Amherst County Government 2021 New Hire Booklet (11.16.21)

EMPLOYEE BENEFITS PLAN AMHERST COUNTY GOVERNMENT PLAN YEAR: JULY 1, 2021 - JUNE 30, 2022

ARRANGED BY PIERCE GROUP BENEFITS WWW.PIERCEGROUPBENEFITS.COM

EMPLOYEE BENEFITS GUIDE

TABLE OF CONTENTS Welcome to the Amherst County Government comprehensive benefits program. This booklet highlights the benefits offered to all eligible employees for the plan year listed below. Benefits described in this booklet are voluntary, employee-paid benefits unless otherwise noted.

EFFECTIVE DATES: JULY 1, 2021 - JUNE 30, 2022

Benefits Plan Overview

page

2

Online Enrollment Instructions

page

6

Health Benefits

page

15

Dental Benefits

page

16

Vision Benefits

page

19

EAP

Health, Dental & Vision Rates

page

23

Employee Assistance Program

page

24

Required Notices

page

25

Cobra Continuation Of Coverage Rights

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29

Rev. 12/06/2021

PRE-TAX BENEFITS

AMHERST COUNTY GOVERNMENT EFFECTIVE DATES: JULY 1, 2021 - JUNE 30, 2022

PRE-TAX BENEFITS Health Insurance

Dental Insurance

Piedmont Community HealthCare

Delta Dental of VA

Vision Insurance VSP

IMPORTANT INFORMATION: • Regular Full-time employees working 30 hours or more per week are eligible for benefits. Coverage effective date is determined by Human Resources.

• Please visit www.piercegroupbenefits.com/AmherstCountyGovernment to review plan summaries and other required health plan notices.

• You may enroll for coverage when you first meet eligibility requirements, during Open Enrollment, or if you experience a change in status. Examples of eligible changes in status include: • Marriage, divorce, birth, adoption, legal directive • A change in your employment status (or that of your spouse) that affects healthcare coverage • Your child losing “eligible dependent” status • Death of a dependent • Eligibility for Medicare • Any changes you make must be made within 30 days of the event. If you miss this 30-day window, you will be required to wait until the next benefits Open Enrollment period to make any changes for the upcoming year.

• You are responsible for notifying Amherst County at hr@countyofamherst.com of any qualifying event and for requesting information on changing your elections.

• If you choose not to enroll in any of the health insurance plans offered by Amherst County, you must waive coverage in the online enrollment portal.

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IMPORTANT INFORMATION ABOUT YOUR ENROLLMENT Amherst County offers an excellent benefits package which includes the following employer paid and voluntary benefits for full-time employees: • • • • • •

Employer subsidized medical, dental and vision insurance Voluntary supplemental health insurance policies through American Fidelity and AFLAC Required participation in the Virginia Retirement System plans and voluntary deferred compensation Employer paid life insurance and optional voluntary life insurance through Securian/ Minnesota Life Paid Leave Benefits Employee Assistance Plan (EAP) through Health Works

More information is provided about these benefits below and in Employee Navigator. Please call HR at 434-946-9420 if you have any additional questions about employee benefits.

HEALTH INSURANCE Summaries of each of the County’s medical, dental and vision plans are provided in Employee Navigator. You may mix and match tiers according to your needs [Example - you could choose employee only medical and family dental and/or vision]. In order for dependents to be covered, the employee must be on the same plan(s) that the dependents are on.

If you decide to enroll in these plans, you will receive a welcome packet and member cards from PCHP and Delta Dental. As a cost saving measure, Vision Services Plan (VSP) does not provide cards. Your provider will use your social security number to access your benefits online. You may search for participating providers at www.vsp.com. If you register for an account on the website, you can print out a card if you would prefer.

Medical Plans – Amherst County offers three medical plans through Piedmont Community Health Plan (PCHP) – two PPOs and an HMO. If you only see Centra physicians, you may want to consider enrolling in the HMO. At the employee only level, the HMO is offered at no cost to the employee. The PPOs have a broad network that includes most of the state of Virginia and Duke University in NC. Emergency care is provided in network for all three plans. More information about the plans and participating providers may be found at www.pchp.net.

Dental Plan – Amherst County offers a single combined basic and major dental plan through Delta Dental.

Vision Plan – Amherst County offers comprehensive vision insurance through Vision Services Plan (VSP).

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IMPORTANT INFORMATION ABOUT YOUR ENROLLMENT SUPPLEMENTAL HEALTH Amherst County offers voluntary supplemental health benefits through American Fidelity and AFLAC. Employees may put aside funds on a pre-tax basis in a Flexible Spending Account (FSA) and/or purchase supplemental health insurance plans for Cancer, Critical Illness, Hospital Indemnification, Accident, Long and Short Term Disability, Whole Life Insurance, etc. Employees contact the vendors themselves and then the vendor sends us the completed enrollment paperwork. Contact information is listed at the end of the guide.

American Fidelity – American Fidelity is our Flexible Spending Account (FSA) and cafeteria plan (pre-tax) administrator. An FSA allows you to put away money from your payroll on a pre-tax basis to pay for qualified health expenses such as co-pays, deductibles, prosthetics, etc., and/or child care.

AFLAC – AFLAC offers all the same plans as American Fidelity except the FSA. We recommend getting quotes from both vendors in order to make an informed decision and get the best price.

RETIREMENT Amherst County employees are eligible to participate in the state’s Virginia Retirement System (VRS). The state mandated required employee contribution is 5% of your monthly gross pay which is withheld on a pre-tax basis. There are three plans – eligibility is based on your hire date and prior VRS service credit – and HR assigns you to the appropriate plan when we set you up in the Employee Navigator system. You are enrolled with VRS automatically when Finance completes your first full month's payroll.

You should receive a letter from VRS when that occurs.

Plan 1 – This plan is the original VRS pension plan. If you were hired prior to July 1, 2010 and were vested in the plan as of January 1, 2013, then you will be enrolled in Plan 1.

Plan 2 – This plan is also a traditional pension plan with a lower multiplier than Plan 1.

If you were hired between July 1, 2010 and December 31, 2013 and were not vested in Plan 1 on January 1, 2013, then you will be enrolled in Plan 2. If you are employed in a hazardous duty position, you will be either a Plan 1 or Plan 2 participant.

Hybrid – The Hybrid plan is a combination of a traditional pension plan and deferred compensation. If you are not in a hazardous duty position and you were hired on January 1, 2014 or later, or you were rehired on January 1, 2014 with no prior service credits in VRS, you will be enrolled in the Hybrid plan. For Hybrid employees, your 5% payroll contribution is split with 4% going to your pension plan and 1% going to deferred compensation. The deferred compensation portion is administered by ICMA-RC and includes an employer match. You may voluntarily choose to contribute up to an additional 4% of your pay to the deferred compensation portion of your retirement.

Please call HR if you are interested in contributing more than the required 1% to your Hybrid deferred compensation.

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IMPORTANT INFORMATION ABOUT YOUR ENROLLMENT

After one calendar year of employment, Hybrid employees receive paid short and long term disability. If you are in the Hybrid plan and you choose to purchase short and/or long term disability through one of the supplemental health vendors, you will want to cancel it at that point. State law greatly limits the benefit that the vendor is allowed to pay if you have employer paid short and/or long term disability.

DEFERRED COMPENSATION Amherst County also offers a deferred compensation plan through Nationwide Retirement Solutions. Employees assigned to Plan 1 or Plan 2 or those Hybrid employees who have exceeded the allowable voluntary contribution in the Hybrid plan may participate. There is no employer match. You may contact Nationwide Retirement Solutions Representative Lynn Robinette at 434-534-5673 or lynn.robinette@nationwide.com or stop by HR for a Retirement Planning 101 guide.

LIFE INSURANCE Amherst County provides employer paid group term life insurance at no cost to you through Securian/Minnesota Life. Coverage starts on your first day of employment. The benefit is twice your annual salary (rounded up to the next one thousand) at the time of death. You may purchase additional optional group term life insurance through Securian/Minnesota Life for yourself, your spouse or your children. If you do not purchase optional life insurance in your first 30 days of employment, a Certificate of Insurability form for the person(s) you are trying to insure must be completed and the Securian/Minnesota Life underwriters will determine whether you are eligible to purchase additional life insurance at that time.

PAID LEAVE Amherst County provides paid vacation leave, sick leave, personal leave and personal business leave for employees. New employees are granted and may begin to use personal leave and personal business leave upon hire. Annual leave and sick leave accrues at the end of each full calendar month of employment during the six month probationary period but may not be used until the new employee is released from probation. Other types of available leave include paid holidays, civic leave, military leave, FMLA, and administrative leave. Leave benefits and accrual rates are outlined in Section 6 of the Amherst County HR Regulation. The most current version of the HR Regulation may be found on the Human Resources page of the county website at www.countyofamherst.com.

EMPLOYEE ASSISTANCE PROGRAM Amherst County offers an Employee Assistance Program (EAP) through HealthWorks.

Confidential professional counseling at no cost may be accessed by calling 434-200-6000.

HealthWorks also offers a Work-Life Balance portal and a Wellness Program portal which can provide additional information and valuable resources for full-time employees. If you are interested, please inquire at HR how to access the portals.

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EMPLOYEE BENEFITS GUIDE

AMHERST COUNTY GOVERNMENT ENROLL ONLINE

To enroll online, please see the information below and on the following pages.

YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS ONLINE: • Enroll in Health Insurance.

• Enroll in Dental Insurance.

• Enroll in Vision Insurance.

ACCESS YOUR BENEFITS ONLINE WHENEVER, WHEREVER. Benefits Details | Educational Videos | Download Forms | Online Chat with Service Center To view your personalized benefits website, go to:

www.piercegroupbenefits.com/AmherstCountyGovernment or piercegroupbenefits.com and click “Find Your Benefits”.

IMPORTANT NOTE & DISCLAIMER

This is neither an insurance contract nor a Summary Plan Description and only the actual policy provisions will prevail. All information in this booklet including premiums quoted is subject to change.

All policy descriptions are for information purposes only.

Your actual policies may be different than those in this booklet.

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ENROLL IN YOUR BENEFITS: One step at a time Step 1: Log In

Go to www.employeenavigator.com and click Login • Returning users: Log in with the username and password you selected.

Click Reset a forgotten password.

• First time users: Click on your Registration Link in the email sent to you by your admin or Register as a new user. Create an account, and create your own username and password.

Step 2: Welcome!

After you login click Let’s Begin to complete your required tasks.

Step 3: Onboarding (For first time users, if applicable)

Complete any assigned onboarding tasks before enrolling in your benefits.

Once you’ve completed your tasks click Start Enrollment to begin your enrollments.

TIP

Enrollment Instructions

if you hit “Dismiss, complete later” you’ll be taken to your Home Page. You’ll still be able to start enrollments again by clicking “Start Enrollments”

Step 4: Start Enrollments

After clicking Start Enrollment, you’ll need to complete some personal & dependent information before moving to your benefit elections.

TIP Have dependent details handy. To enroll a dependent in coverage you will need their date of birth and Social Security number.

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Step 5: Benefit Elections

To enroll dependents in a benefit, click the checkbox next to the dependent’s name under Who am I enrolling?

Below your dependents you can view your available plans and the cost per pay. To elect a benefit, click Select Plan underneath the plan cost.

Click Save & Continue at the bottom of each screen to save your elections.

If you do not want a benefit, click Don’t want this benefit? at the bottom of the screen and select a reason from the drop-down menu.

Step 6: Forms

If you have elected benefits that require a beneficiary designation, Primary Care Physician, or completion of an Evidence of Insurability form, you will be prompted to add in those details.

Step 7: Review & Confirm Elections

Review the benefits you selected on the enrollment summary page to make sure they are correct then click Sign & Agree to complete your enrollment. You can either print a summary of your elections for your records or login at any point during the year to view your summary online.

TIP

If you miss a step you’ll see Enrollment Not Complete in the progress bar with the incomplete steps highlighted. Click on any incomplete steps to complete them.

Step 8: HR Tasks (if applicable)

Enrollment Instructions

To complete any required HR tasks, click Start Tasks. If your HR department has not assigned any tasks, you’re finished!

You can login to review your benefits 24/7 8

Welcome to Amherst County Government!

Onboarding Guide As you continue forward, you will be asked to review, acknowledge, download, and complete required forms requested by your employer. There are instructions listed for each form and this guide is built to be used in conjunction with them.

1. For most of the forms, you will see a set of instructions that reads as: “Please view, download, and upload a completed copy of the form listed below…”. a. Read through the Helpful Steps listed in the instructions: i. Click ‘View’ to review the document; when you have finished, select ‘Finish’.

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ii. If you have not already downloaded this form from your document library, then hover your mouse over the Red PDF Logo. A link will appear for you to ‘Download Original’.

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iii. Complete the form in Adobe Acrobat and save your own copy.

1. Please keep in mind that no matter which web browser (Google Chrome, Microsoft Edge/Internet Explorer, Mozilla Firefox), you will want to open the form in Adobe. If you open it elsewhere, the electronic signature field may not appear. Also, if you are having trouble locating the form you downloaded, then search your file directory for your ‘Downloads’ folder (example pictured below).

iv. Upload your completed version of the form via the two options listed – 1. Click to add a file a. Click the link for ‘Click to add a file’. This should open up your file directory. Navigate to where your signed and completed version of the form is saved. Select the file, click Open.

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b. You should see a status bar appear below the link reflecting if the upload was successful.

2. Drop file here a. If you choose this method, you will open your file directory to where your signed and completed version of the form is saved. Then simply select and drag the file over the ‘Drop file here link.

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2. The other task you may be asked to complete is to review and acknowledge a webpage. a. For this task, the instructions will start with, “Please review the link below and acknowledge you have read the information provided…” . Follow the Helpful Steps: i. Please click the link, Amherst County Government HR Manual, below

ii. Once the new webpage opens, then locate the HR Manual link under the Human Resources Documents header, titled Human Resources Regulation

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iii. After selecting the link, a PDF will open; this is your HR Manual. Review all information in the document.

iv. After you have finished, you may exit and return to the original Employee Navigator page. Mark the check box below to acknowledge you have reviewed the HR manual.

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Medical Plans In Network Benefits

Preferred PPO 200

Preferred PPO 500

Preferred HMO 500

Referrals Required

No

No

No

Plan Accumulator

Plan Year

Plan Year

Plan Year

$200 individual $400 family

$500 individual $1000 family

$500 individual $1,000 family

Coinsurance

20%

20%

20%

Maximum Out-ofPocket

$3,000 individual $6,000 family

$2,500 individual $5,000 family

$2,500 individual $5,000 family

Preventive Care

Covered 100%

Covered 100%

Covered 100%

Physician’s Office Visits

PCP: $20 Specialist: $30 Virtual Visit: $15

PCP: $20 copay Specialist: $40 copay Virtual Visit: $15 copay

PCP: $20 copay Specialist: $40 copay Virtual Visit: $15 copay

Urgent Care

$30 copay

$40 copay

$40 copay

Emergency Room Facility

$200 copay per visit

$250 copay per visit

$250 copay per visit

Inpatient Facility

$20, after deductible

20%, after deductible

20%, after deductible

Outpatient Facility

20%, after deductible

20%, after deductible

20%, after deductible

20% coinsurance

20%, after deductible

20% after deductible

Annual Deductible (embedded)

Diagnostic Lab Services

Advanced Imaging Services

20% at outpatient facility, 10% at freestanding facility, after deductible

20% at outpatient facility, 10% at freestanding facility, after deductible

20% at outpatient facility, 10% at freestanding facility, after deductible

Pharmacy Prescription Drugs

$10/$30/$50/$125

$10/$20/$30/$125

$10/$30/$50/$125

Mail Order Prescription Drugs

$20/$60/$100/n/a

$20/$60/$100/n/a

$20/$60/$100/n/a

Out of Network Benefits

Preferred PPO 200

Preferred PPO 500

Preferred HMO 500

$500 individual $1,000 family

$1,000 individual $2,000 family

No Out of Network coverage

$6,000 individual $12,000 family

$5,000 individual $10,000 family

No Out of Network coverage

Annual Deductible Maximum Out-ofPocket

The benefit plan information shown in this guide is illustrative only. To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlying insurance documents will govern in all cases.

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Delta Dental PPO

Benefits for Amherst County Board of Supervisors Account Number: 600472 Effective Date: July 1, 2021 Annual Deductible (Applies to basic and major services)

$25 per person; $75 per family, per contract year

Annual Maximum

$1,500 per enrollee, per contract year

Orthodontic Lifetime Maximum

$1,500 per person

Healthy Smile, Healthy You® Program

Your plan provides additional cleanings and/or application of topical fluoride to enrollees with specific health conditions such as pregnancy, diabetes, high-risk cardiac conditions or who are undergoing cancer treatment via chemotherapy and/or radiation. Enrollment in Healthy Smile, Healthy You® is simple. Visit DeltaDentalVA.com/members to download and print an enrollment form.

Covered Benefits

Delta Dental will pay the stated percentage of the plan allowance based on the

participation with Delta Dental.

Coinsurances Coverage Diagnostic and Preventive Services

In-Network PPO

Premier

Out-ofNetwork

100%

100%

100%

Benefit Limitations

None

Oral exams and cleanings

Twice in a contract year. Periodontal cleaning is considered a regular cleaning and is subject to the benefit limits for regular cleanings.

Fluoride applications

Once in a contract year for enrollees under the age of 19.

Bitewing X-rays

Bitewing X-rays are limited to once in a contract year limited to a maximum of four films or a set (seven to eight films) of vertical bitewings.

Full mouth/panelipse X-rays

Once in a three-year period.

Sealants

One application per tooth for enrollees under the age of 16 on non-carious, non-restored first and second permanent molars.

Space maintainers

Once per quadrant per arch for enrollees under the age of 14.

Basic Services

80%

80%

Benefit Waiting Period

80%

None

Amalgam (silver) and composite (white) fillings

Once per surface in a 24-month period.

Stainless steel crowns

Primary (baby) teeth for enrollees under the age of 14.

Simple extractions Endodontic services/root canal therapy

Retreatment only after 24 months from initial root canal therapy treatment.

Periodontic services

Once per quadrant in a 24-36-month period based on services rendered.

 Delta Dental of Virginia | 4818 Starkey Road, Roanoke, VA 24018 | 800.237.6060 | DeltaDentalVA.com

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Rev 5.2021

Delta Dental PPO Covered Benefits Delta Dental will pay the stated percentage of the plan allowance based on the

participation with Delta Dental.

Coinsurances Coverage Basic Services

In-Network PPO

Premier

Out-ofNetwork

80%

80%

80%

Benefit Waiting Period

Benefit Limitations

None

Complex oral surgery

Surgical extractions and other surgical procedures.

Denture repair and recementation of crowns, bridges and dentures

Once in a 12-month period after six months from initial placement.

Major Services

50%

50%

50%

None

Crowns

Once per tooth in a 60-month period for enrollees age 12 and older.

Prosthodontics, removable and fixed

Once in a 60-month period for enrollees age 16 and older.

Implants

Once per site for enrollees age 16 and older.

Orthodontic Services

50%

50%

50%

Treatment for the proper alignment of teeth

None For subscriber and covered dependents.

Coverage is Available for: Enrollee and spouse Dependent children, only to the end of the month they reach age 26 Choosing a Dentist To ensure services are covered and that you receive the greatest value for your dental benefits, it is important that your dentist participates in the network listed at the top of your Delta Dental ID card. With Delta Dental , you have the option of visiting any dentist. However, your out-of-pocket costs may be lowest if you see a Delta Dental network dentist and highest if you choose an out-of-network dentist. Delta Dental network dentists agree to discount their fees, submit claims on your behalf and not bill you for the difference. Visit DeltaDentalVA.com to find a participating dentist in your area. ll payment. After Delta Dental pays Out-of-network its portion of the bill, you are responsible for any required coinsurance and deductible (if applicable), as well as the difference between the non. Payment will be made to you, unless state law requires otherwise.

The chart below illustrates how choosing an in-network dentist may help you save on out-of-pocket costs.

Procedure Coinsurance Percentage Patient Payment*

Delta Dental Premier®

Out-of-Network

$215.00

$215.00

$215.00

$126.00 80% $100.80 $25.20

$169.00 80% $135.20 $33.80

$113.00 80% $90.40 $124.60

The example shown is for illustrative purposes only. Payment structures may vary between plans.

The preceding information is a brief description of the services covered under your plan. It is not intended for use as a summary plan description nor is it designed to serve as an Evidence of Coverage. If you have specific questions regarding benefit structure, limitations or exclusions, consult the p 800-237-6060.

17

Rev 5.2021

Delta Dental Mobile Helping members manage their oral health

Oral health is important to Delta Dental — and to overall health! Our mobile app makes it easy for employees to make the most of their dental benefits.

Members have access to a dentist search, claims and coverage, ID cards and more, right from their mobile device.

Getting Started Delta Dental’s mobile app is optimized for iOS (Apple) and Android.

To download the app, visit the App Store (Apple) or Google Play (Android) and search for Delta Dental. You will need an internet connection to download and use most of the features of our free app.

Delta Dental Mobile App Features • Mobile ID card — no more looking for ID cards!

•C laims and coverage information on the go, putting benefits information right at members’ fingertips.

•A dentist search that helps members quickly find an in-network dentist nearby.

•O ur easy-to-use Dental Care Cost Estimator tool provides estimated cost ranges for common dental services.* •L ifeSmileTM Score, our easy-to-use, risk assessment tool, helps members understand their risk for tooth decay, gum disease and oral cancer.

DeltaDental.com

*Not available in all geographic areas.

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0637 3/20

A LOOK AT YOUR VSP VISION COVERAGE

SEE HEALTHY AND LIVE HAPPY WITH HELP FROM AMHERST COUNTY BOARD OF SUPERVISORS AND VSP. Enroll in VSP® Vision Care to get personalized care from a VSP network doctor at low out-of-pocket costs.

VALUE AND SAVINGS YOU LOVE. Save on eyewear and eye care when you see a VSP network doctor. Plus, take advantage of Exclusive Member Extras for additional savings.

PROVIDER CHOICES YOU WANT. With an average of five VSP network doctors within six miles of you, it’s easy to find a nearby in-network doctor. Plus, maximize your coverage with bonus offers and additional savings that are exclusive to Premier Program locations.

Like shopping online? Go to eyeconic.com and use your vision benefits to shop over 50 brands of contacts, eyeglasses, and sunglasses.

QUALITY VISION CARE YOU NEED. You’ll get great care from a VSP network doctor, including a WellVision Exam®—a comprehensive exam designed to detect eye and health conditions.

GET YOUR PERFECT PAIR

EXTRA $20 + TO SPEND ON FEATURED FRAME BRANDS*

UP TO

40%

SAVINGS ON LENS ENHANCEMENTS

SEE MORE BRANDS AT VSP.COM/OFFERS.

Enroll today.

Contact us: 800.877.7195 or vsp.com

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USING YOUR BENEFIT IS EASY! Create an account on vsp.com to view your in-network coverage, find the VSP network doctor who’s right for you, and discover savings with exclusive member extras. At your appointment, just tell them you have VSP.

YOUR VSP VISION BENEFITS SUMMARY AMHERST COUNTY BOARD OF SUPERVISORS and VSP provide you with an affordable vision plan.

BENEFIT

PROVIDER NETWORK: VSP Choice

DESCRIPTION

COPAY

FREQUENCY

YOUR COVERAGE WITH A VSP PROVIDER WELLVISION EXAM

Focuses on your eyes and overall wellness

PRESCRIPTION GLASSES

$20

Every 12 months

$20

See frame and lenses

FRAME

$150 featured frame brands allowance $130 frame allowance 20% savings on the amount over your allowance $130 Walmart®/Sam's Club® frame allowance $70 Costco® frame allowance

Included in Prescription Glasses

Every 12 months

LENSES

Single vision, lined bifocal, and lined trifocal lenses Impact-resistant lenses for dependent children

Included in Prescription Glasses

Every 12 months

LENS ENHANCEMENTS

Standard progressive lenses Premium progressive lenses Custom progressive lenses Average savings of 30% on other lens enhancements

CONTACTS (INSTEAD OF GLASSES)

$130 allowance for contacts; copay does not apply Contact lens exam (fitting and evaluation)

PRIMARY EYECARESM

Retinal screening for members with diabetes Additional exams and services for members with diabetes, glaucoma, or age-related macular degeneration.

Treatment and diagnoses of eye conditions, including pink eye, vision loss, and cataracts available for all members.

Limitations and coordination with your medical coverage may apply. Ask your VSP doctor for details.

$0 $95 - $105 $150 - $175

Up to $60

Every 12 months

Every 12 months

$0 $20 per exam As needed

Glasses and Sunglasses Extra $20 to spend on featured frame brands. Go to vsp.com/offers for details.

20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam.

EXTRA SAVINGS

Routine Retinal Screening No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam Laser Vision Correction Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities

YOUR COVERAGE WITH OUT-OF-NETWORK PROVIDERS Get the most out of your benefits and greater savings with a VSP network doctor. Call Member Services for out-of-network plan details.

Coverage with a retail chain may be different or not apply. Log in to vsp.com to check your benefits for eligibility and to confirm in-network locations based on your plan type. VSP guarantees coverage from VSP network providers only. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. In the state of Washington, VSP Vision Care, Inc., is the legal name of the corporation through which VSP does business.

*Only available to VSP members with applicable plan benefits. Frame brands and promotions are subject to change. Savings based on doctor’s retail price and vary by plan and purchase selection; average savings determined after benefits are applied. Ask your VSP network doctor for more details.

Classification: Restricted ©2021 Vision Service Plan. All rights reserved.

VSP, VSP Vision Care for life, Eyeconic, and WellVision Exam are registered trademarks, VSP Diabetic Eyecare Plus Program is servicemark of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear, Inc. All other brands or marks are the property of their respective owners.

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SAVINGS NEVER LOOKED SO GOOD Get access to more than $3,000 in savings with Exclusive Member Extras from VSP and industry-leading brands.

DISCOVER EXCLUSIVE MEMBER EXTRAS Special offers are available at all VSP® network doctor locations!

This interactive flier allows you to click on any offer shown below and find out more details.

GLASSES AND SUNGLASSES

EXTRA

$20

Save an average of $325 on Nike prescription sunglasses.

TO SPEND Get more value with an Extra $20 to spend on select featured frame brands by bebe, CALVIN KLEIN, and many others.

BONUS OFFERS 1,3

Save up to 40%* on SunSync® Light-Reactive Lenses.

EXTRA

$40

TO SPEND

®

Extra $40 to spend on select frame brands.

1,3

Save up to 40% on all TechShield® Anti-Reflective Coatings.

Maximize your savings with bonus offers only available at Premier Program locations.

EYEWEAR PROTECTION Get a one year worry-free warranty on featured frame brands.

UP TO

40% OFF

LENS ENHANCEMENTS Upgrade your lenses and save up to 40% off lens enhancements such as anti-glare coatings and light-reactive lenses.

2,3

Try Unity® single vision or progressive lenses risk-free with The Unity Promise.

Save up to $210 on an annual supply of contact lenses.

GLASSES REBATE

Savings on Eyeconic® when you shop for glasses, sunglasses, and contacts with your VSP benefits.

Get up to a $100 rebate on the perfect pair of glasses.* Try ZEISS SmartLife Lenses Risk-Free for six months.

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SPECIAL OFFERS ARE AVAILABLE AT ALL VSP NETWORK DOCTOR LOCATIONS! Improve your health and increase your savings.

CONTACTS

Receive savings of up to $200 in mail-in rebates when you purchase an annual supply of participating Bausch + Lomb contact lenses from your VSP network doctor.

Save up to $220 when purchasing an annual supply of Unity BioSync® contact lenses.

LASIK

Save via mail-in rebates when you purchase your annual supply of eligible CooperVision contact lenses from your VSP network doctor.

HEARING AIDS

20% off Custom LASIK and Custom PRK.

Get $1,000 off LASIK at TLC Nationwide Locations.

• • •

HEALTH AND ENTERTAINMENT

Save up to 60% on top of the line hearing aids Get batteries for less than $2.50 a month and free delivery Free online hearing screening 5

FINANCING

DIABETES RESOURCES Find resources to help prevent or delay Type 2 Diabetes like lifestyle coaching, diabetes educational materials, and more.

Receive free access to a variety of everyday savings like family entertainment, health and wellness, cash rewards, travel, and more.

Get instant, in-office application for promotional financing available on eye care and eyewear.

4

View all Exclusive Member Extras at vsp.com/offers Offers subject to change without notice. Some members may not be eligible for all offers. Visit vsp.com/offers for terms and conditions on specific offers. *Perfect Pair glasses rebate expires 6/30/2021, rebate offer terms and conditions apply and are subject to change. Rebate offer good from February 1, 2021 through June 30, 2021, and redeemed by July 31, 2021. The Sponsor/Offeror of this rebate is Plexus Optix, Inc. All third-party marks, product names, logos, and brands are the property of their respective owners. Use of these marks, names, logos and/or brands does not imply endorsement.

1. Brands and promotions are subject to change. 2. Savings based on doctor’s retail price and vary by plan and purchase selection; average savings determined after benefits are applied. 3. Available to VSP members with applicable plan benefits. 4. Some members may not be eligible for this program; visit vsp.com/simplevalues for terms and conditions. 5. VSP is providing information to its members, but does not offer or provide any discount hearing program. The relationship between VSP and TruHearing is that of independent contractors. VSP makes no endorsement, representations, or warranties regarding any products or services offered by TruHearing, a third-party vendor. The vendor is solely responsible for the products or services offered by them. If you have any questions regarding the services offered here, you should contact the vendor directly. TruHearing offers individuals the opportunity to purchase hearing aids at discounted prices, including individuals covered by self-funded health plans not subject to state insurance or health plan regulations. TruHearing is not insurance and not subject to state insurance regulations. TruHearing provides discounts to certain healthcare groups for hearing aid sales and services; TruHearing provides fitting, programming, and three adjustment visits at no cost; the member is obligated to pay for testing, and all post-fitting hearing care services, but will receive a discount from those healthcare providers who have contracted with TruHearing. Not available directly from VSP in the states of Washington and California.

Information Classification: Restricted ©2021 Vision Service Plan. All rights reserved.

VSP and Eyeconic are registered trademarks of Vision Service Plan. Unity, TechShield, SunSync, and Unity BioSync are registered trademarks of Plexus Optix, Inc. All other brands or marks are the property of their respective owners. 90389 VCCM

22

&zϮϬϮϮ ,ĞĂůƚŚ /ŶƐƵƌĂŶĐĞ ZĂƚĞƐ :ƵůLJ ϭ͕ ϮϬϮϭͲ:ƵŶĞ ϯϬ͕ ϮϬϮϮ WůĂŶ zĞĂƌ &zϮϬϮϮ W ,W DĞĚŝĐĂů WůĂŶƐ Θ ZĂƚĞƐ WŝĞĚŵŽŶƚ WƌĞĨĞƌƌĞĚ WWK ϮϬϬ

WƌĞŵŝƵŵ ĨŽƌ ϮϬϮϭͲϮϬϮϮ WůĂŶ zĞĂƌ

DŽŶƚŚůLJ ŽƐƚ ƉĞƌ ƚŝĞƌ ;&d ĞŵƉůŽLJĞĞƐͿ

&zϮϬϮϮ dŽƚĂů DŽŶƚŚůLJ WƌĞŵŝƵŵ

ŵƉůŽLJĞĞ ŽƐƚ

ŵƉůŽLJĞƌ ŽƐƚ

Single (Employee only)

$

557.01

$ 115.00

$ 442.01

Dual (Employee plus one)

$ 1,057.76

$ 439.00

$ 618.76

Family

$ 1,608.09

$ 663.00

$ 945.09

WŝĞĚŵŽŶƚ WƌĞĨĞƌƌĞĚ WWK ϱϬϬ DŽŶƚŚůLJ ŽƐƚ ƉĞƌ ƚŝĞƌ ;&d ĞŵƉůŽLJĞĞƐͿ

WƌĞŵŝƵŵ ĨŽƌ ϮϬϮϭͲϮϬϮϮ WůĂŶ zĞĂƌ &zϮϬϮϮ dŽƚĂů DŽŶƚŚůLJ WƌĞŵŝƵŵ ŵƉůŽLJĞĞ ŽƐƚ ŵƉůŽLJĞƌ ŽƐƚ

Single (Employee only)

$

Dual (Employee plus one) Family

546.74

60.00

$ 486.74

$ 1,038.27

$ 334.00

$ 704.27

$ 1,578.45

$ 506.00

$ 1,072.45

WŝĞĚŵŽŶƚ WƌĞĨĞƌƌĞĚ ,DK ϱϬϬ

$

WƌĞŵŝƵŵ ĨŽƌ ϮϬϮϭͲϮϬϮϮ WůĂŶ zĞĂƌ

DŽŶƚŚůLJ ŽƐƚ ƉĞƌ ƚŝĞƌ ;&d ĞŵƉůŽLJĞĞƐͿ

&zϮϬϮϮ dŽƚĂů DŽŶƚŚůLJ WƌĞŵŝƵŵ

ŵƉůŽLJĞĞ ŽƐƚ

ŵƉůŽLJĞƌ ŽƐƚ

Single (Employee only)

$ 476.97

$

00.00

$ 476.97

Dual (Employee plus one)

$ 905.76

$ 292.00

$ 613.76

Family

$ 1,377.00

$ 428.00

$ 949.00

&zϮϬϮϮ ĞŶƚĂů ZĂƚĞƐ Ͳ ĞůƚĂ ĞŶƚĂů WƌĞŵŝĞƌ DŽŶƚŚůLJ ŽƐƚ ƉĞƌ ƚŝĞƌ ;&d ĞŵƉůŽLJĞĞƐͿ

&zϮϬϮϮ dŽƚĂů DŽŶƚŚůLJ WƌĞŵŝƵŵ

ŵƉůŽLJĞĞ ŽƐƚ

ŵƉůŽLJĞƌ ŽƐƚ

Single (Employee only)

$ 30.42

$ 20.00

$

10.42

Dual (Employee plus one)

$ 60.82

$ 40.00

$

20.82

Family

$ 80.58

$ 53.00

$

27.58

&zϮϬϮϮ sŝƐŝŽŶ ZĂƚĞƐ Ͳ sŝƐŝŽŶ ^ĞƌǀŝĐĞ WůĂŶ ;s^WͿ &zϮϬϮϮ DŽŶƚŚůLJ ŽƐƚ ƉĞƌ ƚŝĞƌ ;&d ĞŵƉůŽLJĞĞƐͿ dŽƚĂů DŽŶƚŚůLJ WƌĞŵŝƵŵ ŵƉůŽLJĞĞ ŽƐƚ

ŵƉůŽLJĞƌ ŽƐƚ

Single (Employee only)

$

5.22

$

3.00

$

2.22

Dual (Employee plus one)

$

7.96

$

6.00

$

1.96

Family

$

14.28

$

11.00

$

3.28

WůĞĂƐĞ EŽƚĞ͗ dŚĞ ŵƉůŽLJĞĞ KŶůLJ ,DK ƉůĂŶ ŝƐ ŶŽǁ ŽĨĨĞƌĞĚ Ăƚ ŶŽ ĐŽƐƚ ƚŽ ŽƵŶƚLJ ĞŵƉůŽLJĞĞƐ͊

23

Real-time support for real living:

Your Work-Life Website

Work-Life Resource and Referral is a service that’s available as part of your employee benefits to assist you with any work or life issue that matters to you and your family. For professional assistance and supportive resources, call or log on any time, any day.

EAP: 434-200-6000

WORKLIFE: 800-537-2153

WEBSITE:

HealthWorks.PersonalAdvantage.com Login with your username and password, or click on Register to create account. Use company name:

To help you simplify life, your HealthWorks work-life website provides access to a wide range of supportive resources and information on topics of interest to you and your family. We invite you to log on and explore the practical tools and enhanced features:

• 1000s of pieces of content in every major life area (20K+ resources total), available in English and Spanish: • Family, caregiving, and parenting • Health • Relationships • Emotional wellbeing • Legal and financial •Personal and professional growth • Self-search locators representing over 850,000 records that cover categories of adoption, child care, elder care and education • Tools, assessments, videos, courses, calculators, legal forms, quizzes, articles, and more • Expansive work-life Training Library that is continually updated with new topics

24

Required Notices Newborn 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 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 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 the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Women’s Health and Cancer Rights Act

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 covered mastectomy is also entitled to the following benefits: 1. All stages of reconstruction of the breast on which the mastectomy has been performed: 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and 3.

Prostheses and treatment of physical complications of the mastectomy , including lymphedemas. Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient.

Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan.

25

Required Notices 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).

COLORADO – Health First Colorado (Colorado’s Medicaid If you live in one of the –following ALABAMA Medicaid states, you may be eligible for assistance paying your Program) & Child Health Plan Plus (CHP+) employer health plan premiums. The following Health list ofFirst states is Website: current as of July 31, 2020.

Colorado Contact your State for more information on eligibility – https://www.healthfirstcolorado.com/

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

ALASKA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx ARKANSAS – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447) CALIFORNIA – Medicaid Website: https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx

Phone: 916-440-5676

Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/child-healthplan-plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711 Health Insurance Buy-In Program (HIBI): https://www.colorado.gov/pacific/hcpf/healthinsurance-buy-program HIBI Customer Service: 1-855-692-6442 FLORIDA – Medicaid

Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery. com/hipp/index.html Phone: 1-877-357-3268 GEORGIA – Medicaid Website: https://medicaid.georgia.gov/health-insurancepremium-payment-program-hipp Phone: 678-564-1162 ext 2131 INDIANA – Medicaid Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: https://www.in.gov/medicaid/ Phone 1-800-457-4584

26

Required Notices IOWA – Medicaid and CHIP (Hawki)

Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563

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

KANSAS – Medicaid Website: http://www.kdheks.gov/hcf/default.htm Phone: 1-800-792-4884

NEBRASKA – Medicaid

Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178

KENTUCKY – Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov

NEVADA – Medicaid

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

LOUISIANA – Medicaid Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)

NEW HAMPSHIRE – Medicaid Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext 5218

MAINE – Medicaid Website: http://www.maine.gov/dhhs/ofi/publicassistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711

NEW JERSEY – Medicaid and CHIP

Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

MASSACHUSETTS – Medicaid and CHIP Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840

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

MINNESOTA – Medicaid

NORTH CAROLINA – Medicaid

Website: https://mn.gov/dhs/people-we-serve/children-andWebsite: https://medicaid.ncdhhs.gov/ families/health-care/health-care-programs/programs-andservices/medical-assistance.jsp [Under ELIGIBILITY tab, see “what Phone: 919-855-4100 if I have other health insurance?”]

Phone: 1-800-657-3739

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

NORTH DAKOTA – Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

27

Required Notices OKLAHOMA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

OREGON – Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075 PENNSYLVANIA – Medicaid Website: https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HI PP-Program.aspx Phone: 1-800-692-7462 RHODE ISLAND – Medicaid and CHIP

UTAH – Medicaid and CHIP Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669 VERMONT– Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427 VIRGINIA – Medicaid and CHIP Website: https://www.coverva.org/hipp/ Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282

WASHINGTON – Medicaid

Website: http://www.eohhs.ri.gov/ Website: https://www.hca.wa.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line) Phone: 1-800-562-3022 SOUTH CAROLINA – Medicaid Website: https://www.scdhhs.gov Phone: 1-888-549-0820 SOUTH DAKOTA - Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059 TEXAS – Medicaid Website: http://gethipptexas.com/ Phone: 1-800-440-0493

WEST VIRGINIA – Medicaid Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447) WISCONSIN – Medicaid and CHIP Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002 WYOMING – Medicaid Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531

To see if any other states have added a premium assistance program since July 31, 2020, 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 Services 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 12/31/2019)

28

General Notice of COBRA Continuation Coverage Rights ** Continuation Coverage Rights Under COBRA** Introduction You are receiving 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.”

Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to County of Amherst and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.

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; • Commencement of a proceeding in bankruptcy with respect to the employer; or • 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: Linda Warner at County of Amherst. Applicable documentation will be required i.e. court order, certificate of coverage etc.

29

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, Medicaid, 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.

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: County of Amherst Linda Martin Warner, SPHR, SHRM-SCP Director of Human Resources PO Box 390 Amherst, VA 24521 Phone: 434.946.9420 Fax: 434.946.9305 Health, Dental, Vision COBRA Administrator: Flex Facts 1200 River Ave, Suite 10E Lakewood, NJ 08701 Phone: 877.943.2287 Fax: 877.747.8564

30

CONTACT INFORMATION: PIEDMONT COMMUNITY HEALTHCARE HEALTH INSURANCE • Customer Service: 1-800-400-7247 • Rx Questions: 1-800-966-5772 • Website: www.pchp.net

DELTA - DENTAL INSURANCE • Customer Service: 1-800-237-6060 • Website: www.deltadentalVA.com

VSP - VISION INSURANCE • Customer Service: 1-800-877-7195 • Website: www.vsp.com

AMHERST COUNTY HUMAN RESOURCES • Telephone: 434-946-9420 • Email: hr@countyofamherst.com

TO VIEW YOUR BENEFITS ONLINE Visit www.piercegroupbenefits.com/

AmherstCountyGovernment

For additional information concerning plans offered to employees of Amherst County Government, please contact our Pierce Group Benefits Service Center at 1-800-387-5955