2026-2027 BENEFIT GUIDE February 1, 2026 – January 31, 2027
Last Edited 1.2026
TABLE OF CONTENTS At Diversified Utility Services, 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 Benefit 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. Details can be found in the plan specific Summary Plan Description and/or Summary of Coverage. In the case of a discrepancy, the plan specific documents will prevail.
Page 2
A Smarter Way to Better Health
Page 3
Eligibility & Enrollment
Page 4-5
Level Health Traditional Medical Plans
Page 6-7
Level Health High Deductible/HSA Plan
Page 8-9
A Map To Your Medical Plans
Page 10
Level Health Member Portal
Page 11
Rezilient Health TeleMedicine
Page 12
Principal Dental Plan
Page 13
Principal Vision Plan and Employer Paid Life/AD&D
Page 14
Voluntary Benefits with The Hartford and IDX
Page 15-16
Employee Navigator Enrollment Guide
Page 17
Employee Payroll Deductions
Page 18
Key Contacts & Resources
Page 19-26
Important Notices
Diversified Utility Services Benefit Guide |1
A SMARTER WAY TO BETTER HEALTH
It’s Your Health. Get Involved.
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. 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.
Preventive Health Care Services
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. It’s important for everyone to get the preventive care they need. Some examples of preventive care services are: ▪ ▪ ▪ ▪
Blood pressure, diabetes, and cholesterol tests Certain cancer screenings, such as mammograms, colonoscopies Counseling, screenings and vaccines to help ensure healthy pregnancies Regular well-baby and well-child visits
Immunizations
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.
Understanding What’s Covered
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.
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ELIGIBILITY & ENROLLMENT Who is Eligible to Join the Benefit Plan?
Qualifying Event Changes
You and your dependents are eligible to join Diversified Utility Services' health and welfare benefit plans if you are a full-time employee who works an average of at least 30 hours per week. You must be enrolled in the plan to add dependent coverage.
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. If you have a status change, you must notify Human Resources within 30 days of the event. If you do not notify Human Resources during that time, you and/or your dependents must wait until the next open enrollment to change your coverage.
Who is an Eligible Dependent? •
Your spouse to whom you are legally married
•
Your dependent child under the maximum age specified in the Carriers’ plan documents including: o Natural child o Adopted child o Stepchild o Child for whom you have been appointed as the legal guardian
IRS-approved qualifying life status changes include: •
Marriage, divorce or legal separation
•
Birth or adoption of a child or placement of a child for adoption
•
Death of a dependent
•
Child no longer eligible due to reaching age limit
*Your child’s spouse and a child for whom you are not the legal guardian are not eligible.
•
Change in employment status, including loss or gain of employment, for your spouse or a dependent
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 married.
•
Change in work schedule, including switching between full-time and part-time status, by you, your spouse or a dependent
•
Change in residence or work site for you, your spouse, or a dependent that results in a change of eligibility
•
If you or your dependents lose eligibility for Medicaid or the Children’s Health Insurance Program (CHIP) coverage or become eligible for a state’s premium assistance subsidy under Medicaid or CHIP, then you have 60 days from the date of the Medicaid/eligibility change to request enrollment in Diversified Utility Services' plans.
Once 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 plan if the child is primarily dependent on the enrolled member for support and maintenance.
When Do Benefits Become Effective? Your benefits become effective on your date of hire as a full-time employee with Diversified Utility Services. Annual Open Enrollment Each year during the annual open enrollment period, you are given the opportunity to make changes to your current benefit elections. Annual open enrollment is the only time during the year you can make changes to your benefits unless you experience a qualified life status change (qualifying event).
!
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. Find more information on page 30. You should read this notice even if you plan to waive coverage at this time.
Please note, loss of coverage due to non-payment or voluntary termination of other coverage outside a spouse’s or parent’s open enrollment is not an IRS-approved qualifying life event and you do not qualify for a special enrollment period. Diversified Utility Services Benefit Guide | 3
MEDICAL Diversified Utility Services offers you three medical plan options through Level Health and Edison Health Solutions. Please refer to the following charts for a list of the major features for each plan. As a plan member, you have access to many consumer education tools and value-added programs designed to help you manage you and your dependents’ medical care, all of which can be accessed by visiting www.edisonehs.com and registering. You can estimate your medical costs, view your Explanation of Benefits (EOB), order ID cards, and more. The prescription drug coverage provided by our two Traditional medical plans are expected to pay out as much as standard Medicare prescription drug coverage pays; The prescription drug coverage provided by our HDHP/HSA medical plan is not expected to pay out as much as standard Medicare prescription drug coverage pays (see pages 28-29). BASE PLAN
$5,000 Deductible | Cigna Choice Fund PPO Benefits
YOU PAY IN NETWORK
Deductible Individual
$5,000
Family
$10,000
Coinsurance
30%
Total Out-of-Pocket Maximum Individual
$9,450
Family
$18,900
Hospitalization
Ded, then 30%
Outpatient Surgery
Ded, then 30% $300 copay
Emergency Room
(penalty for non-emergency use of ER)
Urgent Care
$25 copay
Outpatient Diagnostic Lab & X-ray
Ded, then 30%
Major Diagnostic and Imaging
Ded, then 30%
Office Visit Rezilient Health Telemedicine
Plan pays 100%
Primary Care Physician
$25 copay
Specialist
$55 copay
Preventive Care
Plan pays 100%
Prescription Drugs – Ventegra PBM Rx Deductible
None
Tier 1 Generic
$0 copay
Tier 2 Preferred Brand
$25 copay
Tier 3 Non-Preferred Brand
$55 copay
Tier 4 Specialty
$200 copay
Mail-Order (90-day supply)
3x retail copay
!
This chart is a summary of your benefits. If there is a discrepancy between the chart and official documents, the documents will prevail. Diversified Utility Services Benefit Guide | 4
MEDICAL BUY-UP PLAN $3,000 Deductible | Cigna Choice Fund PPO Benefits
YOU PAY IN NETWORK
Deductible Individual
$3,000
Family
$6,000
Coinsurance
20%
Total Out-of-Pocket Maximum Individual
$6,000
Family
$12,000
Hospitalization
Ded, then 20%
Outpatient Surgery
Ded, then 20% $300 copay
Emergency Room
(penalty for non-emergency use of ER)
Urgent Care
$25 copay
Outpatient Diagnostic Lab & X-ray
Ded, then 20%
Major Diagnostic and Imaging
Ded, then 20%
Office Visit Rezilient Health Telemedicine
Plan pays 100%
Primary Care Physician
$25 copay
Specialist
$55 copay
Preventive Care
Plan pays 100%
Prescription Drugs – Ventegra PBM Rx Deductible
None
Tier 1 Generic
$0 copay
Tier 2 Preferred Brand
$25 copay
Tier 3 Non-Preferred Brand
$55 copay
Tier 4 Specialty
$200 copay
Mail-Order (90-day supply)
3x retail copay
!
This chart is a summary of your benefits. If there is a discrepancy between the chart and official documents, the documents will prevail.
Diversified Utility Services Benefit Guide | 5
MEDICAL High Deductible Health Plan (HDHP) An HDHP has a higher annual deductible than a typical health plan and must meet certain criteria outlined by the IRS. Several items you need to be aware of prior to enrolling in an HDHP: •
The plan requires you to meet your annual deductible before your HDHP pays benefits; every dollar you spend for covered services goes toward meeting your annual deductible. Expenses can be paid for by your Health Savings Account (HSA).
•
Preventive care is always covered at 100% when received from an in-network provider
•
One deductible for prescription drugs and medical services (no copays)
•
Covered services accumulate to a combined family deductible (for you, your spouse and your dependents), with an embedded individual deductible for covered members
•
If enrolled, you cannot be covered by another medical plan. Benefits
HIGH DEDUCTIBLE HEALTH PLAN $2,500 Deductible | Cigna Choice Fund PPO YOU PAY IN NETWORK
Deductible Individual
$2,500
Family
$5,000
Coinsurance
20%
Total Out-of-Pocket Maximum Individual
$5,000
Family
$10,000
Hospitalization
Ded, then 20%
Outpatient Surgery
Ded, then 20% Ded, then 20%
Emergency Room
(penalty for non-emergency use of ER)
Urgent Care
Ded, then 20%
Outpatient Diagnostic Lab & X-ray
Ded, then 20%
Major Diagnostic and Imaging
Ded, then 20%
Office Visit Recuro Health Telemedicine
Ded, then 20%
Primary Care Physician
Ded, then 20%
Specialist
Ded, then 20%
Preventive Care
Plan pays 100%
Prescription Drugs – Ventegra PBM Rx Deductible
Combined with Medical Deductible
Tier 1 Generic
Ded, then 20%
Tier 2 Preferred Brand
Ded, then 20%
Tier 3 Non-Preferred Brand
Ded, then 20%
Tier 4 Specialty
Ded, then 20%
Mail-Order (90-day supply)
Ded, then 20%
!
This chart is a summary of your benefits. If there is a discrepancy between the chart and official documents, the documents will prevail. Diversified Utility Services Benefit Guide | 6
HEALTH CARE SAVINGS ACCOUNT Health Savings Account (HSA) An HSA is an interest-bearing savings account funded with pre-tax dollars and used to pay for eligible health care expenses not covered by the insurance plan. You decide how much to contribute, the amount you want to spend on qualified medical expenses, as well as which expenses you will pay out of the account. How does an HSA work? First, you must have coverage under the qualified HDHP High Deductible Health Plan offered by Diversified Utility Services (there can be no secondary medical coverage in place). Once covered by a qualified HDHP, you may open an HSA and contribute up to the 2026 regulatory limits of: - $4,400 for an individual - $8,750 for a family *If you are age 55 or above, the catch-up provision allows you to contribute an additional $1,000 per year. Pre-tax contributions to your HSA can continue until age 65 and you enroll in Medicare Part A or B. (If you are currently enrolled in Medicare or are currently being claimed as a dependent on another person’s tax return, you are not eligible to open an HSA.) Also, it’s very important to remember only qualified healthcare expenses, as allowed by the IRS, are eligible for reimbursement from and HSA on a tax-free basis. Any funds used for non-qualified expenses are taxable as income AND subject to a 20% tax penalty. IRS Publication #502 is a good general guide to expenses considered as qualifying medical expenses for purposes of HSA reimbursement. Once your HSA is established and you have a qualified expense, (1) you may make a tax-free withdrawal from your account to cover the costs, or (2) pay out of your pocket and save your HSA for future qualified expenses even in retirement! HSA money rolls over indefinitely so you do not need to make a withdrawal. Additional information on qualified expenses can be found here:
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A MAP TO YOUR MEDICAL PLAN HOW TO SEARCH FOR PROVIDERS
• Cigna Health: https://hcpdirectory.cigna.com/web/public/consumer/directory/search • Enter your Zip code and select how you want to search • Continue as a Guest (until you are enrolled and can login) • Select the plan: Choice Fund PPO
HOW TO SEARCH FOR PRESCRIPTIONS
• Ventegra PBM: https://issuu.com/pjmarcomm/docs/ventegrapremiumformulary_2_?fr=xKAE9_zU1NQ
Have questions about the registration process or your Member or Benefits Portal? Please contact us! 877-426-2162
Diversified Utility Services Benefit Guide | 8
A MAP TO YOUR MEDICAL PLAN
Diversified Utility Services Benefit Guide | 9
A MAP TO YOUR MEDICAL PLAN
Diversified Utility Services Benefit Guide | 10
TELE-HEALTH
Diversified Utility Services Benefit Guide | 11
DENTAL Our Dental benefits, administered by Principal, 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. 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 negotiated rate. Eligible employees may elect coverage for themselves and eligible dependents. Dependent children are covered up to age 26, regardless of student status. To find a dentist, log on to www.principal.com/dentist or call 800-247-4695 In-Network You Pay
Benefits
Out-Of-Network You Pay
Deductible (waived for Preventive) Individual
$50
Family
$150
Annual Maximum Per person
$2,000
Diagnostic & Preventive
Exams & Cleanings
0%
0% up to allowable amount
Fluoride Treatment (children Under 14)
0%
0% up to allowable amount
X-Rays
0%
0% up to allowable amount
Sealants
0%
0% up to allowable amount
Endodontics (Root Canal)
20%
20% up to allowable amount
Fillings
20%
20% up to allowable amount
General Anesthesia
20%
20% up to allowable amount
Oral Surgery
20%
50% up to allowable amount
Periodontics (Gum Disease)
20%
20% up to allowable amount
Bridges and Dentures
50%
50% up to allowable amount
Crowns, Inlays, Onlays
50%
50% up to allowable amount
Repairs to Bridges and Dentures
50%
50% up to allowable amount
Basic Services
Major Services
Orthodontia Deductible Coverage
$0 50%
50% up to allowable amount
Orthodontia Maximum Per person to age 19
$2,000
Dependent Eligibility Dependents Eligible to Age Claim Reimbursement Method
26
26
Negotiated Fee Schedule
90th UCR
Diversified Utility Services Benefit Guide | 12
VISION Principal Vision Care, offers easy access to thousands of conveniently located vision care providers. Unlike other programs that may restrict provider options, Principal through the VSP Choice Network, offers a nationwide network of convenient, accessible options for eye care including optometrists, ophthalmologists, opticians and many leading optical retailers, such as Private Practitioners, LensCrafters, Target Optical, most Sears Optical, Pearl Vision and JC Penny Optical locations. BENEFITS
In-Network
Out-of-Network Reimbursement
Exam
$10 copay
up to $45
Single Vision
$10 copay
up to $30
Bifocal
$10 copay
up to $50
Trifocal
$10 copay
up to $65
Lenticular
$10 copay
up to $100
$130 allowance, 20% off remaining balance
up to $70
Standard Plastic Lenses
Frames Frequency Exam
Once per 12 months
Lenses or Contacts
Once per 12 months
Frames
Once per 24 months
Contact Lenses
(in lieu of complete set of glasses)
Elective Therapeutic/Medically Necessary
$130 allowance
up to $105
$10 copay
up to $210
LIFE AND AD&D Basic Group Life/AD&D Insurance provided by Diversified Utility Services Life Insurance is a key element of proper financial planning and helps provide financial stability and protection for families in case of an untimely death. If you are an eligible full-time employee, Diversified Utility Services provides $20,000 of basic group term Life insurance and an additional matching amount of Accident Death and Dismemberment (AD&D) insurance through Principal at no cost to you. This coverage is guaranteed issue, which means there are no health questions. There is a reduction in benefit at age 65 (benefit reduces to $13,000) and at age 70 (benefit reduces to $10,000). You will need to name a beneficiary for this plan, which is required. Diversified Utility Services Benefit Guide | 13
VOLUNTARY BENEFITS Diversified Utility Services is Proud To Offer you The Hartford & IDX voluntary benefits. The Hartford Accident Insurance With Accident insurance, you’ll receive payment(s) associated with a covered injury and related services. You can use the payment in any way you choose – from expenses not covered by your major medical plan to day-to-day costs of living such as the mortgage or your utility bills. The Hartford Critical Illness Insurance Facing a serious illness can be challenging both emotionally and financially. Major medical insurance may pick up most of the tab but can still leave out-of-pocket expenses that add up quickly. Critical Illness insurance can provide a lump-sum benefit upon diagnosis of a covered illness that can be used however you choose - from expenses related to treatment, to deductibles or day-to-day costs of living such as the mortgage or your utility bills. The Hartford Short Term Disability Insurance A disability can happen to anyone. A back injury, pregnancy, or serious illness can lead to months without a regular paycheck. If you’re unable to work for a short period of time due to a non-work-related condition, illness or injury, short-term disability insurance offers financial protection by paying you a portion of your earnings. The Hartford Long Term Disability Insurance A disability can happen to anyone. Long-term disability insurance helps protect your paycheck if you’re unable to work for a long period of time after a serious condition, injury or sickness. The Hartford Supplemental Life/AD&D Insurance The group term life insurance available through your employer is a smart, affordable way to purchase the extra protection that you and your family may need. Life insurance offers financial protection by providing you coverage in case of an untimely death. Life insurance is disbursed to your beneficiaries in a lump sum in the event of your death. IDX Identity Theft & Privacy Protection You’re busy enough, the last thing you need to worry about is protecting your identity and your privacy. That’s why we’re here. More than 40 million Americans trust IDX for identity theft and privacy protection. Use IDX - so you can focus on what really matters.
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EMPLOYEE NAVIGATOR ENROLLMENT GUIDE Step 1: Log In Go to www.employeenavigator.com and click Login •
Register as a new user. Create an account. You will need: • Your full name as it appears in payroll • Last 4 digits of your SSN • Date of birth • Company ID: DIVERSIFIEDUS
•
Your Company ID is DIVERSIFIEDUS This needs to be entered exactly as shown.
•
Once registered, create your username and password.
Step 2: Welcome! After you login, click Let’s Begin to complete your enrollment and additional required tasks if applicable.
Step 3: 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.
Step 4: 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.
Diversified Utility Services Benefit Guide | 15
EMPLOYEE NAVIGATOR ENROLLMENT GUIDE
Step 5: 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 6: 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 7: You’re Finished You are finished. You can go back to your homepage to view your elections and you can make changes until the enrollment window closes.
You can login to review your benefits 24/7! Diversified Utility Services Benefit Guide | 16
EMPLOYEE PAYROLL DEDUCTIONS Diversified Utility Services contributes to the cost of medical coverage for all eligible employees and fully pays for the Basic Life/AD&D coverage. Please refer to the chart below for your weekly payroll deductions. Plans
Employee Only
Employee & Spouse
Employee & Child(ren)
Family
2026 Base Plan
$38.87
$137.58
$110.83
$224.07
2026 Buy-Up Plan
$44.71
$145.26
$129.41
$237.94
2026 HDHP (HSA) Plan
$35.63
$124.40
$113.08
$203.49
2026 Principal Dental
$6.87
$14.31
$21.90
$31.14
2026 Principal Vision
$1.24
$2.85
$2.96
$4.91
Diversified Utility Services Benefit Guide | 17
KEY CONTACTS & RESOURCES Benefit
Company
Phone
Medical Coverage
Level Health Edison Health
1-877-426-2162
Pharmacy Benefits
Ventegra
1-877-867-0943
Dental, Vision Coverage
Principal
1-800-843-1371
www.principal.com
Basic Life/AD&D Coverage
Principal
1-800-843-1371
www.principal.com
Voluntary Benefits
VB@Work
678-888-0849
info@vbwork.com
Diversified Utility Services Human Resources
David Gill
470-427-3655
david.gill@dullc.com
Website
members@levelhealthplans.com
Your Broker Support Contacts JEN RAKESTRAW CLIENT SERVICE EXECUTIVE 678.553.8293 jrakestraw@sspins.com ABIGAIL RIVES CLIENT SERVICE ASSISTANT 404.698.4419 arives@sspins.com
NEED HELP WITH A CLAIM? BE SURE TO HAVE THE FOLLOWING INFORMATION WHEN CALLING: Subscriber ID # Date of Service Name of Patient Name of Doctor, Facility or Hospital Copy of Bill or Explanation of Benefits (EOB)
Diversified Utility Services Benefit Guide | 18
IMPORTANT NOTICES COBRA Continuation of 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. 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.
Newborns’ and Mothers’ Health Protection Act 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).
Premium Assistance under Medical and CHIP
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 employersponsored 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 1877-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.
Special Enrollment Events 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. 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.
Women’s Health and Cancer Rights Act 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.
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IMPORTANT NOTICES GINA
The Genetic Information Nondiscrimination Act (GINA) prohibits health benefit plans from discriminating on the basis of genetic information in regard to eligibility, premium and contributions. This generally also means that private employers with more than 15 employees, its health plan or “business employee” 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.
PPACA Compliant Plan Notice
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. 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 purposes.
USERRA Notice 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. 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.
Definitions "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. "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. Diversified Utility Services Benefit Guide | 20
IMPORTANT NOTICES Duration of USERRA Coverage 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.
Notice of Privacy Provision 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 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:
• Your past, present, or future physical or mental health or condition; • The provision of health care to you; or • The past, present, or future payment for the provision of health care to you. 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.
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IMPORTANT NOTICES 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: Special Open Enrollment Rights Children’s Health Insurance Program (CHIP) Premium Assistance
General Notice of the Cobra Continuations Rights Affordable Care Act (ACA) – Insurance Mandate
Health Insurance Marketplace Coverage Options and Your Group Health Coverage
Affordable Care Act (ACA) – Preventive Services for Non-grandfathered Plans Newborns’ and Mothers’ Health Protection Act of 1996 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 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.
Marriage, Birth, or Adoption
If you have a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, or placement for adoption.
Loss of Other Coverage
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).
Medicaid or CHIP
If you or your 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. To request special enrollment or obtain more information, please contact HR. Diversified Utility Services Benefit Guide | 22
HEALTH INSURANCE MARKETPLACE PART A: GENERAL INFORMATION To assist you as you evaluate options for you and your family, this notice provides some basic information about the Marketplace and employment-based health coverage offered by your employer.
What is the Health Insurance Marketplace? 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. Open enrollment for health insurance coverage through the Marketplace runs from November 1, 2026, through December 15, 2026, for coverage starting as early as January 1, 2027.
Can I Save Money on my Health Insurance Premiums in the 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.
Does Employer Health Coverage Affect Eligibility for Premium Savings Through 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.
!
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.
How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact Human Resources.
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.
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HEALTH INSURANCE MARKETPLACE PART B: INFORMATION ABOUT HEALTH COVERAGE OFFERED BY YOUR EMPLOYER 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. 3. Employer Name Diversified Utility Services, LLC
4. Employer Identification Number (EIN) 81-0994499
5. Employer Address 5371 Cook Road
6. Employer Phone Number 470-427-3655
7. City Morrow
8. State GA
9. Zip Code 30260
10. Who can we contact about health coverage at this job? David Gill 11. Phone Number (if different from above)
12. Email Address david.gill@dullc.com
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:
X
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:
X
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. Diversified Utility Services Benefit Guide | 24
IMPORTANT NOTICE ABOUT PRESCRIPTION DRUG COVERAGE & MEDICARE CREDITABLE Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Diversified Utility Services and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: •
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.
•
Diversified Utility Services has determined that the prescription drug coverage offered by the Traditional Level Health plans in this Benefit Guide 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.
When Can You Join a Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Diversified Utility Services coverage will not be affected. Please review prescription drug coverage plan provisions/options under the certificate booklet provided by Level Health. See pages 7- 9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance which outlines the prescription drug plan provisions/ options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D. If you do decide to join a Medicare drug plan and drop your current Diversified Utility Services coverage, be aware that you and your dependents may not be able to get this coverage back.
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 Diversified Utility Services 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 Diversified Utility Services 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 1-800-7721213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).
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IMPORTANT NOTICE ABOUT YOUR PRESCRIPTION DRUG COVERAGE & MEDICARE NON-CREDITABLE Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Diversified Utility Services and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: •
•
•
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. Diversified Utility Services has determined that the prescription drug coverage offered by the Level Health HSA Plan, 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 NonCreditable 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 Level Health HSA Plans. 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. You can keep your current coverage from the Level Health HSA 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.
When Can You Join a Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. EMPLOYER GROUP PLAN If you decide to drop your current coverage with Diversified Utility Services, 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? Since the coverage under Level Health 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.
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