2024 Benefits Guide

2024 Benefits Guide Palmer Trinity School

Table of Contents Benefits Overview ................................................................................................ 3 Qualifying Life Events .......................................................................................... 4 Annual Open Enrollment (2024-2025) .................................................................. 4 Medical Benefits .................................................................................................... 5 UHC Rewards ....................................................................................................... 6 Dental Benefits ...................................................................................................... 7 Vision Benefits ...................................................................................................... 8 Flexible Spending Account .................................................................................. 9 Basic Life and AD&D Insurance ......................................................................... 11 Voluntary Life and AD&D Insurance .................................................................. 11 Employer Paid Short Term Disability ................................................................. 11

Employer Paid Long Term Disability .................................................................. 11 Employee Assistance Program ........................................................................... 12 Critical Illness Insurance ..................................................................................... 13 Accident Insurance ............................................................................................. 15 Hospital Indemnity Insurance .............................................................................. 16 Permanent Life with Long Term Care ................................................................. 17 Legal Protection / Identity Theft .......................................................................... 18 Contact Information ............................................................................................ 19 Key Terms ........................................................................................................... 20 Legal Notices ...................................................................................................... 21

If you have Medicare or will become eligible for Medicare in the next 12 months, a Federal law gives you more choices about your prescription drug coverage.

Please see page 26-27 for more details.

This document is an outline of the coverage provided under your employer’s benefit plans based on information provided by your company. It does not include all the terms, coverage, exclusions, limitations, and conditions contained in the official Plan Document, applicable insurance policies and contracts (collectively, the “plan documents”). The plan documents themselves must be read for those details. The intent of this document is to provide you with general information about your employer’s benefit plans. It does not necessarily address all the specific issues which may be applicable to you. It should not be construed as, nor is it intended to provide, legal advice. To the extent that any of the information contained in this document is inconsistent with the plan documents, the provisions set forth in the plan documents will govern in all cases. If you wish to review the plan documents or you have questions regarding specific issues or plan provisions, you should contact your Human Resources/Benefits Department.

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Benefits Overview Palmer Trinity School is proud to offer a comprehensive benefits package to eligible, full-time regular working 40 hours or more per week. The complete benefits package is briefly summarized in this booklet. Please login to Employee Navigator in order to access plan summaries, which will provide more detailed information about each of these programs. Palmer Trinity School is covering the employee only cost at 100% for the following plans: Medical HMO, Dental HMO, Vision, Basic Life, Short and Long Term disability.

There is a cost share on all other tiers and plans.

Benefits Offered • • • • • • • • • • • • • • •

Medical Dental Vision Flexible Spending Account (FSA) Basic Life Insurance & AD&D Voluntary Life and AD&D Short Term Disability Long Term Disability Employee Assistance Program Accident Insurance Critical Illness Insurance Hospital Indemnity Insurance Permanent Life Insurance w/ Long Term Care Legal Protection Identity Theft Protection

Eligibility You and your eligible dependents are eligible for Palmer Trinity School benefits on the first of the month following 60 days of employment.

Eligible dependents are:

• •

• •

Your spouse (including same sex spouses) Domestic partner, assuming: - You are both at least 18 years old - You reside in the same principal residence and have done so for at least 6 month - You are mutually responsible for basic living expenses and debts - Neither of you are legal married to anyone else - You are not blood relatives Dependent children under age 26 who is your or your spouse/domestic partner’s natural child, stepchild, or legally adopted child; or a child for whom you or your spouse/domestic partner are legal guardian; or disabled child over age of 26 Unmarried dependent children between the ages of 27-30, if they have no dependents of their own, are FL residents, regardless of student status

If you enroll a spouse, domestic partner, or child on a company health plan, you will need to attest in the Benefits Enrollment System that each dependent meets the company eligibility rules. Before enrolling dependents, please ensure that they meet the eligibility requirements above. If they don’t qualify, coverage will be cancelled, and you may be liable for the cost of any ineligible claims and premiums paid.

Coverage for domestic partners is not currently tax-free unless your domestic partner is a tax dependent under the IRS– see HR for a form where you can attest that your domestic partner is a tax dependent if applicable. If that is not applicable, the value of the domestic partner coverage will be included on your W-2 as taxable income.

Elections made now will remain until the next open enrollment unless you or your family members experience a qualifying event. If you experience a qualifying event, you must contact HR within 30 days.

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Qualifying Life Events Generally, you may only change your benefit elections during the annual open enrollment period. However, you may change your benefit elections during the year if you experience a qualifying life event, including:

•

Marriage or domestic partnership lasting six months or more

•

Divorce, legal separation, or end of domestic partnership

•

Birth or adoption of a child

•

Death of your spouse, domestic partner or dependent child

•

Adoption of or placement for adoption of dependent child

•

Change in employment status of the employee, spouse/domestic partner, or dependent child

•

Qualification by the Plan Administrator of a child support order for medical coverage

•

Loss of or eligibility for Medicaid or CHIP coverage (within 60 days)

ANNUAL OPEN ENROLLMENT Current employees are eligible to make changes or enroll in new benefits during our Annual Open Enrollment period scheduled:

August 12th - 15th In order to enroll and/or make changes, all employees are required to schedule an appointment with a benefit counselor. Click the link below or scan the QR Code:

https://a.flexbooker.com/reserve/PalmerTrinityOpenEnrollment24

An outbound call will be made to the number you provide at the designated time. If you are enrolling dependents, please have their Date of Birth and Social Security Number with you during your phone call.

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Medical Benefits Administered by UnitedHealthcare

(PCP) Election Required

NHP POS DU2H-M

NHP HMO DU3A-M In-Network Only

Lifetime Benefit Maximum

Unlimited

Calendar Year Deductible

$0 single / $0 family

Out-of-Network

In-Network

Out-of-Network Unlimited

$0 single / $0 family

$500 single / $1,500 family

$2,500 single / $7,500 family

$2,500 single / $5,000 family

$5,000 single / $10,000 family

10%

20%

50%

$0

$0

Primary Care Office Visit

$15 copay per visit

$20 copay per visit

Specialist Office Visit

$35 copay per visit

$40 copay per visit

Urgent Care Center

$35 copay per visit

Calendar Year Out-of-Pocket Maximum Coinsurance

N/A

Doctor’s Office / Facilities Virtual Care Services

N/A

$45 copay per visit

50% after deductible

Preventive Care (screening, immunization)

$0

$0

Diagnostic Test (x-ray, blood work)

$0

0% after deductible

Designated network: $100 copay Network: $200 copay

Designated network: $150 Network: $250 copay

$10 copay/ $50 copay/ $85 copay

$10 copay/ $50 copay/ $85 copay

Imaging (CT/PET scans, MRIs)

Prescription Drugs Retail—Tier 1, Tier 2, Tier 3 (31-day supply)

Not Covered

N/A Mail Order—Tier 1, Tier 2, Tier 3 (90-day supply)

$25 copay/ $125 copay/ $212.50 copay

$25 copay/ $125 copay/ $212.50 copay

$100 copay per visit

$100 copay per visit

$200 copay per day up to max $1,000 per admission

$600 copay per admission

Hospital Services Emergency Room Inpatient Outpatient Surgery

$150 copay per visit

Semi Monthly Cost Employee Employee + Spouse Employee + Child(ren) Family

$0 $230 $90 $317

N/A

50% after deductible

$200 copay per visit

$27 $292 $141 $401

Note: Please see SBC for out-of-network benefits

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UHC Rewards

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Dental Benefits Administered by UnitedHealthcare

HMO Network: FL Managed Care Solstice Access + Calendar Year Deductible Calendar Year Benefit Maximum

HMO Plan - D1068 - S700B In-Network Only No Deductible None

Preventive Dental Services (cleanings, exams, x-rays)

Various copay applies—please see schedule of benefits

Basic Dental Services (fillings, root canal therapy, oral surgery)

Various copay applies—please see schedule of benefits

Major Dental Services (extractions, crowns, inlays, onlays, bridges, dentures, repairs)

Various copay applies—please see schedule of benefits

Orthodontia Services (Child to age 19 & Adult)

$2,250 Child / $2,350 Adult (estimate)

Semi Monthly Cost Employee Employee + Spouse Employee + Child(ren) Family

PPO Network: *National Options PPO 30 Calendar Year Deductible

$0 $6 $10 $16

PPO Plan - P5305 In-Network $50 per person; $150 family limit

Calendar Year Benefit Maximum

$1,000

Preventive Dental Services (cleanings, exams, x-rays)

100%

Basic Dental Services (fillings, root canal therapy, oral surgery)

20% after deductible

Major Dental Services (extractions, crowns, inlays, onlays, bridges, dentures, repairs)

50% after deductible

Orthodontia Services

Not covered

Semi Monthly Cost Employee Employee + Spouse Employee + Child(ren) Family

$16 $36 $43 $63

Note: Please see schedule of benefits to view costs on HMO plan. Please see summary to view out-of-network benefits on PPO plan

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Vision Benefits Administered by UnitedHealthcare

Service Eye Exam - once every 12 months

In-Network $10 copay

Lenses — once every 12 months Single Vision Lenses

$15 copay

Lined Bifocal Lenses

$15 copay

Lenticular Lenses

$15 copay

Frames - once every 12 months

$150 allowance plus 30% off

Contact Lenses — once every 12 months if you elect contacts instead of lenses/frames

Contact Lense Allowance

Medically Necessary Separate Fitting Allowance

Formulary (disposable): up to 6 boxes Non-formulary: $150 allowance Covered in full Up to two follow-up visits

Semi Monthly Cost Employee Employee + Spouse Employee + Child(ren) Family

Note: Please see summary for out-of-network reimbursement schedule

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$0 $3 $5 $8

Spending Accounts Flexible Spending Account Administered by HealthEquity Palmer Trinity School offers Flexible Spending Accounts (FSA) for Health Care and Dependent Care expenses. These Flexible Spending Accounts (FSAs) allow you to contribute monies on a pre-tax basis to cover eligible expenses that you may incur during the calendar year.

Please carefully review the descriptions below in order to determine the plan meet your needs. If you are benefit eligible, you may participate in this plan even if you do not elect other available benefits.

When you enroll in the FSA, the amounts you elect are automatically deducted from your paycheck on a pre-tax basis. The money is held until you have a qualified expense. As you incur qualifying expenses during the year, you simply pay with your HealthEquity issued debit card or file a claim with HealthEquity to be reimbursed.

The money you set aside is never counted as income. That means it is not subject to federal income tax, Social Security, Medicare, and in most cases, state and local taxes. This lowers your taxable income and increases your spendable income.

Health Care Flexible Spending Account You can fund the Health Care FSA up to a maximum of $3,200 per calendar year for health care expenses for yourself and eligible dependents. Eligible health care expenses include health plan deductibles, co-insurance, co-payments, and other related expenses not covered by your health plan. Your contributions should be budgeted expenses that you know you will incur.

Examples of eligible and ineligible services under a Health Care FSA program:

Health Care FSA Eligible Expenses

• • • • • • •

Deductibles, co-payments for medical and dental plans Coinsurance (the percentage of charge you pay) Amounts over Reasonable & Customary Prescription drug copays Smoking cessation prescriptions Eyeglasses, contact lenses, cleaning solutions Dental, artificial teeth/dentures

Ineligible Expenses

• • • • • •

Cosmetic services Teeth bleaching Lens replacement insurance Warranties ·Weight loss maintenance Hair re-growth supplies and/or services Health club membership dues

To obtain a complete list of eligible and ineligible expenses for FSAs, please visit: www.irs.gov, search for Forms and Publications (502 for healthcare plans and 503 for dependent care plans).

Important information about your Health Care FSA: Your FSA elections will be in effect from September 1 through August 31. Claims reimbursement must be submitted by December 31 of the following year. Please plan your contributions carefully. Any money remaining in your account will be forfeited, this is known as the “use it or lose it” rule. You may only roll over the IRS current maximum of $640. Note, FSA elections do not automatically continue from year to year, you must actively enroll each year. New card is sent to those who are enrolling for the first time or who’s card is expiring soon.

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Spending Accounts Flexible Spending Account (FSA) (cont.)

Dependent Care Flexible Spending Account This plan is designed to be used for the physical supervision of your eligible dependents. To be eligible for the dependent care FSA, your child must be 13 years or under and you must be at work during the time your eligible dependent receives care. In certain circumstances, adult dependent care expenses may also be eligible.

The Dependent Care FSA may be funded up to $2,500 per calendar year if you are married and file a separate tax return, and up to $5,000 per calendar year if you are married and file a joint tax return or if you file as single or head of household. Any money left in your Dependent care account at the end of the plan year will be forfeited.

Dependent Care Expenses may be reimbursed for services provided:

•

Inside or outside your home by anyone other than your spouse, a person you list as your dependent for income tax purposes, or one of your children under the age of 13.

•

By a dependent care center or a childcare center (including preschool.) (If the center cares for more than 6 children, it must comply with all applicable state and local regulations.)

•

By a housekeeper whose services partially include caring for a qualifying individual.

•

This account cannot be used for reimbursement of healthcare expenses for dependents

You must also meet one of the following eligibility requirements:

•

You are a single parent

•

You have a working spouse or a spouse looking for work

•

Your spouse is a full-time student for at least five months during the year while you are working

•

Your spouse is physically or mentally unable to provide for his/her own care

•

You are divorced or legally separated and have custody of your child even though your former spouse may claim the child for income tax purposes

Important information about your Dependent Care FSA: Your FSA elections will be in effect from September 1 through August 31. Claims reimbursement must be submitted by December 31 of the following year. Please plan your contributions carefully. Any money remaining in your account will be forfeited, this is known as the “use it or lose it” rule. Note, FSA elections do not automatically continue from year to year, you must actively enroll each year.

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Basic Life and AD&D Insurance Administered by UnitedHealthcare Palmer Trinity School provides basic life and accidental death and dismemberment (AD&D) insurance through UnitedHealthcare at no cost to eligible employees. If you want additional coverage for yourself, your spouse, or your children, you may purchase voluntary coverage at our group rates.

How it Works

Basic Life and AD&D (Company-paid benefit)

Voluntary Life and AD&D (Employee-paid benefit) You: Increments of $10,000 up to 5x Annual Earnings to max $500,000; Guarantee Issue: $150,000

Life

Your beneficiaries receive this benefit if you pass away

2x Annual Earnings to a max $500,000

Your spouse: Increments of $5,000 up to $250,000 (not to exceed 50% of EE's amount); Guarantee Issue: $20,000 Your child(ren): Increment: $2,000; Birth - 14 days: $0; 14 days and Over: $10,000 max, not to exceed 50% of EE's amount You: Increments of $10,000 up to 5x Annual Earnings to max $500,000; Guarantee Issue: $150,000

AD&D

You (or your beneficiaries) receive this benefit if you pass away or are seriously injured in an accident

2x Annual Earnings to a max $500,000

Your spouse: Increments of $5,000 up to $250,000 (not to exceed 50% of EE's amount); Guarantee Issue: $20,000 Your child(ren): Increment: $2,000; Birth - 14 days: $0; 14 days and Over: $10,000 max, not to exceed 50% of EE's amount

Keep Your Beneficiaries Up to Date Please log into Employee Navigator to update. If you have any questions or need assistance please reach out to Human resources.

Disability Insurance Palmer Trinity School also provides disability insurance through UnitedHealthcare. This benefit replaces a portion of your income if you become disabled and are unable to work.

How it Works

Who Pays for the Benefit

Short-term Disability

You receive 66.67% of your income up to $2,000 per week. Benefits begin after 7 calendar days for illness and 0 calendar days for injury of absence from work and continue for up to 13 weeks.

Company

Long-term Disability

You receive 60% of your income up to $10,000 per month. Benefits begin after 90 calendar days of absence from work and continue until you reach the age 65 or Social Security Normal Retirement Age.

Company

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Additional Benefits Employee Assistance Program

To help you with personal issues and concerns, Palmer Trinity School provides you and your family with an employee assistance program (EAP) at no cost to you. Call UnitedHealthcare 24/7 for confidential assistance with personal matters. Experienced consultants are available to listen and help you find solutions. They can also set up in-person sessions with local behavioral health counselors if needed.

•

Address depression, stress, anxiety, or substance use issues

•

Improve relationships at home or work

•

Find support for child or elder care matter

•

Work through emotional issues or grief

•

Legal or financial assistance

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Voluntary Benefits

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Voluntary Benefits (Continued)

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Voluntary Benefits (Continued)

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Voluntary Benefits (Continued)

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Voluntary Benefits (Continued)

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Voluntary Benefits (Continued) Legal Protection Administered by Preferred Legal Our voluntary prepaid legal program, offered through Preferred Legal, gives you and your family access to advice from experienced attorneys over the telephone, through their online legal system, or through in-office consultations about a wide range of personal legal matters, such as:

• • • • • •

Free simple of wills for member and spouse/domestic partner Free notary services Free review of legal documents Free face-to-face consultations with attorneys Free unlimited legal advice via phone consultation Free credit report analysis and repair + settling accounts in collection

Identity Theft Protection now called: Experian IdentityWorks Administered by Preferred Legal Victims of identity theft spend countless hours trying to sort out the damage. Identity protection could help you catch fraud in its early stages through 24/7 monitoring of your personal and financial information. It can also help you act quickly to limit the damage if your personal or financial information is stolen.

Legal Plan + Experian IdentityWorks

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Semi-Monthly

Employee

$8.48

Employee + Spouse

$11.98

Contact Information If you have specific questions about a benefit plan, please contact the administrator listed below, or your local human resources department.

Benefit

Administrator

Phone

Website/Email

Medical

UnitedHealthcare

800.357.0978

www.myuhc.com

Pharmacy

Optum RX

800.377.5154

www.myuhc.com

Dental

UnitedHealthcare

877.816.3596

www.myuhcdental.com

Vision

UnitedHealthcare

800.357.0978

www.myuhcvision.com

HealthEquity

877.924.3967

https://participant.wageworks.com/home

UnitedHealthcare

888.299.2070

www.myuhcfp.com

UnitedHealthcare

888.887.4114

www.myuhc.com

Trustmark Group

210.526.6100 (Laura Mellado - Account Manager)

Laura_Mellado@ajg.com

Preferred Legal

888.577.3476

www.preferredlegal.com

Beverly Hew

305.969.4272

bhew@palmertrinity.org

Flexible Spending Account Basic Life and AD&D Voluntary Life and AD&D Short Term Disability Long Term Disability

Employee Assistance Program Accident Critical Illness Hospital Indemnity Permanent Life with Long Term Care Legal Protection Identity Theft Protection Human Resources

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Legal Notices Women’s Health & Cancer Rights Act Enrollment Notice If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (“WHCRA”). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

• • • •

All stages of reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; Prostheses; and Treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under the plan. Therefore, the following deductibles and coinsurance apply: Plan 1: NHP POS DU2H-M Mod / NH41 (Individual: 20% coinsurance and $0 deductible; Family: 0% coinsurance and $0 deductible) Plan 2: NHP HMO DU3A-M Mod / NH41 (Individual: 10% coinsurance and $0 deductible; Family: 10% coinsurance and $0 deductible) If you would like more information on WHCRA benefits, please call your Plan Administrator at 305.969.4272 or bhew@palmertrinity.org.

Women’s Health And Cancer Rights Act Annual Notice Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services, including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema? Call your plan administrator for more information.

Newborns’ and Mothers’ Health Protection Act Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

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 employersponsored 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.

Please follow the link for a complete list of contact information by state: https://www.dol.gov/sites/dolgov/files/ebsa/lawsand-regulations/laws/chipra/model-notice.pdf

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Legal Notices To see if any other states have added a premium assistance program since January 31, 2024, or for more information on special enrollment rights, 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 Serv Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent.

Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 1/31/2026)

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Legal Notices HIPAA Special Enrollment Rights Palmer Trinity School Health Plan Notice of Your HIPAA Special Enrollment Rights Our records show that you are eligible to participate in the Palmer Trinity School Health Plan (to actually participate, you must complete an enrollment form and pay part of the premium through payroll deduction).

A federal law called HIPAA requires that we notify you about an important provision in the plan - your right to enroll in the plan under its “special enrollment provision” if you acquire a new dependent, or if you decline coverage under this plan for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons.

Loss of Other Coverage (Excluding Medicaid or a State Children’s Health Insurance Program). If you decline enrollment for yourself or for an eligible dependent (including your spouse) while other health insurance or group health plan coverage is in effect, you may be able to 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 request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

Loss of Coverage for Medicaid or a State Children’s Health Insurance Program. If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children’s health insurance program is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your dependents’ coverage ends under Medicaid or a state children’s health insurance program.

New Dependent by Marriage, Birth, Adoption, or Placement for Adoption. If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your new dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

Eligibility for Premium Assistance Under Medicaid or a State Children’s Health Insurance Program – If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children’s health insurance program with respect to coverage under this plan, you may be able to enroll yourself and your dependents in this plan.

However, you must request enrollment within 60 days after your or your dependents’ determination of eligibility for such assistance.

To request special enrollment or to obtain more information about the plan’s special enrollment provisions, contact your Plan Administrator at 305.969.4272 or bhew@palmertrinity.org.

Important Warning If you decline enrollment for yourself or for an eligible dependent, you must complete our form to decline coverage. On the form, you are required to state that coverage under another group health plan or other health insurance coverage (including Medicaid or a state children’s health insurance program) is the reason for declining enrollment, and you are asked to identify that coverage. If you do not complete the form, you and your dependents will not be entitled to special enrollment rights upon a loss of other coverage as described above, but you will still have special enrollment rights when you have a new dependent by marriage, birth, adoption, or placement for adoption, or by virtue of gaining eligibility for a state premium assistance subsidy from Medicaid or through a state children’s health insurance program with respect to coverage under this plan, as described above. If you do not gain special enrollment rights upon a loss of other coverage, you cannot enroll yourself or your dependents in the plan at any time other than the plan’s annual open enrollment period, unless special enrollment rights apply because of a new dependent by marriage, birth, adoption, or placement for adoption, or by virtue of gaining eligibility for a state premium assistance subsidy from Medicaid or through a state children’s health insurance program with respect to coverage under this plan.

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Legal Notices Notice of Creditable Coverage Important Notice from Palmer Trinity School About 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 Palmer Trinity School and about your options under Medicare’s prescription drug coverage.

This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

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

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

2.

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

When Can You Join a Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens to Your Current Coverage if You Decide to Join a Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current Palmer Trinity School coverage will not be affected.

If you do decide to join a Medicare drug plan and drop your current Palmer Trinity School coverage, be aware that you and your dependents will not be able to get this coverage back until the next annual enrollment.

When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with Palmer Trinity School and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage.

In addition, you may have to wait until the following October to join.

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Legal Notices For More Information About This Notice or Your Current Prescription Drug Coverage…

Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Palmer Trinity School changes. You also may request a copy of this notice at any time.

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’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare 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 (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage Notice. If you decide to join one of the Medicare drug plans, 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, therefore, whether or not you are required to pay a higher premium (a penalty).

Date: Name of Entity/Sender: Contact—Position/Office: Office Address:

Phone Number:

September 01, 2024 Palmer Trinity School Beverly Hew - Human Resources 7900 Sw 176 St Miami, Florida 33157 United States 305.969.4272

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Legal Notices COBRA General Notice Model General Notice of COBRA Continuation Coverage Rights (For use by single-employer group health plans) ** Continuation Coverage Rights Under COBRA** Introduction You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.

You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

What is COBRA continuation coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.

If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

• •

Your hours of employment are reduced, or Your employment ends for any reason other than your gross misconduct.

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

• • • • •

Your spouse dies; Your spouse’s hours of employment are reduced; Your spouse’s employment ends for any reason other than his or her gross misconduct; Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:

• • • • • •

The parent-employee dies; The parent-employee’s hours of employment are reduced; The parent-employee’s employment ends for any reason other than his or her gross misconduct; The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); The parents become divorced or legally separated; or The child stops being eligible for coverage under the Plan as a “dependent child.”

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Legal Notices When is COBRA continuation coverage available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:

• • •

The end of employment or reduction of hours of employment; Death of the employee; The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: Beverly Hew. How is COBRA continuation coverage provided?

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage.

Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage.

Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

Are there other coverage options besides COBRA Continuation Coverage?

Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicare, Medicaid, Children’s Health Insurance Program (CHIP) or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov/.

Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?

In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have an 8-month special enrollment period1 to sign up for Medicare Part A or B, beginning on the earlier of

• •

1

The month after your employment ends; or The month after group health plan coverage based on current employment ends.

https://www.medicare.gov/basics/get-started-with-medicare/sign-up/when-does-medicare-coverage-start

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Legal Notices If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.

If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.

For more information visit https://www.medicare.gov/medicare-and-you.

If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.healthcare.gov.

Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.

Plan contact information Palmer Trinity School Beverly Hew - Human Resources 7900 Sw 176 St Miami, Florida 33157 United States

305.969.4272

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Legal Notices Section 125 Under certain circumstances, you may be allowed to make changes to your benefits elections during the plan year, such as additions, deletions and cancellations, depending on whether or not you experience an eligible qualifying event as determined by the Internal Revenue Service (IRS) Code, Section 125. You may change a benefit election upon the occurrence of a valid qualifying event only if the event affects your own, your spouse or your dependent’s coverage (including domestic partners) eligibility.

If you experience a qualifying event, you must report the qualifying event to Human Resources Department within 30 days of the event. Beyond 30 days, additions and deletions will be denied, and you may be responsible both legally and financially for any claims and/or expenses incurred as a result of any dependent(s) who continue to be enrolled who no longer meet the entity’s eligibility requirements.

If approved, most election changes will be effective on the date of the qualifying event for additions; cancellations will be processed at the end of the month.

Payroll deductions for health, dental, vision, and certain supplemental accident insurance premiums, are deducted from your gross income before your income is taxed. The entity's plan is known as a Cafeteria Benefit Plan and is governed by IRS Code, Section 125. This pre-tax benefit means you pay less tax on a per-pay and annual basis.

See examples of Qualifying Life Events for allowable enrollment changes as determined by Section 125 of the IRS Code.

QUALIFYING EVENTS:

•

• • • • • • • • • •

Change is status (for example, employee’s legal marital status, number of dependents, employment status, dependent eligibility change, change in residence or adoption proceedings); Significant cost changes Significant curtailment of coverage Change in coverage under other employer’s plan Addition or significant improvement of benefit package option FMLA leaves of absence Loss of group health coverage sponsored by a governmental or educational institution COBRA qualifying event HIPAA special enrollment events Judgement, decree, or court order, such as Qualified Medical Child Support Order (QMCSO) Medicare or Medicaid enrollment

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Legal Notices Federal Surprise Billing Notice; Your Rights and Protections Against Surprise Medical Bills When you receive emergency care and/or 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. The No Surprises Act Notice for the benefit package options under the Palmer Trinity School Health Benefit Plan are linked below: https://www.uhc.com/legal/federal-surprise-billing-notice Transparency in Coverage Final Rules The Transparency in Coverage Final Rules require certain group health plans to disclose on a public website information regarding in-network provider rates and historical out-of-network allowed amounts and billed charges for covered items and services in two separate machine-readable files (MRFs). The MRFs for the benefit package options under the Palmer Trinity School Health Benefit Plan are linked below: https://www.uhc.com/united-for-reform/health-reform-provisions/transparency-in-coverage-rule https://transparency-in-coverage.uhc.com

https://www.federalregister.gov/documents/2020/11/12/2020-24591/transparency-in-coverage

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This benefit summary prepared by

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