EMPLOYEE BENEFITS GUIDE September 1, 2022 - August 31, 2023
TABLE OF CONTENTS Page 3 A Smarter Way to Better Health Page 4-5 Eligibility & Enrolling Page 6 9 Medical Plans Page 10 Health Savings Account (HSA) Page 11 Flexible Spending Account (FSA) Page 12 Critical Illness Plan Page 13 Accident Plan Page 14 Dental Page 15 Vision Page 16 Life Insurance Page 17 Disability Insurance Page 18 Employee Assistance Program Page 19 Employee Payroll Deductions Page 20 Key Contacts & Resources Page 21 Rx Savings Page 22-30 Insurance Notices Page 31 Health Insurance Terminology Arke Systems Benefits Guide | 2 At Arke Systems, we know that our employees are crucial to our success. That’s why we provide you with an excellent, diverse benefits package that helps protect you and your family now and into the future. *This Benefits Guide outlines the health and welfare plans offered to you and your family. It contains general information and is meant to provide a brief overview. For complete details regarding each benefit plan offered, please refer to the individual plan documents as the information contained herein is for illustrative purposes. More details can be found in the plan specific Summary Plan Description(s) and/or Summary of Coverage. In the case of a discrepancy the plan specific documents will prevail.
ServicesHealthPreventativeCare
Immunizations
o Regular well baby and well child visits
.
Some immunizations and vaccinations are also considered preventive care services.
Standard immunizations recommended by the Centers for Disease Control (CDC) Include: hepatitis A and B, diphtheria, polio, pneumonia, measles, mumps, rubella, tetanus and influenza although these may be subject to age and/or frequency restrictions
Preventive care includes services like checkups, screenings and immunizations that can help you stay healthy and may help you avoid or delay health problems Many serious conditions such as heart disease, cancer, and diabetes are preventable and treatable if caught early.
Your health is a work in progress that needs your consistent attention and support Each choice you make for yourself and your family is part of an ever changing picture Taking steps to improve your health, such as going for annual physicals and living a healthy lifestyle, can make a positive impact on your well being
o Blood pressure, diabetes, and cholesterol tests
What’sUnderstandingCovered
Generally speaking, if a service is considered preventive care, it will be covered at 100%. If it’s not, it may still be covered subject to a copay, deductible or coinsurance The Affordable Care Act (ACA) requires that services considered preventive care be covered by your health plan at 100% in network, without a copay, deductible or coinsurance To get specifics about your plan’s preventive care coverage, call the customer service number on your member ID card. You may want to ask your doctor if the services you’re receiving at a preventive care visit (such as an annual checkup) are all considered standard preventive care If any service performed at an annual checkup is as a result of a prior diagnosed condition, the office visit may not be processed as preventive, and you may be responsible for a copay, coinsurance, or deductible To learn more about the ACA or preventive care and coverage, visit www.healthcare.gov
A SMARTER WAY TO HEALTHBETTER
It’s important for everyone to get the preventive care they need. Some examples of preventive care services are:
Arke Systems Benefits Guide | 3
Get Involved
It’s up to you to take responsibility and get involved, and we are pleased to offer programs that will support your efforts and help you reach goals It’s Your Health.
o Certain cancer screenings, such as mammograms, colonoscopies
o Counseling, screenings and vaccines to help ensure healthy pregnancies
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Arke
You are allowed to make changes to your current benefit elections during the plan year if you experience an IRS approved qualifying change in life status. The change to your benefit elections must be consistent with and on account of the change in life status.
You and your dependents are eligible to join the health and our company welfare benefit plans if you are a full time employee regularly scheduled to work 30 hours per week. You must be enrolled in the plan to add dependent coverage. Who is an Eligible Dependent?
IRS approved qualifying life status changes include:
• Change in employment status, including loss or gain of employment, for your spouse or a dependent
Who is Eligible to Join the Benefit Plan?
• Your dependent child under the maximum age specified in the Carriers’ plan documents including: Natural child Adopted child Stepchild Child for whom you have been appointed as the legal guardian
• Marriage, divorce or legal separation
• If you or your dependents lose eligibility for Medicaid or the Children’s Health Insurance Program (CHIP) coverage
• Your spouse or parent’s open enrollment
Qualifying Event Changes
• Your same sex or opposite sex domestic partner with whom you have shared a residence and financial obligations for 6 months or more
When Do Benefits Become Effective? Your benefits become effective on the first day of the month following 30 days as a full time employee with Arke Systems When Do Benefits Terminate? All insurance benefits end on the date of termination, including your FSA. Your HSA is an employee owned account and will follow you after your termination. You can set up an HSA with the bank of your choosing. Open Enrollment Each year during the annual Open Enrollment Period, you are given the opportunity to make changes to your current benefit elections. To find out when the annual Open Enrollment Period occurs, contact Human Resources.
• Birth or adoption of a child or placement of a child for adoption • Death of a dependent
ELIGIBILITY & ENROLLING
*Your child’s spouse and a child for whom you are not the legal guardian are not eligible. The Dependent Maximum Age Limits is up to age 26. The dependent does not need to be a full time student; does not need to be an eligible dependent on parent’s tax return; is not required to live with you; and may be unmarried or Oncemarried.the dependent reaches age 26, coverage will terminate on the last day of the birth month. A totally disabled child who is physically or mentally disabled prior to age 26 may remain on the if the child is primarily dependent on the enrolled member for support and maintenance.
• Your spouse to whom you are legally married
• Change in work schedule, including switching between full time and part time status, by you, your spouse or a dependent
• If you or your dependents become eligible for a state’s premium assistance subsidy under Medicaid or CHIP
If you have a life status change, you must notify the company within 60 days for changes in life status due to a Medicare or CHIP event and within 30 days of the other
Ifevents.youdo not notify the company during that time, you and/or your dependents must wait until the next annual open enrollment period to make a change in your benefit elections. Systems Benefits
• Change in residence or work site for you, your spouse, or a dependent that results in a change of eligibility
ENROLLING & CHANGES
MEDICAL PLAN OPTION 1 Platinum HMO $0/0% Plan Highlights In Network You Pay Out-of-Network You Pay Deductible $0 Individual | $0 Family Not Covered Coinsurance 0% after deductible Not Covered Annual Out of Pocket Maximum $1,500 Individual | $3,000 Family Not Covered Primary Care Physician Office Visit $25 copay Not Covered Specialist Office Visit $75 copay Not Covered Telemedicine (Phone/Video Chat) Covered Same as In Office Visit Not Covered Preventive Care Services No Charge Not Covered Laboratory Diagnostics & X Ray $75 Copay or 30% non preferred network Not Covered Complex Imaging Services (CT Scans, PET Scans & MRIs) $500 then 30% Not Covered Hospital Inpatient Care $1,500 copay/day Not Covered Outpatient Surgery $1,500 copay/visit Not Covered Emergency Room $500 copay $500 copay Urgent Care $50 copay Not Covered Prescription Drugs Quantity Limits: Retail = 30 day supply Mail Order = 90 day supply Level 1 Preferred, lowest cost generic PreferreddrugsSpecialty Prescription Drug Retail: $10 copay Mail Order: $25 copay Retail: $10 copay Not Covered Level 2 Low cost generic drugs Preferred Specialty Prescription Drug Retail: $40 copay Mail Order: $100 copay Retail: $40 copay Not Covered Level 3 Preferred brand name drugs and higher cost generic drugs Preferred Specialty Prescription Drug Retail: $150 copay Mail Order: $375 copay Retail: $150 copay Not Covered Level 4 Non preferred brand name drugs and high cost generic drugs Preferred Specialty Prescription Drug Retail: $300 copay Mail Order: $750 copay Retail: $500 copay Not Covered Arke Systems Benefits Guide | 6 MEDICAL To search for healthcare providers, visit www.myuhc.com and register.
MEDICAL PLAN OPTION 2 Gold HMO 2500/80% Plan Highlights In Network You Pay Out of Network You Pay Deductible $2,500 Individual | $5,000 Family Not Covered Coinsurance 20% after deductible Not Covered Annual Out of Pocket Maximum $6,250 Individual | $12,500 Family Not Covered Primary Care Physician Office Visit $25 copay Not Covered Specialist Office Visit Deductible, then 20% Not Covered Telemedicine (Phone/Video Chat) Covered Same as In Office Visit Not Covered Preventive Care Services No Charge Not Covered Laboratory Diagnostics & X Ray No Charge or 30% for non preferred network Not Covered Complex Imaging Services (CT Scans, PET Scans & MRIs) $500 then 30% Not Covered Hospital Inpatient Care Deductible, then 20% Not Covered Outpatient Surgery Deductible, then 20% Not Covered Emergency Room $500 copay $500 copay Urgent Care $50 copay Not Covered Prescription Drugs Quantity Limits: Retail = 30 day supply Mail Order = 90 day supply Level 1 Low cost generic and brand name drugs Preferred Specialty Prescription Drug Retail: $10 copay Mail Order: $25 copay Retail: $10 copay Not Covered Level 2 Higher cost generic and brand name drugs Preferred Specialty Prescription Drug Retail: $40 copay Mail Order: $100 copay Retail: $40 copay Not Covered Level 3 High cost, mostly brand name PreferreddrugsSpecialty Prescription Drug Retail: $150 copay Mail Order: $375 copay Retail: $150 copay Not Covered Level 4 Highest cost drugs Preferred Specialty Prescription Drug Retail: $300 copay Mail Order: $750 copay Retail: $500 copay Not Covered Arke Systems Benefits Guide | 7 MEDICAL To search for healthcare providers, visit www.myuhc.com and register.
MEDICAL PLAN OPTION 3 Gold POS 3000/0% Plan Highlights In Network You Pay Out of Network You Pay Deductible $3,000 Individual | $6,000 Family $10,000 Individual | $20,000 Family Coinsurance 0% after deductible 30% after deductible Annual Out of Pocket Maximum $8,500 Individual | $17,000 Family $20,000 Individual | $40,000 Family Primary Care Physician Office Visit $30 copay Deductible, then 30% Specialist Office Visit $100 copay Deductible, then 30% Telemedicine (Phone/Video Chat) Covered Same as In Office Visit Deductible, then 30% Preventive Care Services No Charge Deductible, then 30% Laboratory Diagnostics & X Ray No Charge or 30% for non preferred network Deductible, then 30% Complex Imaging Services (CT Scans, PET Scans & MRIs) $500 then 30% Deductible, then 30% Hospital Inpatient Care Deductible Deductible, then 30% Outpatient Surgery Deductible Deductible, then 30% Emergency Room $500 copay $500 copay Urgent Care $50 copay Deductible, then 30% Prescription Drugs Quantity Limits: Retail = 30 day supply Mail Order = 90 day supply Tier 1 Low cost Generic & Brand name PreferredDrugsSpecialty Prescription Drugs Retail: $10 copay Mail Order: $25 copay Retail: $10 copay Retail: $25 copay Mail Order: Not Covered Retail: $10 copay Tier 2 Higher cost Generic & Brand name PreferredDrugsSpecialty Prescription Drugs Retail: $40 copay Mail Order: $100 copay Retail: $40 copay Retail: Deductible, then 30% Mail Order: Not Covered Retail: $40 copay Tier 3 High cost, mostly Brand name PreferredDrugsSpecialty Prescription Drugs Retail: $150 copay Mail Order: $375 copay Retail: $150 copay Retail: Deductible, then 30% Mail Order: Not Covered Retail: $150 copay Tier 4 Highest cost Drugs Preferred Specialty Prescription Drugs Retail: $300 copay Mail Order: $750 copay Retail: $500 copay Retail: Deductible, then 30% Mail Order: Not Covered Retail: $500 copay Arke Systems Benefits Guide | 8 MEDICAL To search for healthcare providers, visit www.myuhc.com and register.
Retail: Deductible, then $150 copay Mail Order: Deductible, then $375 copay Retail: Deductible, then $150 copay Retail: Deductible, then $150 copay Mail Order: N/A Retail: Deductible, then $150 copay Drugs
Tier 4 Highest cost Drugs Preferred Specialty Prescription
Retail: Deductible, then $300 copay Mail Order: Deductible, then $750 copay Retail: Deductible, then $500 copay Retail: Deductible, then $300 copay Mail Order: N/A Retail: Deductible, then $500 copay Arke visit www.myuhc.com and register.
name PreferredDrugsSpecialty Prescription
Retail: Deductible, $10 copay Mail Order: Deductible, $25 copay Retail: Deductible, then $10 copay Retail: Deductible, then $10 copay Mail Order: N/A Retail: Deductible, then $10 copay Retail: Deductible, $40 copay Mail Order: Deductible, then $100 copay Retail: Deductible, then $40 copay Retail: Deductible, then $40 copay Mail Order: N/A Retail: Deductible, then $40 copay
Tier 3 High cost, mostly Brand Drugs
MEDICAL
Tier 2 Higher cost Generic & Brand name PreferredDrugsSpecialty Prescription Drugs
MEDICAL PLAN OPTION 4 Bronze HSA 6500 Plan Highlights In Network You Pay Out of Network You Pay Deductible $6,500 Individual | $13,000 Family $10,000 Individual | $20,000 Family Coinsurance 30% after deductible 40% after deductible Annual Out of Pocket Maximum $7,000 Individual | $14,000 Family $20,000 Individual | $40,000 Family Primary Care Physician Office Visit Deductible, then 30% Deductible, then 40% Specialist Office Visit Deductible, then 30% Deductible, then 40% Telemedicine (Phone/Video Chat) Covered Same as In Office Visits Deductible, then 40% Preventive Care Services No Charge Deductible, then 30% Laboratory Diagnostics & X Ray Deductible, then 30% Deductible, then 40% Complex Imaging Services (CT Scans, PET Scans & MRIs) Deductible, then 30% Deductible, then 40% Hospital Inpatient Care Deductible, then 30% Deductible, then 40% Outpatient Surgery Deductible, then 30% Deductible, then 40% Emergency Room Deductible, then 30% Deductible, then 30% Urgent Care Deductible, then 30% Deductible, then 40% Prescription Drugs Quantity Limits: Retail = 30 day supply Mail Order = 90 day supply Deductible Medical Deductible Applies Medical Deductible Applies Tier 1 Low cost Generic & Brand name PreferredDrugsSpecialty Prescription Drugs
Systems Benefits Guide | 9 To search for healthcare providers,
How Does an HSA Work? How Do I Enroll in an HSA? You can receive tax free distributions from your HSA to pay for or to be reimbursed for qualified medical expenses that are incurred after you establish your HSA. These include: What Type of Expenses Can Be Paid From an HSA? ▪ Any medical expenses that apply toward your deductible, ▪ Any healthcare expenses that are qualified expenses for tax purposes under Section 213 of the Internal Revenue Code. Some of these expenses are described in IRS Publication 502, ▪ Once your reach age 65, Medicare premiums or other health insurance, other than a Medicare supplemental policy. You may begin funding your HSA account as soon as your account is established. When can I Begin Contributions to My HSA Account?
Depending upon who you choose to be your HSA custodian there could be different options. Can I Invest My HSA Funds? You can withdraw your HSA at anytime and use it for any purpose; however, you will pay income taxes on the amount withdrawn, plus a 20% penalty. After age 65, the 20% penalty no longer applies. Can I Use The Money in My HSA for Anything Other Than Eligible Medical Expenses? As noted by federal law, the annual contribution limits for 2022 are: HSA CONTRIBUTION LIMITS 2022 2023 INDIVIDUAL INDIVIDUAL $3,650 $3,850 FAMILY FAMILY $7,300 $7,750 Individuals ages 55 or older may be eligible to make a catch up contribution of $1,000. How Much Can I Contribute to An HSA? Health Savings Account (HSA) ▪ Use money in your account to pay for qualified health care expenses ▪ Reduce the amount of your federal taxes ▪ Earn tax free interest on money in your HSA ▪ Funds in your account roll over every year ▪ The money is yours, so the account stays with you if you leave your employer ▪ Once you have a certain amount in your account, you may invest your funds ▪ Investment gains grow, tax free You can go to any banking institution that administers HSAs and apply for an HSA account. This account works similarly to how a bank would manage your personal savings or checking account. When you open your HSA, you may receive a debit card to be used on many out of pocket qualified expenses like doctor visits, vision and dental care, and prescriptions. Arke Systems Benefits |
HEALTH SAVINGS ACCOUNT
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Loss of Other Coverage A Health Savings Account (HSA) is an account permitted under the federal tax law that allows you to save money for healthcare expenses on a tax favored basis. It is an individual account that belongs to you and is not part of Arke’s medical plan. The account is portable, which means it is not tied to your employment at Arke Systems. Your HSA stays with you if you retire or leave the company. Because the HSA has special tax status under the law, it is governed by numerous mandatory tax rules and regulations. What is a Health Savings Account? Available only if you enrolled in the Medical Plan Option 4, Bronze HSA 6500 Generally, to be eligible to set up and contribute to an HSA, you: Who is Eligible for an HSA? ▪ Must be covered by a Consumer Directed Health Plan (CDHP) the Medical Plan Option 4, Bronze HSA 6500
▪ Cannot be claimed as a dependent on anyone else’s tax return ▪ Are not enrolled in Medicare (due to age or disability) or Tricare ▪ Cannot be enrolled in a general purpose healthcare FSA, nor can your spouse You may find information about these rules on the IRS website (www.irs.gov), including IRS Publication 969 and 502. You may also want to consult a tax advisor. You fund the HSA with your dollars up to a certain limit each year by making a deposit directly into your HSA account. The account must be funded prior to any withdrawals. Then, as you have eligible qualified expenses, you may withdraw money from your HSA to pay expenses that are not otherwise paid by the health, dental or vision plans, e.g., your deductible or coinsurance. It’s up to you whether to use your HSA funds. You are not required to use the money, and you may save it for the future and let it continue to accumulate. It’s important to understand that the HSA, unlike a Healthcare Flexible Spending Account (FSA), will not pay for qualified expenses that exceed the balance in the HSA. When filing your taxes each year, you will provide your tax advisor a report showing the amount you contributed to the HSA account, and you will receive a tax deduction for that amount.
FLEXIBLE SPENDING ACCOUNT You may not enroll in the FSA if you are contributing to an HSA. Arke Systems Benefits Guide | 11 Arke Systems offers employees the opportunity to participate in the Healthcare Flexible Spending Account (FSA) and Dependent Care FSA. These programs may provide you with significant tax advantages as they allow you to pay for eligible out of pocket expenses with pre tax dollars through payroll deductions. It is very important that you estimate your annual expenses as accurately as possible because the plan only allows for a $570 carryover maximum annually FSA Administrator: Medcom In 2022, you may defer up to $2,850 to your Healthcare FSA to fund eligible out of pocket healthcare expenses The following list provides examples of expenses eligible for reimbursement under the IRS guidelines: 1. Healthcare Flexible Spending Account • Non covered medical expenses that quality under Section 217 of the IRS code • Deductibles • Office visit copays • Prescription medication • Over the counter medications • Hearing and dental expenses not covered by insurance Examples of non eligible expenses include: cosmetic surgery, electrolysis, toiletries, vitamins, health club dues. 2. Dependent Care FSA You may defer up to $5,000 or $2,500 if married and filing separately to your Dependent Care FSA to fund eligible out of pocket expenses for childcare and eldercare. To be eligible for reimbursement, expenses must meet the following criteria established by the IRS: ▪ The person cared for must be under age 13, or if older, physically or mentally incapable of self care. ▪ Day care must be necessary in order for you and your spouse to work. ▪ The person cared for must be claimed as a dependent on your federal tax return and must reside in your home at least eight hours per day ▪ Payment for care cannot be made to anyone you claim as a dependent on your income tax return, to your spouse or to a child under age 19 ▪ If care is provided by a center that cares for more than six individuals, it must be licensed. For a complete list of eligible medical and dependent care expenses, you may access publications #502 (healthcare) and #503 (dependent care) on the web at www.irs.gov. FSA Open Enrollment occurs at the end of the year for a January effective date each year.
Cancer In Situ 30% of lump
CRITICALCOVEREDILLNESSCONDITIONS ConditionsCardiovascular 1st Occurrence 2nd Occurrence Invasive Cancer 100% of lump sum
Benefit Amounts Employees may elect a basic benefit of $5,000 or increments of $5,000 up to a maximum of $20,000, subject to guaranteed issue schedule. The Employee Guarantee issue amount is $10,000. Spouses may elect increments of $2,500 up to a maximum of $10,000, subject to guaranteed issue schedule. The spouse's Voluntary critical illness benefit cannot exceed 50% of the employee’s critical illness benefit amount. The Spouse Guarantee issue amount is $5,000. Dependent Child(ren) benefit will be 25% of the employee benefit, up to a maximum benefit of $5,000. All benefit amounts for child(ren) is guarantee issue. $50 lump sum sum 0% lump sum sum 0% lump sum
Benign Brain Tumor 75% of lump
of
A critical illness has a dramatic and immediate impact on employees and their families. The costs associated with such illnesses create hardships for many, especially with the trend toward higher out of pocket healthcare costs.
Guardian’s Critical Illness plan pays lump sum cash benefit to insured employees upon the first occurrence, and even reoccurrence, of a covered illness. These benefit dollars may be used to help replace lost income, travel, childcare, medical deductible, and other uncovered expenses.
of
of
Skin Cancer $250 per lifetime $250 per lifetime Heart Attack 100% of lump sum 50% of lump sum Stroke 100% of lump sum 50% of lump sum Arteriosclerosis 30% of lump sum 0% of lump sum Organ Failure 100% of lump sum 50% of lump sum Kidney Failure 100% of lump sum 50% of lump sum Addison's Disease 100% of lump sum ALS (Lou Gehrig's Disease) 100% of lump sum Alzheimer's Disease 100% of lump sum Coma 100% of lump sum Huntington's Disease 100% of lump sum Multiple Sclerosis 100% of lump sum Loss of Speech 100% of lump sum Loss of Sight 100% of lump sum Loss of Hearing 100% of lump sum Parkinson's Disease 100% of lump sum Permanent Paralysis 100% of lump sum Arke Systems Benefits Guide | 12 Other Covered Conditions • Child Specific Conditions such as Cerebral Palsy, Cleft Lip/Cleft Palate, Club Foot, Cystic Fibrosis, Down’s Syndrome, Muscular Dystrophy, Spina Bifida, and Type 1 Diabetes • Plan pays $100 benefit if a Spouse’s Parent is diagnosed with Alzheimer’s Disease while the Spouse is covered by the plan. Wellness Benefit • Employee $100 • Spouse $100 • Child $100
The Sports Package increases the total benefit payment by 25% No one plans on getting injured…but just in case, we’ve got you covered. You do everything you can to stay active and healthy, but accidents happen every day, especially sports related accidents. An injury that hurts an arm or a leg can hurt your finances too. That’s where Guardians Accident coverage can help. Guardian pays cash benefits directly to you or anyone you choose regardless of any other coverages you have Let Guardian help take care of yourself and your family including dependent children up to age 26. This coverage includes benefits for treatments or procedures due to an accident. These include hospitalization, emergency room treatment, X rays and much more. Guardian Accident Advantage Benefits Include: Emergency Room Treatment Air ProstheticLodgingConcussionsChiropracticBurnBlood/Plasma/PlateletsAmbulanceSkinGraftVisitsDevise/Artificial Limbs ACCIDENT PLAN Arke Systems Benefits Guide | 13 Wellness Benefit for completing certain wellness screenings or procedures is: • Employee $100 • Spouse $100 • Child $100 Pricing is available in the Employee Navigator enrollment system.
DENTAL Arke Systems Benefits Guide | 14 Value Plan Highlights InYOUNetworkPAY Out of YOUNetworkPAY Your Deductible $50 individual / $150 Family $50 individual / $150 Family Calendar Year Maximum Applies to preventive, basic, and major services $2,000 per person $2,000 per person Preventive & Diagnostic Services Exams, Cleanings, Bitewing X Rays, Fluoride to age 19, Sealants 0% coinsurance 0% coinsurance Basic Services Fillings, Extractions, Endodontics (root canal), Periodontics 0% Coinsurance 0% Coinsurance Major Services Bridges & Dentures, Single Crowns, Inlays, Onlays 40% Coinsurance 40% Coinsurance Orthodontics Children up to age 19 Lifetime Orthodontia Maximum $2,000 50% Coinsurance 50% Coinsurance NAP Plan Highlights InYOUNetworkPAY Out of YOUNetworkPAY Your Deductible $50 individual / $150 Family $50 individual / $150 Family Calendar Year Maximum Applies to preventive, basic, and major services $2,000 per person $2,000 per person Preventive & Diagnostic Services Exams, Cleanings, Bitewing X Rays, Fluoride to age 19, Sealants 0% coinsurance 0% coinsurance Basic Services Fillings, Extractions, Endodontics (root canal), Periodontics 20% Coinsurance 20% Coinsurance Major Services Bridges & Dentures, Single Crowns, Inlays, Onlays 50% Coinsurance 50% Coinsurance Orthodontics Children up to age 19 Lifetime Orthodontia Maximum $2,000 50% Coinsurance 50% Coinsurance Staying healthy includes obtaining quality dental care for you and your family. Our dental benefits, administered by Guardian, provide a wide range of dental services including preventive care, fillings, and x rays. You have the freedom of choice to utilize in network or out of network providers. For a list of in network providers, visit www.guardiananytime.com. The network is the PPO network. When you visit an in network dentist, your out of pocket expenses are lower. In network dentists will file the claim for you, and services are paid at the Guardian negotiated rate. Select A Dental Plan That Meets Your Needs IMPORTANT: You have a choice between the two plans below. They are both the same cost to you. If your dental provider is in network then the Value Plan is best. If your dental provider is out of network then it would be best to chose the NAP Plan. *A late entrant waiting period may apply if you do not enroll in your initial eligibility period. To find a dentist, log on to www.guardiananytime.com
VISION GUARDIAN VISION VSP CHOICE NETWORK Services In Network Out Of Network Eye Exam: Routine Exam with Dilation $10 Copay $39 allowance Standard Contact Lens fit and follow up $50 Copay Included in Contact Lens Allowance Custom Contact Lens fit and follow up $75 Copay Included in Contact Lens Allowance Frames: Any available frame at provider location $130 frame allowance 20% off balance over allowance $46 allowance Standard Plastic Lenses: Single $10 Copay $23 Bifocal $10 Copay $37 Trifocal $10 Copay $49 Contact Lenses: (Material Only) Elective Conventional or Disposable Lenses $130 allowance 15% off balance over allowance $100 allowance Medically Necessary Paid in full $120 allowance Frequency: Examination 12 months Frames 12 months Eyeglass Lenses* 12 months** Contact Lenses* 12 months** * Plan pays covers the purchase of Eyeglass Lenses or Contact Lenses but not both during in a 12 month period. Your eyes deserve the best care to keep them healthy year after year. Regular eye examinations may determine your need for corrective eyewear and may also detect general health problems in their earliest Forstages.alist of in network providers, visit www.guardiananytime.com When you visit an in network vision provider, your out of pocket expenses are lower. Eligible employees may elect coverage for themselves, a spouse and eligible dependent children. Dependent children are covered up to age 26, regardless of student status. Benefits cover the purchase of Eyeglass lenses OR Contact lenses Arke Systems Benefits Guide | 15
Basic Life Insurance – Company Paid Arke Systems provides a Basic Life and Accidental Death & Dismemberment (AD&D) benefit to eligible employees through Guardian. Your benefit amount is $25,000 Life Benefit reduces to 65% at age 65 & 50% at age 70. *Be sure you name a beneficiary when you enroll in Life and AD&D benefits Supplemental Life Insurance Employee Paid All full time employees and their eligible spouses and children can purchase supplemental life insurance through Guardian. If you do not enroll within 30 days of your eligibility date, you can apply for coverage at any time during the year and will be required to complete an evidence of insurability (EOI) form. Coverage will be effective once written approval is received from Guardian. Employee coverage is available in $10,000 increments up to $500,000, subject to the guaranteed issue Spouseschedule*.coverage is available in $5,000 increments up to $100,000. not to exceed 50% of the employee’s elected amount and subject to the guaranteed issue schedule*. Spouse coverage terminates at age 70. Dependent Child coverage is available in $1,000 increments up to $10,000 subject to child’s age: LIFEGuaranteedINSURANCEIssueSchedule* Employee < 65 years of age $100,000 65 69 years of age $50,000 70+ years of age $10,000 Spouse < 65 years of age $25,000 65 69 years of age $10,000 70+ years of age $0 Child 14+ days old $10,000 *Guaranteed issue schedule amounts are only available during your initial eligibility period. If you are enrolling at Open Enrollment after your initial eligibility period or increasing your coverage amount, you will be required to complete an Evidence of Insurability (EOI) form. Employee life benefit amount reduces to 65% at age 65 and 50% at age 70. Spouse life benefit amount will reduce in accordance with the spouse’s age and terminate at age 70. Arke Systems Benefits Guide | 16
Pre existing condition limitation The disability policies include a pre existing condition limitation. The policies will not pay, in the first 12 months of the policy, for a condition that you had within 3 months prior to the effective date. You have a pre existing condition if you received medical treatment, consultation, care or services including diagnostic measures for the condition, or took prescribed drugs or medicines for it in the 3 months just prior to your effective date of coverage.
Disability coverage provides the financial security of knowing that you will continue to receive income if you are unable to work due to illness or injury.
DISABILITY INSURANCE
Arke Systems Benefits Guide | 17
Short-Term Disability – Arke pays 50% Even a few weeks away from work can make it difficult to manage household expenses. Short Term Disability is available to you through Guardian. This coverage will pay up to 60% of your weekly salary up to a maximum of $2,400 for non work related illnesses or injuries, so you can focus on getting better and worry less about keeping up with your bills. Benefits begin on the 1st day for injuries and 8th day for illnesses. Benefits are payable up to a maximum of 13 weeks. The cost of short term disability coverage is determined by the weekly salary amount. Arke Systems will contribute 50% toward the monthly premium for short term disability.
Long-Term Disability Company Paid Serious illnesses or injuries can come out of nowhere. They can interrupt your life and your ability to work for months ─ even years. Long Term Disability coverage is provided to you through Guardian. This benefit pays 60% of your monthly earnings in the event of a disability after 90 days for illnesses or injuries up to a maximum weekly benefit of $10,000. The Long Term Disability benefit pays up to the Social Security Normal Retirement Age
For(SSNRA).allfull time employees, Arke Systems pays 100% of the monthly premium for long term disability coverage.
Arke Systems Benefits Guide | 18 EMPLOYEE ASSISTANCE PROGRAM Some of the program highlights include: • Unlimited telephonic assistance on common employee/workplace issues • Up to three free in person visits
EMPLOYEE PAYROLL DEDUCTIONS Arke Systems contributes to the cost of the benefits package for all fulltime employees. For an additional premium, employees can add dependent coverage. Please refer to the chart below and Employee Navigator for your semi-monthly payroll deductions. EmployeeOnly Employee & Spouse EmployeeChild(ren)& Family Medical Plan Option 1 Platinum HMO $0/0% $213.71 $683.06 $550.57 $1,019.93 Medical Plan Option 2 Gold HMO 2500/80% $92.32 $440.28 $326.00 $673.97 Medical Plan Option 3 Gold POS 3000/0% $102.93 $461.50 $345.63 $704.21 Medical Plan Option 4 Bronze HSA 6500 $0.00 $255.65 $155.22 $410.87 Dental Choice Value $9.43 $31.98 $41.56 $70.26 Dental Choice NAP $9.43 $31.98 $41.56 $70.26 Vision $2.23 $8.89 $10.21 $19.11 Supplementary Life / AD&D Rates will vary depending on the member(s) age(s) and benefit amounts elected Short Term Disability See Employee Navigator Arke Systems pays 50% of the premium Long Term Disability Arke Systems pays 100% of the premium Accident See Employee Navigator Critical Illness See Employee Navigator Arke Systems Benefits Guide | 19 EMPLOYEE PAYROLL DEDUCTIONS PER PAY PERIOD (Semi-Monthly) EFFECTIVE: September 1, 2022 – August 31,2023
DEBBIE FAZZONE SENIOR CLIENT SERVICE ASSISTANT 404 995 dfazzone@sspins.com1792 NEED HELP WITH A CLAIM? BE SURE TO HAVE THE FOLLOWING INFORMATION WHEN CALLING: Subscriber ID # OR SSN Date of Service Name of Patient Name of Doctor, Facility or Hospital Copy of Bill or Explanation of Benefits (EOB) Your Employee Support Contact KEY CONTACTS & RESOURCES Questions on your benefits or need assistance with Claims, contact : Sterling Seacrest Pritchard Arke Systems Benefits Guide | 20 Benefit Company Phone Website Arke Systems Courtney Roth 404 561 7575 croth@arke.com Medical Coverage United Healthcare 866 414 1959 www.myuhc.com Non Medical Benefits Guardian 888 600 1600 www.guardiananytime..com FSA Medcom 800 623 7542 www.medcom.net Employee Assistance Program WorkLife Matters 800 386 7055 www.ibhworklife.com
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This notice is being provided to ensure that you understand your right to apply for group health insurance coverage. A special enrollment period is a time outside of the annual open enrollment period during which you and your family have a right to sign up for health coverage. In the Marketplace, you qualify for a special enrollment period 60 days following certain life events that involve a change in family status (for example, marriage or birth of a child) or loss of other health coverage Job based plans must provide a special enrollment period of 30 days Some events will require additional documentation to be submitted with the application at the time of enrollment You should read this notice even if you plan to waive coverage at this time To request special enrollment or obtain more information, please contact HR. If you have a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents However, you must request enrollment within 30 days after the marriage, birth, or placement for adoption If you are declining coverage for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, 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).Ifyouoryour dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or become eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must request enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistance subsidy.
Marriage, Birth, or Adoption
Loss of Other Coverage Medicaid or CHIP
IMPORTANT INFORMATION This guide provides a summary of you employee benefits rights and regulations as determined by Federal and State Laws. Information included in this guide includes the following: Arke Systems Benefits Guide | 22 Affordable Care Act (ACA) Insurance Mandate General Notice of the Cobra Continuations Rights Special Open Enrollment Rights Children’s Health Insurance Program (CHIP) Premium Assistance Affordable Care Act (ACA) Preventive Services for Non grandfathered Plans Newborns’ and Mothers’ Health Protection Act of 1996 Health Insurance Marketplace Coverage Options and Your Group Health Coverage Break Time for Nursing Mothers Under the Fair Labor Standards Acts (FLSA) Women’s Health & Cancer Rights Act The Generic Information Nondiscrimination Act of 2008 (GINA) HIPAA Privacy Rules SPECIAL OPEN ENROLLMENT RIGHTS
Premium Assistance under Medical and CHIP Special Enrollment Events
IMPORTANT
Women’s Health and Cancer Rights Act
Newborns’ and Mothers’ Health Protection Act
An Eligible Person and/or Dependent may also be able to enroll during a special enrollment period A special enrollment period is not available to an Eligible Person and his or her dependents if coverage under the prior plan was terminated for cause, or because premiums were not paid on a timely basis
COBRA Continuation
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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 has been performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; and Prostheses and treatment of physical complications of the mastectomy, including lymphedemas These benefits will be provided subject to deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan If you would like more information on WHCRA benefits, call your plan administrator
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 For additional information regarding COBRA qualifying events, how coverage is provided and actions required to participate in COBRA coverage, please see your Human Resources department.
The group health coverage provided complies with the Newborns’ and Mothers’ Health Protection Act of 1996 Under this law 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 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 the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours) If you or your children are eligible for Medicaid or CHIP (Children’s Health Insurance Program) and you are eligible for health coverage from your employer, your State may have a premium assistance program that can help you pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer sponsored health coverage but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP you can 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, you can 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, you can ask the State if it has a program that might help you pay the premiums for an employer sponsored plan Please see Human Resources for a list of state Medicaid or CHIP offices to find out more about premium assistance. of Coverage
INFORMATION
An Eligible Person and/or Dependent does not need to elect COBRA continuation coverage to preserve special enrollment rights. Special enrollment is available to an Eligible Person and/or Dependent even if COBRA is elected. Please be aware that most special enrollment events require action within 30 days of the event Please see Human Resources for a list of special enrollment opportunities and procedures
NOTE: If you purchase a health plan through the marketplace instead of accepting health coverage offered by your employer, then you will lose the employer contribution to the employer offered coverage Also, this employer contribution, as well as your employee contribution to employer offered coverage, is excluded from income for Federal and State income tax purposed
USERRA Notice
"Service in the uniformed services" or "service" means the performance of duty on a voluntary or involuntary basis in the uniformed services under competent authority, including active duty, active and inactive duty for training, National Guard duty under federal statute, a period for which a person is absent from employment for an examination to determine his or her fitness to perform any of these duties, and a period for which a person is absent from employment to perform certain funeral honors duty. It also includes certain service by intermittent disaster response appointees of the National Disaster Medical System.
Definitions
The Genetic Information Nondiscrimination Act (GINA) prohibits health benefit plans from discriminating on the basis of genetic information in regards to eligibility, premium and contributions This generally also means that private employers with more than 15 employees, its health plan or “business associate” of the employer, cannot collect or use genetic information, (including family medical history information). The once exception would be that a minimum amount of genetic testing results make be used to make a determination regarding a claim.
You should know that GINA is treated as protected health information (PHI) under HIPAA The plan must provide that an employer cannot request or require that you reveal whether or not you have had genetic testing; nor can your employer require that you participate in a genetic test An employer cannot use any genetic information to set contribution rates or premiums Since key parts of the health care law took effect in 2014, there is a new way to buy health insurance: the Health Insurance Marketplace To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment based health coverage offered by your employer If your employer offers health coverage that meets the “minimum value” plan standard, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer’s health plan The “minimum value” plan standard is set by the Affordable Care Act. Your health plans offered by [Company] are ACA compliant plans (surpassing the “minimum value” standard), thus you would not be eligible for the tax credit offered to those who do not have access to such a plan.
Guide
24
The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) established requirements that employers must meet for certain employees who are involved in the uniformed services In addition to the rights that you have under COBRA, you (the employee) are entitled under USERRA lo continue the coverage that you (and your covered dependents, if any) had under the [Company] plan.
"Uniformed services" means the Armed Forces, the Army National Guard, and the Air National Guard when an individual is engaged in active duty for training, inactive duty training, or full time National Guard duty (i e , pursuant to orders issued under federal law), the commissioned corps of the Public Health Service, and any other category of persons designated by the President in time of war or national emergency.
Compliant Plan Notice
PPACAGINA
Arke
IMPORTANT INFORMATION
You Have Rights Under Both COBRA and USERRA Your rights under COBRA and USERRA are similar but not identical Any election that you make pursuant to COBRA will also be an election under USERRA, and COBRA and USERRA will both apply with respect to the continuation coverage elected If COBRA and USERRA give you different rights or protections, the law that provides the greater benefit will apply The administrative policies and procedures described in the attached COBRA Election Notice also apply to USERRA coverage, unless compliance with the procedures is precluded by military necessity or is otherwise impossible or unreasonable under the circumstances. Systems Benefits |
INFORMATION
Duration of USERRA Coverage
Notice
• Your past, present, or future physical or mental health or condition;
IMPORTANT
If you have any questions about this Notice or about our privacy practices, please contact your Human Resources department The full privacy notice is available with your Human Resources Department of Privacy Provision Systems Benefits Guide | General Rule: 24 Month Maximum When a covered employee takes a leave for service in the uniformed services, USERRA coverage for the employee (and covered dependents for whom coverage is elected) can continue until up to 24 months from the date on which the employee's leave for uniformed service began However, USERRA coverage will end earlier if one of the following events takes place: A premium payment is not made within the required time; You fail to return to work or to apply for reemployment within the time required under USERRA (see below) following the completion of your service in the uniformed services ; You lose your rights under USERRA as a result of a dishonorable discharge or other conduct specified in USERRA
25
• The provision of health care to you; or
Arke
The HIPAA Privacy Rule protects only certain medical information known as "protected health information " Generally, protected health information is health information, including demographic information, collected from you or created or received by a health care provider, a health care clearinghouse, a health plan, or your employer on behalf of a group health plan, from which it is possible to individually identify you and that relates to:
This Notice of Privacy Practices (the "Notice") describes the legal obligations of [Company] (the "Plan") and your legal rights regarding your protected health information held by the Plan under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH Act) Among other things, this Notice describes how your protected health information may be used or disclosed to carry out treatment, payment, or health care operations, or for any other purposes that are permitted or required by law. We are required to provide this Notice of Privacy Practices to you pursuant to HIPAA.
• The past, present, or future payment for the provision of health care to you.
The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers “one stop shopping” to find and compare private health insurance options You may also be eligible for a new kind of tax credit that lowers your monthly premium right away Historically, open enrollment for health insurance coverage through the Marketplace begins on November 1st and ends on December 15th for coverage starting as early as January of the following year Due to the current issues, special circumstances may apply Please see www healthcare gov for the most up to date information surrounding the Marketplace What is the Health Insurance Marketplace? You may quality to save money and lower your monthly premium, but only if our employer does not offer coverage, or offers coverage that doesn’t meet certain standards The savings on your premium that you’re eligible for depends on your household income Can I Save Money on my Health Insurance Premiums in the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer’s health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9 5% of your household income for the year, or if the coverage your employer provides does not meet the “minimum value” standard set by the Affordable Care Act, you may be eligible for a tax credit.
A key part of the 2014 health care law take effect in 2014, created a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment based health coverage offered by your employer.
HEALTH INSURANCE MARKETPLACE PART A: GENERAL INFORMATION
Arke Systems Benefits Guide | 26
Does Employer Health Coverage Affect Eligibility for Premium Savings Through the Marketplace? If you purchase a health plan through the Marketplace instead of accepting health coverage by your employer, then you may lose the employer contribution (if any) to the employer offered coverage Also, this employer contribution as well as your employee contribution to employer offered coverage is often excluded from income for Federal and State income tax purposes Your payments for coverage through the Marketplace are made on an alter tax basis. ! For more information about your coverage offered by your employer, please check your summary plan description or contact your Human Resources representative
How Can I Get More Information? The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit www.healthcare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.
Arke Systems Benefits Guide | 27 This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information This information is numbered to correspond to the Marketplace application HEALTH INSURANCE MARKETPLACE PART B: INFORMATION ABOUT HEALTH COVERAGE OFFERED BY YOUR EMPLOYER Here is some basic information about health coverage offered by this employer: As your employer, we offer a health plan to: All employees. Eligible employees are: Active full time employees working 30 or more hours a week Some employees. Eligible employees are: With respect to dependents: We do offer coverage. Eligible dependents are: Spouses and children up to age 26 We do not offer coverage If checked, this coverage meets the minimum value standard and the cost of this coverage to you is intended to be affordable, based on employee wages ** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through Marketplace The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount If for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid year, or if you have other income losses, you may still qualify for a premium discount If you decide to shop for coverage in the Marketplace, Healthcare.gov will guide you through the process Here’s the employer information you’ll enter when you visit to find out if you can get a tax credit to lower your monthly premiums 3. Employee Name Arke Systems 4. Employee Identification Number (EIN) 20 3231650 5. Employer Address 3400 Peachtree Rd NW, Ste. 200 6. Employer Phone Number 404 812 3123 7. City Atlanta 8. State GA 9. Zip Code 30326 10. Who can we contact about health coverage at this job? Courtney Roth 11. Phone Number (if different from above) 12. Email Address croth@arke.com
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Arke Systems 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.
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).
Arke Systems Benefits Guide | 28 IMPORTA NT NOTICE ABOUT YOUR PRESCRIPTION DRUG COVERAGE & MEDICARECREDITABLE
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
When Can You Join a Medicare Drug Plan? What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
• 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.
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 Arke Systems 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. For more information about this notice or your current prescription drug coverage, contact your carrier.
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 Arke Systems changes. You also may request a copy of this notice at any time.
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).
You can retain your existing group coverage and choose to enroll in a Medicare prescription drug plan, or you can enroll in a Medicare Prescription drug plan as a supplement to or in lieu of the Arke Systems group health coverage If you decide to join a Medicare drug plan, your current Arke Systems coverage will not be affected Your group medical plan will be the primary payee on prescription drug claims and your Medicare prescription dug plan will be the secondary payee on prescription drug plans.. If you do decide to join a Medicare drug plan and drop your current Arke Systems coverage, be aware that you and your dependents may not be able to get this coverage back
• Arke Systems has determined that the prescription drug coverage offered by the United Healthcare Platinum and Gold medical plans are, 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. 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.
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Arke Systems 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.
Since the coverage under United Healthcare Bronze 6500 medical plan, is not creditable, depending on how long you go without creditable prescription drug coverage you may pay a penalty to join a Medicare drug plan. Starting with the end of the last month that you were first eligible to join a Medicare drug plan but didn’t join, if you go 63 continuous days or longer without prescription drug coverage that’s creditable, 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 (penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. If you decide to drop your current coverage with Arke Systems, you will be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. However you also may pay a higher premium (a penalty) because you did not have creditable coverage under HDHP.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
• You can keep your current coverage from the United Healthcare Bronze 6500 plan. However, because your coverage is non creditable, you have decisions to make about Medicare prescription drug coverage that may affect how much you pay for that coverage, depending on if and when you join a drug plan. When you make your decision, you should compare your current coverage, including what drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. Read this notice carefully it explains your options.
• Arke Systems has determined that the prescription drug coverage offered by the United Healthcare Bronze 6500 medical plan is, on average for all plan participants, NOT expected to pay out as much as standard Medicare prescription drug coverage pays. Therefore, your coverage is considered Non Creditable Coverage. This is important because, most likely, you will get more help with your drug costs if you join a Medicare drug plan, than if you only have prescription drug coverage from the United Healthcare Bronze 6500 medical plan. This also is important because it may mean that you may pay a higher premium (a penalty) if you do not join a Medicare drug plan when you first become eligible.
• 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.
Arke Systems Benefits Guide | 29 IMPORTA NT NOTICE ABOUT YOUR PRESCRIPTION DRUG COVERAGE & MEDICARENONCREDITABLE
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. When Can You Join a Medicare Drug Plan?
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)
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
Arke Systems Benefits Guide | 30
If you decide to join a Medicare drug plan, your current Arke Systems coverage may be affected. Please review prescription drug coverage plan provisions/options under the certificate booklet provided by United Healthcare. You can retain your existing group coverage and choose to enroll in a Medicare prescription drug plan, or you can enroll in a Medicare Prescription drug plan as a supplement to or in lieu of the Arke Systems group health coverage If you decide to join a Medicare drug plan, your current Arke Systems coverage will not be affected Your group medical plan will be the primary payee on prescription drug claims and your Medicare prescription dug plan will be the secondary payee on prescription drug plans. If you do decide to join a Medicare drug plan and drop your current Arke Systems coverage, be aware that you and your dependents may not be able to get this coverage back drug plan When you make your decision, you should compare your current coverage, including what drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area Read this notice carefully it explains your options For more information about this notice or your current prescription drug coverage contact human resources. 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 Arke Systems changes You also may request a copy of this notice at any time 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)
NT
(CONT.)
IMPORTA NOTICE ABOUT YOUR PRESCRIPTION DRUG COVERAGE & MEDICARENONCREDITABLE
20%
HEALTH INSURANCE TERMINOLOGY
Deductible The amount you owe for health care services each year before the insurance plan begins to pay. Your deductible may not apply to all services, such as preventive care. Copay(ment) The fixed amount that you pay for a covered health care service. That amount can vary by the type of covered health care service (for example, a doctor’s office visit or a specialist, urgent care or emergency room visit).
Coinsurance The percentage of a medial bill that you pay (for example, 20 percent) and the percentage that the health plan pays (for example, 80 percent). You pay coinsurance plus any deductible you owe for a covered health service Out of pocket maximum (OOPM) The most you should have to pay for health care during a year, excluding the monthly premium. After you reach the annual OOPM, your plan begins to pay 100 percent of the allowed amount for covered health services. 80% Pay Plan
Health
To better understand your health insurance, be aware of the following terms: Participant There are a few different participants involved in health insurance. One is the “provider”, or a clinic, hospital, doctor lab, health care practitioner or pharmacy. The ”insurer” or the “carrier” is the insurance company providing coverage. The “policyholder” is the individual or entity who purchased the coverage, and the “insured” is the person with the coverage”. Premium The amount of money charged by the health plan administrator for coverage. Rates are typically paid annually or in smaller payments over the course of the year (for example monthly).
Health insurance terminology can be confusing. As a result, understanding your benefits and what you may owe out of pocket can be difficult. In order to make sure you are using your coverage effectively, it is important to understand some key insurance terms. You can purchase either group or individual health insurance. Group health insurance is typically acquired through your employer and covers many people. Individual insurance, on the other hand, is usually purchased by an individual or a family and is not tied to a job.
You
Pays Arke Systems Benefits Guide | 31
