
Your benefit elections remain in effect for the entire plan year until the following OE. You may only change coverage during the plan year if you have a QLE, and you must do so within 31 days of the event.
• Marriage, divorce, legal separation, or annulment
• Birth, adoption, or placement for adoption of an eligible child
• Death of a spouse or child
• Change in your spouse’s employment that affects benefits eligibility
• Change in your child’s eligibility for benefits (e.g., reaching the age limit)
• Change in residence that affects your eligibility for coverage
• Significant change in coverage or cost in your, your spouse’s, or your child’s benefit plans
• FMLA event, COBRA event, or court judgment or decree
• Becoming eligible for Medicare, Medicaid, or TRICARE
• Receiving a Qualified Medical Child Support Order
If you have a QLE and want to request a midyear change, you must notify Human Resources and complete your election changes within 31 days following the event. Email documentation of your change to hrconnect@achservices.org
Remember
You must notify Human Resources when you experience a Qualifying Life Event. This includes adding a newborn or child placed for adoption. You need to do so within 31 days of the date of the event.
When Benefits Start and End
Medical/Rx, HealthJoy, Dental, FSA
Vision, Legal/Identity Theft
EAP, Life and AD&D, Disability
Accident, Critical Illness
First day of the month following date of hire
First day of the month following date of hire
First day of the month following date of hire
First day of the month after hire date or enrollment, whichever is later
Payroll Deductions (Biweekly)
Last day at ACH/OCOK
Last day of the month you leave ACH/OCOK
Last day at ACH/OCOK (some benefits may be portable; check plan summaries for details)
Last day at ACH/OCOK; benefits are portable
Coverage continues as long as premiums are paid to Nationwide
Note: Premiums are not prorated when coverage is terminated mid-month.
Additional Benefits
• HealthJoy – Paid by ACH/OCOK (page 11)
• EAP – Paid by ACH/OCOK (page 12)
• Basic Life and AD&D – Paid by ACH/OCOK (page 17)
• Voluntary Life and AD&D – See rates on page 17
• Short Term Disability – Paid by ACH/OCOK (Buy-up Protection rate shown on page 18)
• Long Term Disability – Paid by ACH/OCOK (Buy-up Protection rate shown on page 18)
• Accident – See rates on page 20
• Critical Illness – See rates on page 21
• Legal/ID Theft – See rates on page 22
• Pet Insurance – Contact Nationwide for quote (page 23)
• 401(k) – Manage your account by logging into Empower (page 26)
Medical Coverage
The medical plan offered through Aetna protects you and your family from major financial hardship in the event of illness or injury.
You have a choice of two networks:
• Aetna Choice POS II (Broader) Network
• Aetna Whole Health Open Access Select Network
Aetna Choice POS II (Broader) Network
If you enroll in this network, you will have a higher cost per paycheck and a broader network of providers. When you use in-network providers, you receive services at a discounted network cost. You will pay more for services if you use an outof-network provider. To search for providers in the network, go to https://www.aetna.com/docfind , enter your ZIP code and click search, then select the Aetna Choice POS II (Open Access) plan.
Aetna Whole Health Open Access Select (Limited) Network
If you enroll in this network, you will have a lower cost per paycheck and a more limited network of providers. When you use in-network providers, you receive services at a discounted network cost. There are no out-of-network benefits if you select this network. To search for providers in the network, go to https://www.aetna.com/docfind, enter your ZIP code and click search, then select (TX) Aetna Whole Health - Texas Health Aetna Select/OA Aetna Select/OA Elect Choice plan.
Balance Billing (Surprise Billing)
When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. See a detailed explanation in the Required Notices section of this guide.
Calendar Year Deductible and Out-of-Pocket Maximum
Qualified health care expenses that apply toward your annual deductible and out-of-pocket maximum are credited on a calendar year basis. Both your deductible and out-of-pocket maximum resets to $0 on January 1 each year, regardless of the expenses incurred the previous year or when your enrollment occurred.
You’re in good hands.
MEDICAL BENEFITS SUMMARY
Calendar Year Deductible
(See page 16 for assistance in paying your deductible) •
Calendar Year Out-of-Pocket Maximum
Includes
coinsurance and copays •
Retail Pharmacy (Up to 30-day supply)
• Generic
• Preferred brand name
• Non-preferred brand name
• Specialty (PrudentRx)
Mail Order Pharmacy (31 to 90-day supply)
• Generic •
1 After deductible
copay
copay
copay
copay
2 You must pay a $400 penalty per occurrence for failure to preauthorize the following services: hospital admissions, treatment facility admissions, convalescent facility admissions, home health care, hospice care and private duty nursing. Download the Aetna Health app
PRESCRIPTION DRUG COVERAGE
To locate the prescription drug list (formulary), visit the Aetna portal. Not every prescription drug is covered.
• Mandatory Generics — Your prescription will be filled with a generic equivalent if one is available. If you or your physician request a brand name drug, you will pay the brand name level copay, plus the difference in cost between the generic and brand name.
• Maintenance Medications — After two retail pharmacy fills, you are required to fill a 90-day supply at CVS Caremark Mail Service Pharmacy (mail order) or CVS Pharmacy. You are automatically enrolled in this feature to save you money. You may opt out by contacting Aetna.
Specialty Drugs
PrudentRx Copay Program — Aetna has partnered with PrudentRx , which allows you to get your specialty drugs for $0 when you fill at CVS Specialty. The medication must be on the plan’s Exclusive Specialty Drug List*. In order to take advantage of this program, you will need to enroll in the PrudentRx program. Call 800-578-4403 to register. If you do not contact PrudentRx, you will be responsible for 30% of the cost of your specialty medications.
*You will need to pay 20% ($300 maximum) for limited distribution drugs/ transplant medications.
Contact PrudentRx
• Call 800-578-4403 to register in the program.
• If you do not contact PrudentRx, you will be responsible for 30% of the cost of your specialty medications.
ACH/OCOK partners with HealthJoy to provide you with health care guidance and virtual medical consultations at no cost to you.
This program is available to all employees and is available at no cost to you and your eligible family members, including spouses and dependent children. Be sure to add your family members to your HealthJoy profile. Download the HealthJoy app to your mobile device to access these services.
Virtual Care
HealthJoy provides 24/7/365 access to U.S. board-certified doctors in less than 15 minutes. While it does not replace your primary care physician, HealthJoy is a convenient and costeffective option if you cannot see your primary care physician and you:
• Have a non-emergency issue and are considering an urgent care clinic or emergency room for treatment
• Are on a business trip, vacation, or away from home
Get the Care You Need
HealthJoy doctors can treat many medical conditions, including:
• Cold/flu symptoms
• Allergies
• Bronchitis
• Urinary tract infections
• Respiratory infections
• Sinus problems
HealthJoy offers consultations in the following areas for a fee:
• Dermatology ($85 consult fee)
• Nutrition ($59 consult fee)
Contact HealthJoy
• Call 877-500-3212
• Download the HealthJoy app
• Email support@healthjoy.com
Therapy Services (ages 13+): Choose a therapist or psychologist who fits your or your minor dependents’ needs and schedule visits seven days a week from wherever you are most comfortable.
Psychiatric Medication Management (ages 18+): Consult with a board-certified psychiatrist for to receive medication evaluation and management support for anxiety, depression, mood disorder, PTSD, and a variety of other mental health diagnoses.
Mental Health consults are unlimited through HealthJoy with Teladoc providers. If you are currently under the care of a provider and would like to transition your care, you are able search for your provider in the HealthJoy app.
Healthcare Concierge
HealthJoy can help answer your health care questions and guide you through the complexities of your medical, dental, vision, and FSA plans. HealthJoy services are simple to use and available to you and your family members through the mobile app.
• Provider Recommendations — The concierge will research and confirm for in-network participation and availability. HealthJoy can schedule your appointments with specialists and facilities, including schedule testing.
• Health Cost Estimation — The concierge will provide price comparisons before you receive care. Even when you use innetwork providers, costs for services can vary by hundreds or thousands of dollars.
• Prescription Drug Savings — HealthJoy can compare medication prices and explore lower-cost options for you.
• Medical Bill Review — HealthJoy will review your bill, answer any questions, and negotiate to save you money.
GLP-1 Management
What’s new:
• Instant price comparison across pharmacies (powered by GoodRx)
• Easier discovery of generic alternatives and manufactures coupons
• In-app reminders of eligible prescription programs (if applicable)”
Activate your HealthJoy account
Employee Assistance Program
MYSTRENGTH
myStrength is an online wellness suite of articles, videos, and more that can help you with:
• Stress and anxiety
• Depression
• Nicotine recovery
• Mindfulness
• Being a new parent
• Chronic pain
• Sleep
• Substance misuse
If you download the myStrength app, you can also get custom inspiration on your smartphone, track your mood over time, upload inspiring photos, and opt in to receive check in reminders.
AETNA RESOURCES FOR LIVING
If you need telephone assistance with personal issues, you have access to call 888-238-6232 to receive up to six confidential face-to-face assessment and counseling sessions for matters such as:
• Childcare/eldercare
• Alcohol/drug abuse
• Grief and loss
• Financial and legal concerns
Talkspace is an online therapy platform that makes it easy and convenient for you to connect with a licensed behavioral therapist. You can send unlimited text, video, and audio messages to your dedicated therapist via a web browser or the Talkspace app You can also schedule real-time, 30-minute live sessions (a total of six counseling sessions are available to you each year utilizing combined telephone and online live sessions). To get started, visit www.talkspace.com/rfl and complete a short questionnaire. You will be matched with a therapist within 48 hours. You will have 120 days from the date you sign up to use your sessions.
Aetna Resources For Living has a $0 copay!
Gym Discounts
DISCOUNTS
Wellness
NUTRITION COACHING
If you enroll for medical coverage, you will have access to Aetna’s Nutrition Coaching through HUSK . Your first visit is FREE . If you reach the required >25 Body Mass Index (BMI), you can meet with a Registered Dietitian up to 10 visits per year for free. You must meet the criteria for enrollment.
Personalized for Your Lifestyle
• Convenient Visits — Visits are conducted via Zoom. Join from the computer or a smartphone.
• Exercise and Diet App — Take control of your goals, track calories, break down ingredients, and log activities.
• Custom Plans — Get a plan designed by an expert and customized to support your goals and unique lifestyle.
• Backed by Science — There are no fad diets or magic pills. HUSK uses science to guide you step-by-step toward lifelong results.
Scan the QR code associated with your plan to register and schedule your first visit!
LifeMart makes everyday life more affordable with exclusive savings on travel, entertainment, wellness, child and senior care, home, auto, and more—all from trusted brands in one convenient place. Simply search by category, select an offer, and follow the redemption instructions to save.
• Visit www.aetna.com, go to the Health & Wellness tab, and access the LifeMart Discount Website through the Wellness Discounts tiles.
• Download the LifeMart mobile app
CAMP GLADIATOR FITNESS PROGRAM
(Outside and Online Workout Programs)
This voluntary benefit is paid by you. You will be billed monthly direct from Camp Gladiator.
As an employee of ACH/OCOK you can sign up for any BOLD membership and receive a 10% discount. Once registered, you can use the CampGladiator app or connect with your trainer to check in to your workout and track your progress. Points will be awarded with your workouts that can be used for discounts on Camp Gladiator gear and much more!
Contact Camp Gladiator
• Visit www.campgladiator.com and register using your ACH/OCOK email address.
• Select “ACH” as your employer in the billing section of your profile online or with your trainer.
• Check your email to complete the employee verification process and the 10% discount will be added to your account automatically and applied to your monthly bill.
Aetna Whole Health OA
Aetna Choice POS ll
Dental Coverage
Our dental plan helps you maintain good oral health through affordable options for preventive care, including regular checkups and other dental work. Coverage is provided through Aetna and the PDNII Network .
Dental ID Card
You will not receive an ID card in the mail. View your benefits on the HealthJoy app (see page 11 for details).
DENTAL BENEFITS SUMMARY
• Visit www.aetna.com
• Call 877-238-6200
You Pay
Preventive Services
Exams, cleanings, X-rays, fluoride treatments, space maintainers, sealants (permanent molars)
Basic Services
Fillings, scaling and root planing, uncomplicated extractions, oral surgery, gingivectomy, general anesthesia/intravenous sedation
Major Services
Surgical removal of impacted tooth, inlays/onlays, crowns, dentures, bridges, implants
1 Out-of-network providers have not agreed to negotiated fees and you could be balance billed for amounts over the Reasonable and Customary charge (90th percentile) and for non-covered services.
2 The calendar year is January 1 – December 31. Your calendar year deductible and benefit maximum will reset to $0 every January 1. Find an In-Network Dental Provider
Aetna
Vision Coverage
Our vision plan provides quality care to help preserve your health and eyesight. In addition to identifying vision and eye problems, regular exams can detect certain medical issues such as diabetes and high cholesterol. You may seek care from any licensed optometrist, ophthalmologist, or optician, but plan benefits are better if you use an in-network provider. Coverage is provided by the Aetna Vision Network .
VISION BENEFITS SUMMARY
• Vision
• Contacts fitting
• Single vision
• Bifocals
• Trifocals
• Lenticular
• Standard progressive
copay
copay
copay
copay
Additional pairs of eyeglasses or prescription sunglasses
Lasik Laser vision correction or PRK from U.S. Laser Network, 800-422-6600
Exam
Flexible Spending Accounts
FSAs let you save on taxes for certain health and dependent care expenses.
When you enroll, you decide how much you want to contribute to your account(s) for the year. Deductions are taken pretax from each paycheck and deposited into your account(s). When you incur expenses and submit claims, you are reimbursed with pretax dollars from your account.
The Health Care FSA is for eligible expenses not covered by a medical, prescription drug, dental, or vision plan (including copays, deductibles, and coinsurance). The Dependent Care FSA is for eligible eldercare/ daycare expenses. Higginbotham is the administrator of these plans. Contributions are spread across 26 pay periods (example: $500 ÷ 26 = $19.23 per paycheck).
Important Rules
• Expenses incurred between November 1, 2025 and October 31, 2026 (or your date of termination, if earlier) are eligible for reimbursement. Claims must be filed by December 30, 2026.
• You cannot change your election during the year unless you experience a QLE.
• For 2025, you can carry over up to $660 in your Health Care FSA into the next plan year. Any amount over the carryover amount in your account will be forfeited, per the IRS. The carryover rule does not apply to your Dependent Care FSA.
Health Care FSA Dependent Care FSA
• Eligible Expenses — Medical, dental, vision, and hearing expenses not covered by your health plan. For a complete list of expenses, visit flexservices.higginbotham.net or www.irs.gov and search for IRS Publication502.
• Annual Contribution Maximum — For 2025, you may contribute up to $3,300 to your account.
• Reimbursement Details — Pay for services with your FSA debit card at most locations or reimburse yourself the total amount of your claim up to the amount you elected to contribute for the year. Keep all receipts for your purchases as you may be required to substantiate expenses or if you receive an IRS audit.
• Eligible Expenses — Dependent or eldercare expenses so you and your spouse can work or attend school full-time.
• Annual Contribution Maximum — You may contribute up to $5,000 to your account ($2,500 if married and filing separate tax returns).
• Reimbursement Details — Receive reimbursement for the amount of your claim up to the amount currently available in your account at the time of your claim. The FSA debit card cannot be used for dependent care expenses.
Contact Higginbotham
• Visit flexclaims@higginbotham.net
• Call 866-419-3519
• Download the Higginbotham FSA app
Life and AD&D Insurance
Life and Accidental Death and Dismemberment (AD&D) insurance are important parts of your financial security, especially if others depend on you for support.
With Life insurance, your beneficiary(ies) can use the coverage to pay off your debts such as credit cards, mortgages, and other final expenses. AD&D coverage provides specified benefits for a covered accidental bodily injury that causes dismemberment (e.g., the loss of a hand, foot, or eye). In the event that death occurs from an accident, 100% of the AD&D benefit would be payable to your beneficiary(ies).
BASIC LIFE AND AD&D
Basic Life and AD&D insurance are provided at no premium cost to you through New York Life if you are a full-time, active employee working at least 30 hours per week. Per IRS regulations, the value of the benefit amount over $50,000 is subject to Social Security and Medicare taxes (not the benefit itself). Upon disability or termination of employment, you may be able to convert to an individual policy.
VOLUNTARY LIFE AND AD&D
If you need additional coverage, you may purchase Voluntary Life and AD&D insurance for yourself and your eligible dependents through New York Life. You must purchase coverage for yourself in order to elect coverage for your spouse or children. You may enroll up to the Guaranteed Issue amount with no Evidence of Insurability (EOI) — proof of good health*.
Voluntary Life and AD&D
Employee Increments of $10,000 to the lesser of five times your annual salary or $500,000
Spouse Increments of $5,000 to the lesser of $500,000, or 100% of the employee amount
Child(ren) To age 26
Age
Reduction
Birth to six months: $1,000 Six months to 26 years: Increments of $2,000 up to $10,000
Benefits are reduced at age 65 and again at age 70
You may receive 100% of your voluntary life coverage (up to $500,000) if you are diagnosed with a terminal illness with a life expectancy of 12 months or less
Rates
Designating a Beneficiary
A beneficiary is the person or entity you designate to receive the death benefits of your Life and AD&D insurance policies. You can name more than one beneficiary, and you can change your beneficiary at anytime. If you name more than one beneficiary, you must identify the share for each person.
Child(ren) Monthly
Rates
(Includes all children.)
$0.23 per $1,000
Important: Two-year suicide exclusion applies. If you leave the company, you may be able to take the insurance with you.
See page 19 for calculation examples.
Disability Insurance
ACH/OCOK provides income replacement benefits to assist you and your family if you become disabled and cannot work due to a non-work-related illness or injury (including pregnancy and childbirth).
SHORT TERM DISABILITY
Benefits replace a portion of your earnings, less other income you may receive from other sources. Coverage is provided through New York Life See page 27 of this guide for information on how to file a disability claim.
ACH/OCOK provides a core Short Term Disability (STD) benefit at no cost to you. STD is not a standalone benefit and works in conjunction with FMLA. You may purchase additional buy-up coverage. The cost for additional coverage is based on your income. If you wait to purchase buy-up coverage after initially being eligible, you will need to complete medical questions and be approved prior to receiving coverage.
1 Earnings exclude bonuses and commissions, overtime pay, and extra compensation.
2 Includes the elimination period.
LONG TERM DISABILITY
NOTE: There is an elimination (waiting) period of 30 days in the core plan before you are eligible to receive benefits. You can enroll in the buy-up plan and reduce the elimination (waiting) period to 14 days.
ACH/OCOK provides a core Long Term Disability (LTD) benefit at no cost to you. You may purchase additional buy-up coverage. The cost for additional coverage is based on your income. If you die while receiving benefits, the plan will pay a survivor benefit to your spouse, eligible child(ren), or estate. The plan will pay a single lump-sum equal to three months of benefits. If you wait to purchase buy-up coverage after initially being eligible, you will need to complete medical questions and be approved prior to receiving coverage. There is a limited benefit period for mental or nervous disorders, alcoholism, drug addiction, or abuse.
1 Earnings exclude bonuses and commissions, overtime pay, and extra compensation.
2 A maximum payment period of two years.
3 A maximum payment period up to Social Security Normal Retirement Age (SSNRA).
4 Benefits are not payable for medical conditions if you received medical treatment, care, or services (including diagnostic measures) during the 3 month look back period. You are only eligible for benefits if the disability occurs after you have been insured under this plan for the 12 month waiting period.
See page 19 for calculation examples.
ACH/OCOK Disability & Parental Leave Examples
The Family and Medical Leave Act (FMLA) provides up to 12 weeks of job-protected leave in a 12-month period. Short Term Disability (STD) pays a portion of your income if you are unable to work due to your own health condition.
AT-A-GLANCE
Example A – Maternity Leave (8 weeks off, Core Benefit only)
• Paid Parental Leave: 2 weeks (ACH/OCOK benefit)
• STD Wait period: 4 weeks (Includes Parental Leave)
• STD Paid benefit: 4 weeks
Total: 6 weeks of pay (2 weeks parental leave + 4 weeks STD)
Example B – Maternity Leave (8 weeks off, Core + Buy-Up Benefit)
• Paid Parental Leave: 2 weeks (ACH/OCOK benefit)
• STD Wait period: 2 weeks (Includes Parental Leave)
• STD Paid benefit: 6 weeks
Total: 8 weeks of pay (2 weeks parental leave + 6 weeks STD)
Example C – Illness (12 weeks off, Core Benefit only)
• STD Wait period: 4 weeks (No benefit paid unless PTO available.)
• STD Paid benefit: 8 weeks
Total: 8 weeks of STD pay
Example D – Illness (12 weeks off, Core + Buy-Up Benefit)
• STD Wait period: 2 weeks (No benefit paid unless PTO available)
• STD Paid benefit: 10 weeks
Total: 10 weeks of STD pay
Accident Insurance
Active lifestyles may result in bumps, bruises, and sometimes breaks. Getting the right treatment is important to recovery, but it can be expensive.
For covered off-the-job accidental injuries, benefits are paid directly to you regardless of any other coverage you have, and you can spend it any way you choose. Benefits are paid according to a fixed schedule that includes hospitalization, fractures, dislocations, emergency room visits, major diagnostic exams, physical therapy, and more. You can enroll in the plan even if you are not enrolled in our medical plan. Coverage is provided through Allstate Benefits
Get all fixed up in a hurry.
Care Unit (pays
Sum Injuries (Dislocations, ruptured discs, eye injuries, fractures, lacerations, concussions, etc.)
A claim form for the wellness benefit is located on page 37 of this guide.
Critical Illness Insurance
A sudden illness such as heart attack, stroke, or cancer brings physical and financial stress. Appointments, tests, treatments, and medications can add to your stress level. Critical Illness coverage helps provide financial support if you are diagnosed with a covered critical illness. When a diagnosis occurs, you will receive a cash benefit based on the percentage payable for the condition. Coverage is provided through Allstate Benefits .
FEATURES OF THE PLAN
• Medical questions will not be asked if you enroll when first eligible
• Covered dependents receive 50% of your Basic Benefit Amount
• Benefits are paid regardless of any other medical or disability coverage
Advanced Alzheimer’s disease, advanced Parkinson’s disease, benign brain tumor, coma, paralysis
loss of hearing, sight, or speech
1 A Reoccurrence Benefit is paid for a second diagnosis when at least 12 months have passed after the initial diagnosis.
2 One per covered person per calendar year
Coverage For Children
Coverage for your children is provided at no additional cost. A claim form for the wellness benefit is located on page 37 of this guide.
Note: A Pre-existing Condition Limitation applies. Benefits will not be paid for a critical illness that is caused by, contributed to, or results from a pre-existing condition when the date of diagnosis is within 12 months after the effective date of coverage. A pre-existing condition is a sickness, injury or other condition, whether diagnosed or not, for which symptoms existed within the 12-month period prior to the effective date; or medical advice or treatment was recommended or received from a medical professional within 12 months prior to the effective date.
Legal/Identity Theft Insurance
If you need guidance and assistance with legal consultation, family, or small claims court assistance, you can work with local plan attorneys through LegalShield . Identity theft protection and identity restoration services are provided by IDShield.
Get Started
• Create your accounts at: www.mylegalshield.com and www.idshield.cloud/login
• Download the LegalShield and IDShield Plus apps to begin your will preparation and track identity alerts.
• If you have questions about setting up your account or forgot your member number, call 888-807-0407. If you’d like more information about your plans, visit www.benefits.legalshield.com/ach.
Legal Consultation and Advice
Court Representation
Dedicated Law Firm
Legal Document Preparation and Review
Letters and Phone Calls Made on Your Behalf
Speeding Ticket Assistance
Will Preparation
24/7 Emergency Legal Access
Identity Consultation and Advice
Dedicated Licensed Private Investigators
Identity and Credit Monitoring
Child Monitoring (family plan only)
Comprehensive Identity Restoration
Identity and Credit Threat Alerts
24/7 Emergency Access
Mobile App
Pet Insurance
You can purchase medical and preventive wellness insurance for your pets through Nationwide . Coverage is available for cats, dogs, birds, rabbits, reptiles, and other exotic animals. You can visit any veterinary clinic to receive a 50-80% reimbursement on your bills after a $250 deductible ($15,800 maximum annual benefit). Coverage includes the following benefits as well:
PET RX EXPRESS
Pet Rx Express can save you time and money at Walmart or Sam’s Club pharmacies. Download a digital pet insurance card at www.mypetinsurance.com and show the card at checkout. The pharmacy will submit the claim to Nationwide and you will be reimbursed for eligible expenses.
OPTIONAL WELLNESS COVERAGE
Preventive wellness coverage for dogs and cats includes vaccinations, flea protection, deworming, and more, as well as the additional option of spay and neuter services or teeth cleaning. Wellness coverage for birds is also available.
FLEXIBLE PRICING FOR DIFFERENT BUDGETS AND PET NEEDS
Wellness coverage for dogs and cats is based on a benefit schedule.
Coverage can be dialed up or down by category (accident, illness, hereditary and congenital, and wellness).
Accident-only coverage is available.
HOW TO ENROLL
To obtain preferred rates, enroll for coverage at www.petinsurance.com/ethosgroup or call 877-738-7874 . Nationwide will bill you directly.
GET THE NATIONWIDE
Upload claims and receive reimbursements by check or direct deposit.
Additional Benefits
EMPLOYEE ASSISTANCE AND WELLNESS SUPPORT
In addition to Aetna’s Resources for Living EAP (see page 12) you have access to additional support programs through GuidanceResources in partnership with New York Life Group Benefit Solutions.
Available Programs
• Life Assistance Program — This program can help you and your family when you feel overwhelmed by the demands of work and family life. You have access to various counseling services, including legal, financial, and work-life balance support. Receive three sessions, per issue, per year.
• GuidanceResources — When you need information quickly to help you handle issues pertaining to health and wellness, legal, family relationships, work, education, money, or investments, visit www.guidanceresources.com. Here you can access articles, podcasts, videos, and on-demand trainings. You can even get personal responses to your questions via “Ask the Expert.”
• Well-being Coaching — Certified coaches are available for up to five telephonic personal counseling sessions a year to help you with health and well-being issues such as burnout, time management, and coping with stress.
• FamilySource — Family care specialists will provide customized research and referrals for childcare, adoption, eldercare, education, and pet care.
FINANCIAL, LEGAL, AND ESTATE SUPPORT
GuidanceResources also offers the following programs and solutions for your financial and legal challenges.
Available Programs
• FinancialConnect – You and your family members have unlimited access to CPAs, Certified Financial Planners (CFPs), and other financial professionals. Visit www.guidanceresources.com for financial information on topics including debt management, family budgeting, estate planning, tax planning, and more.
• LegalConnect – Receive unlimited phone consultations for guidance on divorce, adoption, estate planning, real estate, and identity theft. If needed, you can be referred to a local attorney for a free 30-minute consultation and a 25% reduction in fees thereafter.
Contact GuidanceResources
• Visit www.guidanceresources.com (Web ID: NYLGBS)
• Call 800-344-9752
Additional Benefits
TRAVEL ASSISTANCE
When you travel 100 miles or more from home, 24-hour emergency travel services are available. At no cost to you, the Secure Travel program available through New York Life, can assist you with trip planning, traveling assistance, and emergency assistance.
Features Include
• Travel advisories and weather conditions
• Cultural information, including referral to interpretation and translation services
• Referrals to physicians and medical and legal assistance
• Assistance with lost or stolen items
• Emergency cash advances, up to $1,500
• Assistance with hospitalization and returning a deceased covered person’s remains
DISCOUNT PROGRAM
As an employee at ACH/OCOK, you have exclusive access to discounts and cash back offers through BenefitHub. This includes savings on brands you love, as well as local offers. Save in a variety of categories, including:
• Travel
• Auto
• Electronics
• Apparel
• Education
• Entertainment
• Restaurants
• Health and Wellness
• Beauty and spa
• Sports and outdoors
Sign Up and Save
• Visit https://ach.benefithub.com Register with referral code: E85GCR
• Call 866-664-4621
Access Travel Assistance
• Call 888-226-4567 for 24/7 support. Outside the U.S., call collect 202-331-7635
• Email ops@us.generaliglobalassistance.com Policy #OK971004, Group #57
401(k)
ACH/OCOK offers a 401(k) retirement plan to help you plan for retirement. The plan is administered by Empower and allows you to defer a percentage of your pay by making deferral contributions to the plan.
You are eligible to make contributions to the plan after you have completed six months of service. Once eligible, you will be automatically enrolled in the plan at 3% with the corresponding company match, unless you elect not to participate or elect a higher or lower percentage.
Save 1% to 100% of your eligible compensation through payroll deduction. Your total salary deferral in 2025 may not be more than $23,500 if you are under the age of 50. If you are age 50 or older, you may contribute an additional $7,500 for a total of $31,000. If you are age 60–63, the additional contribution increases to $11,250, for a total of $34,750. Your maximum deferral percentage and/or dollar amount may also be limited by IRS regulations. You may change your salary deferral percentage at any time. Changes will be reflected in payroll within one to two pay periods.
You may designate all or a portion of your elective contributions as pretax deferral contributions or Roth after-tax contributions. The Roth option allows you to contribute aftertax dollars to your 401(k), which will grow tax free and will not be subject to federal income tax when a distribution is made once you reach age 59½.
Setting Up or Changing an Existing Account
• Visit https://participant.empower-retirement.com or call 800-338-4015
• Plan Name: Higginbotham PEP by ACH Child and Family Services
• Plan Number: 5000348-01
• ACH/OCOK has automatically set a contribution rate for you. Review the contribution and make a change to the percentage if you want
• Designate a beneficiary(ies) on the Empower website to ensure the money in your account goes to a loved one
SAFE HARBOR COMPANY MATCH
For the 2025 plan year, ACH/OCOK will be making the following contribution to the Safe Harbor Plan. ACH/OCOK will match 100% of your contribution up to 3% and 50% of your contribution of the next 2% of deferrals. This is extra money in your pocket. The plan may amend to reduce or suspend the safe harbor match or non-elective contribution at any point during the plan year. Roth contributions are also subject to company matching.
VESTING
The part of your account to which you have a right is called your vested amount. You are 100% vested in the company matching contributions and all salary deferrals.
Special Features
Loans — The plan allows for loans to be taken up to 50% of your total contributions or $50,000, whichever is less (special rules apply).
• Withdrawals — The plan allows withdrawals in certain situations, including financial hardship, disability, separation from employment, reaching age 59½, paying medical expenses, purchasing a primary residence, covering tuition costs, or paying funeral and burial expenses, among others.
• Investments — Your Plan offers a range of investment options. Review the Notice of Investment Returns & Fee Comparison at www.empowermyretirement.com for details. Once enrolled, you can access investment information anytime online or through the 24/7 Voice Response System at 800-338-4015
• Rollover — When deciding what to do with your former employer’s retirement plan savings, choose to 1) roll your savings into an IRA, 2) keep your savings in your employer’s retirement plan if allowed, 3) cash out your savings and close the account, or 4) roll your savings into our 401(k) retirement plan. You may wish to consult a tax or legal advisor before making your decision.
If you work with an advisor or prefer to manage your own investments, call Empower to turn off this feature and reduce fees.
Time Off
2026 HOLIDAYS
ACH/OCOK observes the following holidays:
HOLIDAY Date
New Year’s Day
Thursday, January 1, 2026
Martin Luther King Jr. Day Monday, January 19, 2026
Presidents’ Day Monday, February 16, 2026
Easter Holiday Friday, April 3, 2026
Memorial Day Monday, May 25, 2026
Juneteenth Friday, June 19, 2026
Independence Day Observance Friday, July 3, 2026
Labor Day Monday, September 7, 2026
Thanksgiving Day Thursday, November 26, 2026
Day after Thanksgiving Friday, November 27, 2026
Christmas Eve Holiday Thursday, December 24, 2026
Christmas Day Friday, December 25, 2026
New Year’s Day Observance Friday, January 1, 2027
PAID TIME OFF
Paid Time Off (PTO) is provided for all active, regular fulltime employees based on length of services or as designated by the CEO. You are eligible to use accrued PTO hours after completion of three (3) months of active, regular employment after receiving pre-approval from your manager for the specific dates requested. The below schedule is applicable if you were hired after January 1, 2014
Full-Time Employee PTO Accrual
FAMILY AND MEDICAL LEAVE OF ABSENCE
If you work at an ACH/OCOK location with 50 employees within 75 miles, and if you have completed at least 12 months and 1,250 hours of service with ACH/OCOK (including previous service), you are eligible for up to 12 weeks of paid and/or unpaid leave of absence for certain family care and medical reasons in any rolling 12-month period. You may elect, but are not required to use available PTO if the leave is for the care of a newborn, adopted, or foster child, and no serious health condition exists. The use of leave time such as PTO or Short Term Disability runs concurrently with family medical leave.
How to File Your Disability and Family Medical Leave Claim
• Step 1: Notify your supervisor and HR if you need to be out of work for an illness, injury, or pregnancy.
• Step 2: Contact New York Life/Group Benefit Solutions (NYL GBS) online or by phone to start the claim.
• Online: www.myNYLGBS.com
• Phone: 888-842-4462 or 866-562-8421 (Spanish), 7:00 a.m. – 7:00 p.m. CT.
• Step 3: Grant NYL GBS permission to contact your health care provider or ACH/OCOK for claim-related information by answering “yes” during your claim call, or online when filing your claim.
• Step 4: To receive an updated status on your claim, sign up for text notifications when filing your claim, or go online to www.myNYLGBS.com. You can also contact NYL GBS at 888-842-4462 or 866-562-8421 (Spanish), 7:00 a.m. –7:00 p.m. CT.
• Step 5: While you are out on disability or leave, keep HR informed of your return-to-work plans.
Please refer to the Employee Handbook for additional details. You may also visit the link: www.dol.gov/whd/regs/compliance/posters/fmla.htm .
PAID PARENTAL LEAVE
Please refer to the Employee Handbook for additional details.
ACH/OCOK will provide up to two weeks of Paid Parental Leave following the birth of an employee’s child or the placement of a child with an employee in connection with adoption or foster care. Please refer to The Loop in the Employee Handbook for additional details.
Professional Development
CONTINUING EDUCATION
If you earn a bachelor’s, master’s, or doctoral degree in a field relevant to your position at ACH/OCOK, you will be eligible for an increase of $1,000 to your annual salary. You are eligible once per degree, and the degree must be from an accredited school.
LICENSING OR PROFESSIONAL CERTIFICATION
If you earn a license relevant to your position at ACH/OCOK, you will be eligible to have the fees for the testing reimbursed and a bonus of $500 upon receipt of documentation and approvals. This will be a one-time payment.
TUITION ASSISTANCE
ACH/OCOK may reimburse full-time, regular employees for approved education courses. The approval for reimbursement will be dependent on the course and its relevance to your current or future potential career. Approval must be obtained prior to commencement of each course per semester. You must meet or continue to meet the performance expectations of your current role. You must also be employed for no less than 12 consecutive months in order to be eligible. Applying for assistance is not a guarantee of acceptance.
Reimbursement
The maximum reimbursement amounts are:
• Master’s Degree: $3,000 per semester
• Bachelor’s Degree: $2,400 per semester
• Associate Degree: $1,000 per semester
Please refer to the Employee Handbook for additional details.
For questions regarding FMLA or PPL, email hrconnect@achservices.org
Required Notices
WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998
In October 1998, Congress enacted the Women’s Health and Cancer Rights Act of 1998. This notice explains some important provisions of the Act. Please review this information carefully.
As specified in the Women’s Health and Cancer Rights Act, a plan participant or beneficiary who elects breast reconstruction in connection with a mastectomy is also entitled to the following benefits:
• All stages of reconstruction of the breast on which the mastectomy was performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• Prostheses and treatment of physical complications of the mastectomy, including lymphedema.
Health plans must determine the manner of coverage in consultation with the attending physician and the patient. Coverage for breast reconstruction and related services may be subject to deductibles and coinsurance amounts that are consistent with those that apply to other benefits under the plan.
SPECIAL ENROLLMENT RIGHTS
This notice is being provided to ensure that you understand your right to apply for group health insurance coverage. You should read this notice even if you plan to waive coverage at this time.
Loss of Other Coverage
or Becoming Eligible for Medicaid or a state Children’s Health Insurance Program (CHIP)
If you are declining coverage for yourself or your dependents because of other health insurance or group health plan coverage, you may be able to later enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you
must enroll within 31 days after your or your dependents’ other coverage ends (or after the employer that sponsors that coverage stops contributing toward the other coverage).
If you or your dependents lose eligibility under a Medicaid plan or CHIP, or if you or your dependents become eligible for a subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents in this plan. You must provide notification within 60 days after you or your dependent is terminated from, or determined to be eligible for, such assistance.
Marriage, Birth or Adoption
If you have a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must enroll within 31 days after the marriage, birth, or placement for adoption.
For More Information or Assistance
To request special enrollment or obtain more information, contact:
ACH Child and Family Services Human Resources 3712 Wichita Street Fort Worth, TX 76119 Benefits@ACHservices.org 817-335-4673
YOUR PRESCRIPTION DRUG COVERAGE AND MEDICARE
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with ACH Child and Family Services and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to enroll in a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
If neither you nor any of your covered dependents are eligible for or have Medicare, this notice does not apply to you or the dependents, as the case may be. However, you should still keep a copy of this notice in
the event you or a dependent should qualify for coverage under Medicare in the future. Please note, however, that later notices might supersede this notice.
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that offers prescription drug coverage. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2. ACH Child and Family Services has determined that the prescription drug coverage offered by the ACH Child and Family Services medical plan is, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage pays and is considered Creditable Coverage. The HSA plan is not considered Creditable Coverage.
Because your existing coverage is, on average, at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to enroll in a Medicare prescription drug plan, as long as you later enroll within specific time periods.
You can enroll in a Medicare prescription drug plan when you first become eligible for Medicare. If you decide to wait to enroll in a Medicare prescription drug plan, you may enroll later, during Medicare Part D’s annual enrollment period, which runs each year from October 15 through December 7 but as a general rule, if you delay your enrollment in Medicare Part D after first becoming eligible to enroll, you may have to pay a higher premium (a penalty).
You should compare your current coverage, including which drugs are covered at what cost, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. See the Plan’s summary plan description for a summary of the Plan’s prescription drug coverage. If you don’t
have a copy, you can get one by contacting ACH Child and Family Services at the phone number or address listed at the end of this section.
If you choose to enroll in a Medicare prescription drug plan and cancel your current ACH Child and Family Services prescription drug coverage, be aware that you and your dependents may not be able to get this coverage back. To regain coverage, you would have to re-enroll in the Plan, pursuant to the Plan’s eligibility and enrollment rules. You should review the Plan’s summary plan description to determine if and when you are allowed to add coverage.
If you cancel or lose your current coverage and do not have prescription drug coverage for 63 days or longer prior to enrolling in the Medicare prescription drug coverage, your monthly premium will be at least 1% per month greater for every month that you did not have coverage for as long as you have Medicare prescription drug coverage. For example, if nineteen months lapse without coverage, your premium will always be at least 19% higher than it would have been without the lapse in coverage.
For more information about this notice or your current prescription drug coverage:
Contact the Human Resources Department at 817-335-4673
NOTE: You will receive this notice annually and at other times in the future, such as before the next period you can enroll in Medicare prescription drug coverage and if this coverage changes. You may also request a copy.
For more information about your options under Medicare prescription drug coverage:
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You will get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare prescription drug plans. For more information about Medicare prescription drug coverage:
• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help.
• Call 1-800-MEDICARE (1-800-6334227). TTY users should call 877-4862048
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. Information about this extra help is available from the Social Security Administration (SSA) online at www.socialsecurity.gov, or you can call them at 800-772-1213 . TTY users should call 800-325-0778
Remember: Keep this Creditable Coverage notice. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and whether or not you are required to pay a higher premium (a penalty).
ACH Child and Family Services
Human Resources 3712 Wichita Street Fort Worth, TX 76119 Benefits@ACHservices.org 817-335-4673
NOTICE OF HIPAA PRIVACY PRACTICES
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Effective Date of Notice: September 23, 2013
ACH Child and Family Services’s Plan is required by law to take reasonable steps to ensure the privacy of your personally identifiable health information and to inform you about:
1. the Plan’s uses and disclosures of Protected Health Information (PHI);
2. your privacy rights with respect to your PHI;
3. the Plan’s duties with respect to your PHI;
4. your right to file a complaint with the Plan and to the Secretary of the U.S. Department of Health and Human Services; and
5. the person or office to contact for further information about the Plan’s privacy practices.
The term “Protected Health Information” (PHI) includes all individually identifiable health information transmitted or maintained by the Plan, regardless of form (oral, written, electronic).
Section 1 – Notice of PHI Uses and Disclosures
Required PHI Uses and Disclosures
Upon your request, the Plan is required to give you access to your PHI in order to inspect and copy it.
Use and disclosure of your PHI may be required by the Secretary of the Department of Health and Human Services to investigate or determine the Plan’s compliance with the privacy regulations.
Uses and disclosures to carry out treatment, payment and health care operations.
The Plan and its business associates will use PHI without your authorization to carry out treatment, payment and health care operations. The Plan and its business associates (and any health insurers providing benefits to Plan participants) may also disclose the following to the Plan’s Board of Trustees: (1) PHI for purposes related to Plan administration (payment and health care operations); (2) summary health information for purposes of health or stop loss insurance underwriting or for purposes of modifying the Plan; and (3) enrollment information (whether an individual is eligible for benefits under the Plan). The Trustees have amended the Plan to protect your PHI as required by federal law.
Treatment is the provision, coordination or management of health care and related services. It also includes but is not limited to consultations and referrals between one or more of your providers.
For example, the Plan may disclose to a treating physician the name of your treating radiologist so that the physician may ask for your X-rays from the treating radiologist.
Payment includes but is not limited to actions to make coverage determinations and payment (including billing, claims processing, subrogation, reviews for medical necessity and appropriateness of care, utilization review and preauthorizations).
For example, the Plan may tell a treating doctor whether you are eligible for coverage or what percentage of the bill will be paid by the Plan.
Health care operations include but are not limited to quality assessment and improvement, reviewing competence or qualifications of health care professionals, underwriting, premium rating and other insurance activities relating to creating or renewing insurance contracts. It also includes case management, conducting or arranging for medical review, legal services and auditing functions including fraud and abuse compliance programs, business planning and development, business management and general administrative activities. However, no genetic information can be used or disclosed for underwriting purposes.
For example, the Plan may use information to project future benefit costs or audit the accuracy of its claims processing functions.
Uses and disclosures that require that you be given an opportunity to agree or disagree prior to the use or release.
Unless you object, the Plan may provide relevant portions of your protected health information to a family member, friend or other person you indicate is involved in your health care or in helping you receive payment for your health care. Also, if you are not capable of agreeing or objecting to these disclosures because of, for instance, an emergency situation, the Plan will disclose protected health information (as the Plan
determines) in your best interest. After the emergency, the Plan will give you the opportunity to object to future disclosures to family and friends.
Uses and disclosures for which your consent, authorization or opportunity to object is not required.
The Plan is allowed to use and disclose your PHI without your authorization under the following circumstances:
1. For treatment, payment and health care operations.
2. Enrollment information can be provided to the Trustees.
3. Summary health information can be provided to the Trustees for the purposes designated above.
4. When required by law.
5. When permitted for purposes of public health activities, including when necessary to report product defects and to permit product recalls. PHI may also be disclosed if you have been exposed to a communicable disease or are at risk of spreading a disease or condition, if required by law.
6. When required by law to report information about abuse, neglect or domestic violence to public authorities if there exists a reasonable belief that you may be a victim of abuse, neglect or domestic violence. In which case, the Plan will promptly inform you that such a disclosure has been or will be made unless that notice would cause a risk of serious harm. For the purpose of reporting child abuse or neglect, it is not necessary to inform the minor that such a disclosure has been or will be made. Disclosure may generally be made to the minor’s parents or other representatives although there may be circumstances under federal or state law when the parents or other representatives may not be given access to the minor’s PHI.
7. The Plan may disclose your PHI to a public health oversight agency for oversight activities required by law. This includes uses or disclosures in civil,
administrative or criminal investigations; inspections; licensure or disciplinary actions (for example, to investigate complaints against providers); and other activities necessary for appropriate oversight of government benefit programs (for example, to investigate Medicare or Medicaid fraud).
8. The Plan may disclose your PHI when required for judicial or administrative proceedings. For example, your PHI may be disclosed in response to a subpoena or discovery request.
9. When required for law enforcement purposes, including for the purpose of identifying or locating a suspect, fugitive, material witness or missing person. Also, when disclosing information about an individual who is or is suspected to be a victim of a crime but only if the individual agrees to the disclosure or the Plan is unable to obtain the individual’s agreement because of emergency circumstances. Furthermore, the law enforcement official must represent that the information is not intended to be used against the individual, the immediate law enforcement activity would be materially and adversely affected by waiting to obtain the individual’s agreement and disclosure is in the best interest of the individual as determined by the exercise of the Plan’s best judgment.
10. When required to be given to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death or other duties as authorized by law. Also, disclosure is permitted to funeral directors, consistent with applicable law, as necessary to carry out their duties with respect to the decedent.
11. When consistent with applicable law and standards of ethical conduct if the Plan, in good faith, believes the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to a person
reasonably able to prevent or lessen the threat, including the target of the threat.
12. When authorized by and to the extent necessary to comply with workers’ compensation or other similar programs established by law.
Except as otherwise indicated in this notice, uses and disclosures will be made only with your written authorization subject to your right to revoke such authorization. Uses and disclosures that require your written authorization.
Other uses or disclosures of your protected health information not described above will only be made with your written authorization. For example, in general and subject to specific conditions, the Plan will not use or disclose your psychiatric notes; the Plan will not use or disclose your protected health information for marketing; and the Plan will not sell your protected health information, unless you provide a written authorization to do so. You may revoke written authorizations at any time, so long as the revocation is in writing. Once the Plan receives your written revocation, it will only be effective for future uses and disclosures. It will not be effective for any information that may have been used or disclosed in reliance upon the written authorization and prior to receiving your written revocation.
Section 2 – Rights of Individuals
Right to Request Restrictions on Uses and Disclosures of PHI
You may request the Plan to restrict the uses and disclosures of your PHI. However, the Plan is not required to agree to your request (except that the Plan must comply with your request to restrict a disclosure of your confidential information for payment or health care operations if you paid for the services to which the information relates in full, out of pocket).
You or your personal representative will be required to submit a written request to exercise this right. Such requests should be made to the Plan’s Privacy Official.
Right to Request Confidential Communications
The Plan will accommodate reasonable requests to receive communications of PHI by alternative means or at alternative locations if necessary to prevent a disclosure that could endanger you.
You or your personal representative will be required to submit a written request to exercise this right.
Such requests should be made to the Plan’s Privacy Official.
Right to Inspect and Copy PHI
You have a right to inspect and obtain a copy of your PHI contained in a “designated record set,” for as long as the Plan maintains the PHI. If the information you request is in an electronic designated record set, you may request that these records be transmitted electronically to yourself or a designated individual.
Protected Health Information (PHI)
Includes all individually identifiable health information transmitted or maintained by the Plan, regardless of form.
Designated Record Set
Includes the medical records and billing records about individuals maintained by or for a covered health care provider; enrollment, payment, billing, claims adjudication and case or medical management record systems maintained by or for the Plan; or other information used in whole or in part by or for the Plan to make decisions about individuals. Information used for quality control or peer review analyses and not used to make decisions about individuals is not in the designated record set.
The requested information will be provided within 30 days if the information is maintained on site or within 60 days if the information is maintained off site. A single 30-day extension is allowed if the Plan is unable to comply with the deadline.
You or your personal representative will be required to submit a written request to request access to the PHI in your designated
record set. Such requests should be made to the Plan’s Privacy Official.
If access is denied, you or your personal representative will be provided with a written denial, setting forth the basis for the denial, a description of how you may appeal the Plan’s decision and a description of how you may complain to the Secretary of the U.S. Department of Health and Human Services.
The Plan may charge a reasonable, costbased fee for copying records at your request.
Right to Amend PHI
You have the right to request the Plan to amend your PHI or a record about you in your designated record set for as long as the PHI is maintained in the designated record set.
The Plan has 60 days after the request is made to act on the request. A single 30-day extension is allowed if the Plan is unable to comply with the deadline. If the request is denied in whole or part, the Plan must provide you with a written denial that explains the basis for the denial. You or your personal representative may then submit a written statement disagreeing with the denial and have that statement included with any future disclosures of your PHI.
Such requests should be made to the Plan’s Privacy Official.
You or your personal representative will be required to submit a written request to request amendment of the PHI in your designated record set.
Right to Receive an Accounting of PHI Disclosures
At your request, the Plan will also provide you an accounting of disclosures by the Plan of your PHI during the six years prior to the date of your request. However, such accounting will not include PHI disclosures made: (1) to carry out treatment, payment or health care operations; (2) to individuals about their own PHI; (3) pursuant to your authorization; (4) prior to April 14, 2003; and (5) where otherwise permissible under the law and the Plan’s privacy practices. In addition, the Plan need not account for certain incidental disclosures.
If the accounting cannot be provided within 60 days, an additional 30 days is allowed if the individual is given a written statement of the reasons for the delay and the date by which the accounting will be provided.
If you request more than one accounting within a 12-month period, the Plan will charge a reasonable, cost-based fee for each subsequent accounting.
Such requests should be made to the Plan’s Privacy Official.
Right to Receive a Paper Copy of This Notice Upon Request
You have the right to obtain a paper copy of this Notice. Such requests should be made to the Plan’s Privacy Official.
A Note About Personal Representatives
You may exercise your rights through a personal representative. Your personal representative will be required to produce evidence of his/her authority to act on your behalf before that person will be given access to your PHI or allowed to take any action for you. Proof of such authority may take one of the following forms:
1. a power of attorney for health care purposes;
2. a court order of appointment of the person as the conservator or guardian of the individual; or
3. an individual who is the parent of an unemancipated minor child may generally act as the child’s personal representative (subject to state law).
The Plan retains discretion to deny access to your PHI by a personal representative to provide protection to those vulnerable people who depend on others to exercise their rights under these rules and who may be subject to abuse or neglect.
Section 3 – The Plan’s Duties
The Plan is required by law to maintain the privacy of PHI and to provide individuals (participants and beneficiaries) with notice of the Plan’s legal duties and privacy practices.
This Notice is effective September 23, 2013, and the Plan is required to comply with the terms of this Notice. However, the Plan reserves the right to change its privacy practices and to apply the changes to any PHI received or maintained by the Plan prior to that date. If a privacy practice is changed, a revised version of this Notice will be provided to all participants for whom the Plan still maintains PHI. The revised Notice will be distributed in the same manner as the initial Notice was provided or in any other permissible manner.
If the revised version of this Notice is posted, you will also receive a copy of the Notice or information about any material change and how to receive a copy of the Notice in the Plan’s next annual mailing. Otherwise, the revised version of this Notice will be distributed within 60 days of the effective date of any material change to the Plan’s policies regarding the uses or disclosures of PHI, the individual’s privacy rights, the duties of the Plan or other privacy practices stated in this Notice.
Minimum Necessary Standard
When using or disclosing PHI or when requesting PHI from another covered entity, the Plan will make reasonable efforts not to use, disclose or request more than the minimum amount of PHI necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations. When required by law, the Plan will restrict disclosures to the limited data set, or otherwise as necessary, to the minimum necessary information to accomplish the intended purpose.
However, the minimum necessary standard will not apply in the following situations:
1. disclosures to or requests by a health care provider for treatment;
2. uses or disclosures made to the individual;
3. disclosures made to the Secretary of the U.S. Department of Health and Human Services;
4. uses or disclosures that are required by law; and
5. uses or disclosures that are required for the Plan’s compliance with legal regulations.
De-Identified Information
This notice does not apply to information that has been de-identified. De-identified information is information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual.
Summary Health Information
The Plan may disclose “summary health information” to the Trustees for obtaining insurance premium bids or modifying, amending or terminating the Plan. “Summary health information” summarizes the claims history, claims expenses or type of claims experienced by participants and excludes identifying information in accordance with HIPAA.
Notification of Breach
The Plan is required by law to maintain the privacy of participants’ PHI and to provide individuals with notice of its legal duties and privacy practices. In the event of a breach of unsecured PHI, the Plan will notify affected individuals of the breach.
Section 4 – Your Right to File a Complaint With the Plan or the HHS Secretary
If you believe that your privacy rights have been violated, you may complain to the Plan. Such complaints should be made to the Plan’s Privacy Official.
You may file a complaint with the Secretary of the U.S. Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington, D.C. 20201. The Plan will not retaliate against you for filing a complaint.
Section 5 – Whom to Contact at the Plan for More Information
If you have any questions regarding this notice or the subjects addressed in it, you may contact the Plan’s Privacy Official. Such questions should be directed to the Plan’s Privacy Official at:
ACH Child and Family Services Human Resources
3712 Wichita Street Fort Worth, TX 76119 Benefits@ACHservices.org 817-335-4673
Conclusion
PHI use and disclosure by the Plan is regulated by a federal law known as HIPAA (the Health Insurance Portability and Accountability Act). You may find these rules at 45 Code of Federal Regulations Parts 160 and 164. The Plan intends to comply with these regulations. This Notice attempts to summarize the regulations. The regulations will supersede any discrepancy between the information in this Notice and the regulations.
PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www. insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance . If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol. gov or call 1-866-444-EBSA (3272)
If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of July 31, 2025. Contact your State for more information on eligibility.
TEXAS – MEDICAID
Website: https://www.hhs.texas.gov/services/ financial/health-insurance-premium-paymenthipp-program
Phone: 1-800-440-0493
To see if any other States have added a premium assistance program since July 31, 2025 , or for more information on special enrollment rights, you can contact either:
U.S. Department of Labor
Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services www.cms.hhs.gov
1-877-267-2323, Menu Option 4, Ext. 61565
CONTINUATION OF COVERAGE RIGHTS UNDER COBRA
Under the Federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), if you are covered under the ACH Child and Family Services group health plan you and your eligible dependents may be entitled to continue your group health benefits coverage under the ACH Child and Family Services plan after you have left employment with the company. If you wish to elect COBRA coverage, contact your Human Resources Department for the applicable deadlines to elect coverage and pay the initial premium. Plan Contact Information
Higginbotham PO Box 1271 Fort Worth, TX 76101 877-258-5419
cobra@higginbotham.net
NOTICE REGARDING WELLNESS PROGRAM
The employee wellness program is a voluntary program administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program you may be asked to complete a voluntary health risk assessment or “HRA” that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You may also be asked to complete a biometric screening, which could include a blood test for certain medical conditions such as diabetes, heart disease, etc. You are not required to complete the HRA or to participate in the blood test or other medical examinations.
However, employees who choose to participate in the wellness program may qualify for an incentive. Although you are not required to complete a HRA or biometric screening, the wellness program may specify that only employees who do so will qualify for the incentive. Additional incentives may be available for employees who participate in certain health-related activities or achieve certain health outcomes.
If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive, you may be entitled to a reasonable accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by contacting Human Resources.
If you choose to participate in a HRA and/ or biometric screening, information from your HRA and results from your biometric
screening will be used to provide you with information to help you understand your current health and potential risks and may also be used to offer you services through the wellness program. You also are encouraged to share your results or concerns with your own doctor.
Protections from Disclosure of Medical Information
We are required by law to maintain the privacy and security of your personally identifiable health information. Although the wellness program may use aggregate information it collects to design a program based on identified health risks in the workplace, the wellness program will never disclose any of your personal information either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment.
Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements.
In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making any employment decision.
Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you immediately.
You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate.
If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact Human Resources.
YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/ or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that have not signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
• Emergency services – If you have an emergency medical condition and get emergency services from an out-ofnetwork provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You cannot be balance billed for these emergency services. This includes services you may get after you are in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
• Certain services at an in-network hospital or ambulatory surgical center – When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network costsharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cannot balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers cannot balance bill you, unless you give written consent and give up your protections.
You are never required to give up your protections from balance billing. You also are not required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing is not allowed, you also have the following protections:
• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay outof-network providers and facilities directly.
• Your health plan generally must:
• Cover emergency services without requiring you to get approval for services in advance (prior authorization).
• Cover emergency services by outof-network providers.
• Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
• Count any amount you pay for emergency services or out-ofnetwork services toward your deductible and out-of-pocket limit.
If you believe you have been wrongly billed, you may contact your insurance provider. Visit www.cms.gov/nosurprises for more information about your rights under federal law.
Submit Claims: Online at: www.allstatebenefits.com by Fax to: 1-800-430-4188 or by Mail to: American Heritage Life Insurance Company 1776 American Heritage Life Drive, Jacksonville, FL 32224 For questions regarding the policy benefits, supporting documentation, or for claim assistance, instructions can be found on our website or contact our Customer Care Center at 1-800-521-3535. Please refer to the Coverage Documents for benefits available as well as applicable terms, conditions, exclusions, and limitations.
Direct Deposit: Please complete and submit our Direct Deposit (ACH) form located on our website. Assignment of Benefits: To assign benefit to another individual or provider, please complete and submit our Assignment of Benefits form located on our website.
Incomplete or blank responses may result in a delay in processing the claim request.
Section 1 – POLICY/CERTIFICATE HOLDER & CLAIMANT INFORMATION
COVERAGE NUMBER(S):
POLICY/CERTIFICATE HOLDER INFORMATION:
First Name: _______________________ MI:______ Last Name: ___________________________ Last 4 of SS #: XXX-XX-
Birth Date:___________ Age: ____ Gender: ____ Phone #: ______________________ Email: ________________________________
Mailing Address – We will update our system with this address and use this address to send future correspondence and checks. Number & Street:__________________________ City: ___________________________ ___________________________________ State: ____________________ Zip: _____________
CLAIMANT INFORMATION: (If different than Policy/Certificate Holder)
First Name: __________________________________MI:_______ Last Name: _____________________________________________
Date of Birth: ____________ Age: ______ Gender: __________ Relation to Insured: □ Self □ Spouse □ Domestic Partner □ Child □ Other: _________
Section 2 – WELLLNESS SCREENING AND SUPPORTING DOCUMENTATION
Please select the wellness screening received. Supporting Documentation: Submit a bill or medical record documenting the listed treatment or testing provided.
Date of service: _____________________
□ Biopsy for Skin Cancer
□ Bone Marrow Testing
□ CA15-3 (Cancer Antigen 15-3 Blood Test for Breast Cancer)
□ Chest X-ray
□ Doppler Screen of Carotid Arteries
□ Echocardiogram
□ Flexible Sigmoidoscopy
□ HPV (Human Papillomavirus Vaccination)
□ Mammography, including Breast Ultrasound
□ PSA (Prostate Specific Antigen – Blood Test for Prostate Cancer)
□ Stress Test on Bike or Treadmill
□ Ultrasound Screening of the Abdominal Aorta for Abdominal Aortic Aneurysms
□ Blood Test for Triglycerides
□ CA125 (Cancer Antigen 125 – Blood Test for Ovarian Cancer)
□ CEA (Carcinoembryonic Antigen - Blood Test for Colon Cancer)
□ Colonoscopy
□ Doppler Screening for Peripheral Vascular Disease
□ EKG - Electrocardiogram
□ Hemocult Stool Analysis
□ Lipid Panel (Total Cholesterol Count)
□ Pap Smear, including Thin Prep Pap Test
□ Serum Protein Electrophoresis (Test for Myeloma)
□ Thermography
□ Other Listed Wellness Service
Remember it is a crime to fill out this form with facts you know are false or to leave out facts you know are relevant and important. Please check to be sure all information is correct before signing. Please refer to the fraud notice specific to your state.
Page 1 of 3 11/21
CLAIMANT’S NAME:
DATE OF BIRTH:
COVERAGE NUMBER(S): CLAIM NUMBER:
Note: Don’t forget to provide the supporting claim documentation.
Section 3 – CERTIFICATION: The Policy/Certificate Holder or Claimant who completed the claim form please read and sign below. I acknowledge the receipt of the Department of Insurance Claim Fraud Statements provided with this claim packet. I have read the notices and I am aware that it is a crime to fill out this form with facts I know are false or to leave out facts I know are relevant and important. I certify that the answers given on this claim form are true, complete, and correctly recorded. Please also remember to sign and date the attached authorization required to process your claim.
Signature:_____________________________________ Print Name: ______________________________
Date: _________
FRAUD WARNINGS BY STATE
NOTICE IN ALASKA, ARKANSAS, KENTUCKY, LOUISIANA, MAINE, NEW JERSEY, NEW MEXICO, AND VIRGINIA: Any person who knowingly and with intent to injure, defraud or deceive an insurance company files a claim containing false, incomplete or misleading information may be prosecuted under state law.
NOTICE IN DELAWARE, IDAHO, INDIANA, MINNESOTA, AND OKLAHOMA: Any person who knowingly and with intent to injure, defraud or deceive an insurance company files a claim containing false, incomplete or misleading information is guilty of a felony.
NOTICE IN ARIZONA: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
NOTICE IN CALIFORNIA: For your protection, California law requires the following to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
NOTICE IN COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.
NOTICE IN DISTRICT OF COLUMBIA: FRAUD NOTICE: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant.
NOTICE IN FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
NOTICE IN MARYLAND: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE IN NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638.20.
NOTICE IN NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
NOTICE IN OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE IN OREGON: Any person who makes intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law.
NOTICE IN PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
NOTICE IN PUERTO RICO: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or file, assist or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years
NOTICE IN TENNESSEE AND WASHINGTON: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE IN TEXAS: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
NOTICE IN WEST VIRGINIA AND RHODE ISLAND: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and imprisonment.
Remember it is a crime to fill out this form with facts you know are false or to leave out facts you know are relevant and important. Please check to be sure all information is correct before signing. Please refer to the fraud notice specific to your state.
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CLAIMANT’S NAME:
DATE OF BIRTH:
COVERAGE NUMBER(S): CLAIM NUMBER:
AUTHORIZATION TO RELEASE INFORMATION TO AMERICAN HERITAGE LIFE INSURANCE COMPANY
I hereby authorize any physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, health care provider, Pharmacy Benefit Manager, insurance company, the Medical Information Bureau (MIB) or other organization, institution or person that has any health related records or knowledge of me or minor dependents to disclose the entire medical record (excluding psychotherapy notes and in MAINE and VERMONT HIV related test results) to American Heritage Life Insurance Company (AHL), its duly authorized representatives, its subsidiaries or its reinsurers. This authorization extends to any minor dependent on whom insurance is requested or claim for benefits is being made.
The information to be obtained shall include insurance claim history from any Prescription Drug Database, pharmacy benefit manager, ambulance, insurance company, medical transport service, or the MIB. Also, I authorize any entity, person, or organization that has these records about me, including but not limited to my employer, employer representative and compensation sources, insurance company, financial institution or governmental entities, including departments of public safety and motor vehicle departments, to give any information or record it has about me, my employment, employment history or income to AHL.
I understand that this information will be used to evaluate and administer my claim for benefits or to evaluate my eligibility for insurance. I understand that there is a possibility of redisclosure of any information disclosed pursuant to this authorization and that information, once disclosed, may no longer be protected by certain federal regulations governing privacy and confidentiality, though it may still be protected by state privacy laws or other applicable privacy laws. I also authorize AHL or its reinsurers to make a brief report of my health information to MIB.
This authorization shall remain in force for 24 months following the date of my signature below or termination of my coverage, whichever occurs first. A copy of this authorization is as valid as the original. I or my legal representative may request a copy of this authorization. I understand that I may revoke this authorization at any time by sending a written notification to: Attn: Privacy Officer, American Heritage Life Insurance Company, 1776 American Heritage Life Drive, Jacksonville, FL 32224.
I understand that a revocation of this authorization is not effective if AHL has relied on the protected health information or has a legal right to contest a claim under an insurance policy or to contest the policy itself. The revocation will not apply to any information AHL requests or discloses prior to AHL receiving my revocation request. If I choose not to sign this authorization or if I later revoke it, I understand that AHL may not be able to process my application for coverage, or if coverage has been issued, AHL may not be able to administer my claim for benefits and this may result in a denial of my claim for benefits or request for services.
Your provider may require you to complete an additional authorization form. If asked to complete this authorization, your prompt response will help expedite the process.
Claims submitted on dependents 18 and older require an authorization signed by the dependent.
Claimant/Applicant’s Signature
Claimant/Applicant’s Printed Name
Date Signed (mm/dd/yyyy)
Last Four Digits of Social Security Number
If signed by the legal representative, please describe the authority under which the representative is authorized to act and enclose any related documentation granting authority.
Signature of Legal Representative Relationship
Print Name of Legal Representative
Date Signed (mm/dd/yyyy)
Remember it is a crime to fill out this form with facts you know are false or to leave out facts you know are relevant and important. Please check to be sure all information is correct before signing. Please refer to the fraud notice specific to your state.
ABJ10367-6 Page 3 of 3 11/21
This brochure highlights the main features of the ACH Child and Family Services and Our Community Our Kids employee benefits program. It does not include all plan rules, details, limitations, and exclusions. The terms of your benefit plans are governed by legal documents, including insurance contracts. Should there be an inconsistency between this brochure and the legal plan documents, the plan documents are the final authority. ACH Child and Family Services reserves the right to change or discontinue its employee benefits program at anytime.