EMPLOYEE BENEFITS GUIDE July 1, 2022 – June 30, 2023
KISx
TABLE OF CONTENTS HealthMedicalMeetEligibilityAlliedPlansSavings
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Contacts & Resources Important HealthcareInformationMarketplace Information Medicare Creditable/Non Creditable Healthcare Terminology
– EAP Payroll Deductions
This Benefits Guide outlines the health and welfare plans offered to 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. In the case of a discrepancy the plan specific documents will prevail over this benefits guide.
At (COMPANY NAME), 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.
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Account
Program
Card Surgery & Imaging
Connect Rx Programs EmployeeDisabilityLifeVisionDentalRxHealthJoyCancerCAREGlobalFitSavingsInsuranceInsuranceInsuranceAssistance
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 your goals.
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.
o Certain cancer screenings, such as mammograms and colonoscopies without prior diagnosis
It’s Your Health. Get ServicesHealthcarePreventiveWhat’sUnderstandingImmunizationsInvolvedCovered
If a service is considered preventive care, it will be covered at 100% as long as you stay in the Aetna PPO Network. 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.
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.
o Counseling, screenings and vaccines to help ensure healthy pregnancies
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:
o Blood pressure, diabetes and cholesterol tests
A SMARTER WAY TO BETTER HEALTH
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 Regular well baby and well child visits
If you do 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
• Your dependent children* under the maximum age specified in the carriers’ plan documents including:
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.
If you have a qualifying event, you must notify the company and make your desired changes within 31 days of the event. You have 60 days to make changes due to a Medicare or CHIP event.
When Do Benefits Become Effective?
IRS approved qualifying life status changes include:
Who is Eligible to Join the Employee Benefit Plan?
Annual Open Enrollment?
Once the dependent reaches age 26, coverage will terminate. Some policies may terminate on the last day of the birth month. Other policies may terminate on the birthday.
• If you or your dependents lose eligibility for Medicaid or the Children’s Health Insurance Program (CHIP) coverage
Stepchild
• Change in employment status, including loss or gain of employment, for your spouse or a dependent
A totally disabled child who is physically or mentally disabled prior to age 26 may remain on the medical policy if the child is primarily dependent on the enrolled member for support and maintenance.
Who is an Eligible Dependent?
Each year during the annual open enrollment period, you are given the opportunity to make changes to your current benefit elections.
• Your spouse to whom you are legally married
The dependent maximum age limit 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 the parent’s tax return, is not required to live with you and may be unmarried or married.
• Marriage, divorce or legal separation
Natural child
Adopted child
• Change in work schedule, including switching between full time and part time status, by you, your spouse or a dependent
• Birth or adoption of a child or placement of a child for adoption
• Change in residence or work site for you, your spouse or a dependent that results in a change of eligibility
• Death of a dependent
You are allowed to make certain changes to your current benefit elections during the plan year if you experience an IRS approved qualifying event. 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 welfare benefit plans if you are a full time employee regularly scheduled to work 30 hours per week or more. You must be enrolled in the plan to add dependent coverage.
Child for whom you have been appointed as the legal guardian
Your employee benefits become effective on the first of the month following date of hire.
• If you or your dependents become eligible for a state’s premium assistance subsidy under Medicaid or CHIP
*Your child’s spouse and a child for whom you are not the legal guardian of are not eligible.
ELIGIBILITY
Qualifying Event Changes
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! (COMPANY NAME) Benefits Guide 4
Allied administers and manages JBBG’s health plan.
Review your benefits, copays and coinsurance amounts
• Manage your claims
Get a digital copy of your insurance card
• Check your deductible status
Although it may be confusing, we’re not an insurance company. JBBG has chosen to operate and fund their own health plan with a self funded health plan management model as opposed to purchasing a fully insured plan from an insurance company.
Who RxmedicalFindingNOTWhoAllied?iswe’remyandinfo
Our goal is to ensure that you receive care at a fair price and to be your advocate by helping you navigate the complexities of the healthcare system.
You can access your benefits information anytime, anywhere with the Allied Member portal available via desktop or mobile app. Simply log in at www.alliedbenefit.com/members to:
And much more…
(COMPANYaccount.NAME)Benefits Guide 5
Since JBBG is not using an insurance company, they’ve entrusted us to help administer the health benefits plan that they have designed.
We audit your claims and manage JBBG’s funds to pay for claims. Part of auditing includes identifying any fraud and/or inaccurate fees within your claims.
HEALTH ADMINISTRATORPLANOnline
: www.alliedbenefit.com/members
Scan the QR code to register your
Emergency Room Visit (Emergencies Only) $350 copay Copay waived if admitted $350 copay Copay waived if admitted
Deductible, then 0%
Urgent Care Visit $75 copay
Deductible, then 50%
Hospital Inpatient Care Deductible, then 0%
Deductible $2,500 Individual | $7,500 Family $7,500 Individual | $22,500 Family Coinsurance 0% 50%
Laboratory Diagnostics & X Ray $60 copay
$2,500 DEDUCTIBLE PPO PLAN
Preventive Care Services No Charge
Tier 3 Non Preferred Brand Name
Quantity Limits: Retail = 30 day supply Mail Order = 90 day supply
Retail: $60 copay Mail Order: Not covered
Primary Care Physician Office Visit $30 copay
Retail: $35 copay Mail Order: Not covered
Retail: 25% coinsurance up to $350 per Rx Mail Order: 25% coinsurance up to $350 per Rx
MEDICAL PLAN OVERVIEW
Deductible, then 50%
(COMPANY NAME) Benefits Guide 6
!
Complex Imaging Services (CT Scans, PET Scans & MRIs)
Deductible, then 50%
Deductible, then 50%
Tier 2 Preferred Brand Name & Non preferred Generic
Telemedicine (Phone/Video Chat) $0 copay Not Covered
Deductible, then 50%
Deductible, then 50%
Retail: $15 copay Mail Order: Not covered
Retail: $60 copay Mail Order: $180 copay
For complete details regarding benefits offered, please refer to the individual plan documents as the information contained herein is for illustrative purposes In the case of a discrepancy the plan specific documents will prevail over this benefits guide
Annual Out of Pocket Maximum $3,750 Individual | $11,250 Family $11,250 Individual | $33,750 Family
Outpatient Surgery $150 copay per visit
Prescription Drugs
Deductible, then 50%
Specialist Office Visit $60 copay
AETNA PPO NETWORK
Deductible, then 50%
Retail: 25% coinsurance up to $350 per Rx Mail Order: Not covered
Retail: $35 copay Mail Order: $70 copay
Plan Highlights In Network You Pay Out of Network You Pay
Retail: $15 copay Mail Order: $15 copay
Tier 4 Specialty Drugs
Tier 1 Generic Drugs
Primary Care Physician Office Visit $30 copay
Deductible, then 50%
$350 copay, then 20% Copay waived if admitted
Tier 2 Preferred Brand Name & Non preferred Generic
Tier 1 Generic Drugs
Plan Highlights In Network You Pay Out-of-Network You Pay
Retail: $60 copay Mail Order: $180 copay
Annual Out of Pocket Maximum
Retail: $35 copay Mail Order: $70 copay
Laboratory Diagnostics & X Ray $60 copay Deductible, then 50%
$350 copay then 20% Copay waived if admitted
Retail: $35 copay Mail Order: Not covered
Retail: $15 copay Mail Order: $15 copay
Preventive Care Services No Charge Deductible, then 50%
Tier 3 Non Preferred Brand Name
Specialist Office Visit $60 copay
Quantity Limits: Retail = 30 day supply Mail Order = 90 day supply
Retail: $60 copay Mail Order: Not covered
Deductible, then 20%
Outpatient Surgery
Retail: 25% coinsurance up to $350 per Rx Mail Order: 25% coinsurance up to $350 per Rx
Telemedicine (Phone/Video Chat) $0 copay Not Covered
(COMPANY NAME) Benefits Guide 7 !
Deductible, then 50%
Deductible, then 20%
$7,900 Individual | $15,800 Family $23,700 Individual | $47,400 Family
$3,500 DEDUCTIBLE PPO PLAN
Deductible, then 50%
Deductible, then 50%
Coinsurance 20% after deductible 50% after deductible
$150 copay per visit to facility, then 20% for physician/surgeon fees
Complex Imaging Services (CT Scans, PET Scans & MRIs)
Deductible, then 50%
Tier 4 Specialty Drugs
Retail: 25% coinsurance up to $350 per Rx Mail Order: Not covered
Emergency Room Visit (Emergencies Only)
Urgent Care Visit $75 copay
Retail: $15 copay Mail Order: Not covered
Deductible, then 50%
$3,500 Individual | $10,500 Family $10,500 Individual | $31,500 Family
Prescription Drugs
For complete details regarding benefits offered, please refer to the individual plan documents as the information contained herein is for illustrative purposes In the case of a discrepancy the plan specific documents will prevail over this benefits guide
MEDICAL PLAN OVERVIEW
Deductible
Hospital Inpatient Care
– AETNA PPO NETWORK
Primary Care Physician Office Visit
Specialist Office Visit Deductible, then 0% Deductible, then 50%
$10,500 Individual | $21,000 Family Coinsurance 0%
Telemedicine (Phone/Video Chat)
Urgent Care Visit Deductible, then 0% Deductible, then 50%
Laboratory Diagnostics & X Ray Deductible, then 0% Deductible, then 50% Complex Imaging Services (CT Scans, PET Scans & MRIs) Deductible, then 0% Deductible, then 50%
Deductible, then 0%
Not Covered
Preventive Care Services No Charge Deductible, then 50%
Prescription Drugs
Retail: $60 copay after deductible Mail Order: $180 copay after deductible
Tier 4 Specialty Drugs
Retail: 25% coinsurance up to $350 per Rx after deductible Mail Order: 25% coinsurance up to $350 per RX after deductible
Retail: 25% coinsurance up to $350 per Rx after deductible Mail Order: Not covered
50% after deductible
Tier 2 Preferred Brand Name & Non preferred Generic
Quantity Limits: Retail = 30 day supply Mail Order = 90 day supply
Deductible
Annual Out of Pocket Maximum $4,500 Individual | $9,000 Family $13,500 Individual | $27,000 Family
$3,500 DEDUCTIBLE HSA PLAN
(COMPANY NAME) Benefits Guide 8 !
Tier 3 Non Preferred Brand Name
Hospital Inpatient Care Deductible, then 0% Deductible, then 50% Outpatient Surgery Deductible, then 0% Deductible, then 50% Emergency Room Visit (Emergencies Only) Deductible, then 0% In Network Deductible, then 0%
$0 copay
For complete details regarding benefits offered, please refer to the individual plan documents as the information contained herein is for illustrative purposes In the case of a discrepancy the plan specific documents will prevail over this benefits guide
MEDICAL PLAN OVERVIEW
Tier 1 Generic Drugs
$3,500 Individual | $7,000 Family
Plan Highlights In Network You Pay Out-of-Network You Pay
AETNA PPO NETWORK
Deductible, then 50%
Retail: $35 copay after deductible Mail Order: Not covered
Retail: $35 copay after deductible Mail Order: $70 copay after deductible
Retail: $60 copay after deductible Mail Order: Not covered
Subject to Medical Deductible
Retail: $15 copay after deductible Mail Order: $15 copay after deductible
Retail: $15 copay after deductible Mail Order: Not covered
Any medical expenses that apply toward your deductible
▪ Cannot be enrolled in a general purpose FSA, nor can your spouse
Loss of Other Coverage
▪ Individuals aged 55 or older may be eligible to make a catch up contribution of $1,000
Generally, to be eligible to set up and contribute to an HSA, you:
▪
How Does an HSA Work?
▪
▪
How Much Can I Contribute to An HSA?
Depending upon who you choose to be your HSA custodian there could be different options.
Once you have a certain amount in your account, you may invest your funds
▪ Investment gains grow, tax free
▪ Cannot be claimed as a dependent on anyone else’s tax return
▪
As noted by federal law, the annual contribution limits for 2022 are:
▪
*Employees must get their own HSA outside of company*
The amount is $3,650 for individual coverage and $7,300 for family coverage
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.
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:
Earn tax free interest on money in your HSA
What is a Health Savings Account?
▪ Are not enrolled in Medicare (due to age or disability) or Tricare
▪
Reduce the amount of your federal taxes
You may begin funding your HSA as soon as your account is established.
▪
(COMPANY NAME) Benefits Guide 9
Can I Invest My HSA Funds?
▪
▪
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 can go to any banking institution of your choice and apply for an HSA. This account works similarly to how a bank would manage your personal savings or checking account. When you open your HSA, you receive a debit card and/or checkbook to be used on many out of pocket qualified expenses like doctor visits, vision and dental care, and prescriptions.
Once you reach age 65, Medicare premiums or other health insurance, other than a Medicare supplemental policy
Can I Use The Money in My HSA for Anything Other Than Eligible Medical Expenses?
HEALTH SAVINGS ACCOUNT (HSA)
Health Savings Account (HSA)
▪
Use money in your account to pay for qualified health care expenses
Funds in your account roll over every year
The money is yours, so the account stays with you if you leave your employer
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 (COMPANY NAME)’s medical plan. The account is portable, which means it is not tied to your employment at (COMPANY NAME). 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.
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
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; 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, and you will receive a tax deduction for that amount.
Who is Eligible for an HSA?
What Type of Expenses Can Be Paid From an HSA?
When Can I Begin Contributions to My HSA?
How Do I Enroll in an HSA?
• Are on one of the medical plans with copays, you will pay $0 for your procedures
GET IN TOUCH
*HSA plans require first dollar coverage up the to the IRS minimum from the patient before the procedure in order for the program incentives to be received. The IRS minimum for 2022 is $1,400 for individuals and $2,800 for families.
HOW IT WORKS
Before seeking In Network Providers through your health plan, just call a KISx Card Nurse regarding your elective procedure.
Email: KISx@bdsadmin.com
Call | Schedule | Save
The KISx Card is a surgery & imaging program that your employer has made available to you for the most common surgic al & imaging procedures Some of the most common procedures through KISx Card include: orthopedic & general surgery, colonoscopies, MRls, CT and PET scans. If you utilize the program, and:
Phone: 877 GET KISX
SAVE $ ON IMAGING & SURGERIES
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• Are on the HSA plan, you will need to meet the IRS minimums for HSA first dollar coverage*, then you will pay $0 for your procedures.
CALL US NOW! 877-GET-KISX
SmithRx Connect is a Specialty Drug Cost Management & Member Advocacy Company who partners with Self Funded Health Plans to reduce the financial burden of high cost specialty drugs for the employer and their members, by securing alternate funding through the manufacturer’s assistance programs.
These would include: Enbrel, Otezla, Ozempic, Humalog, Baqsimi, Restasis, Janumet, Eliquis, Pradaxa, Xarelto, Breo Ellipta, and MANY MANY More!
JBBG is making this program available to members enrolled in the health plan. If you are currently on any eligible maintenance medications, you will want to follow the steps below for potential cost savings to you!
SPECIALTY DRUG PROGRAM
$0 MAIL ORDER PROGRAM
The plan will still pay for your medication with no increase in co pay or cost share to you. However, the method of obtaining these medications has changed. Instead of funneling through the insurance policy, this will now funnel through SmithRx Connect. If SmithRx Connect is unable to obtain secure alternative funding then coverage will revert to our traditional coverage.
Is my medication still covered?
What if my income is too high to qualify? Do I still have to work with SmithRx Connect and go through the program?
Please contact SmithRx Connect’s Customer Service at (844) 385 7612.
Which drugs are available?
Who is eligible?
Who do I contact with additional questions?
There are no costs to participate in the Connect program. Your employer has paid 100% of the cost of this service for you and your family as long as you are enrolled in a JBBG medical plan. Prescriptions obtained through this service are NO COST TO YOU! - 385 -
CALL 844
11
CONNECT PROGRAM
What is SmithRx Connect?
What are the costs?
7612 (COMPANY NAME) Benefits Guide
SmithRx Connect is now the interface for all specialty medication. The coverage under the medical benefit’s plan is the same for all employees regardless of pay grade. Therefore, all employees seeking benefits must go through the same process.
12 BEGIN TODAYWELLNESSYOURJOURNEY (COMPANY NAME) Benefits Guide You will use GlobalFit ID: P15106
13(COMPANY NAME) Benefits Guide
Personalized Care
We are available to help you from the day of your diagnosis and beyond. You can register for the program at any point in your cancer journey to gain access to our resources and support. Registration is available through our website or byphone.
A Benefit Specialized In Dealing with Cancer
Expert Medical Team
National Resources
+1 877 640 cancercareprogram.comcancermanagement@cancercareprogram.com9610
Day One Help
What CancerCARE?is
Through CancerCARE, you will have access to some of the best doctors, hospitals, and technology nationwide. Wewill work with your local oncologist to make sure all treatment options are considered, not just local ones.
Our medical staff has decades of experience treating cancer and we pride ourselves on staying up to date with the latest cancer treatments and technology. Each medical staffer has unique cancer expertise and background.
C ancer CARE
Right Care. Right Time. Right Place.
Once you are part of the program, a dedicated nurse will be with you every step of the way. This nurse will be available to answer any questions you might have as well as make sure you are receiving ideal treatment for yourdiagnosis.
The CancerCARE Program is an additional benefit, provided by your health plan, that focuses on helping members diagnosed with cancer. Our passionate medical team will oversee your cancer treatment and ensure the optimal treatment path with proven results is being followed. We are your cancer advocates and will strive to lead you and your dependents to survivorship!
When her baby is sick on Christmas, Emily uses telemedicine to get quick answers.
out of pocket costs.
Click the Download and Activate link in your email or visit www.healthjoy.com/activate to get started
Meet Emily, a busy customer service representative who’s expecting her first baby this
Emily uses the provider search feature to find a pediatrician for her new baby.
HealthJoy connects you with the right care and support throughout the year, making it easier to be healthy and well.
Telemedicine
Rx Savings Review
Before she gives birth, Emily asks a healthcare concierge to estimate
Provider Search
Medical Plan Details
HealthJoy Helps You and Your Family
Her husband requests a review and finds a lower cost prescription for his allergies.
How will HealthJoy help YOU this year ?
Cost Estimation
Emily uses her benefits wallet to track out of pocket and deductible spending.
Rx Savings Find the lowest price on prescriptions right from your phone or iPad. Our free, easy to use mobile apps feature: • Instant access to the lowest prices for prescription drugs at more than 75,000 pharmacies • Coupons and savings tips that can cut your prescription costs by 50% or more • Side effects, pharmacy hours and locations, pill images, and much more! Lowest Rx Prices, Every Day SAVINGS IS EASY SameLowerMedicationPrice. One Low Price No Membership Fees Refundable Purchases Accepted Everywhere Available to Everyone Safe & Secure (COMPANY NAME) Benefits Guide 15
50% Coinsurance subject to balance billing*
Preventive & Diagnostic Services
Major Services
Basic Services
To find In Network Providers visit www.anthem.com or call 855 397 9267
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.
0% Coinsurance
Lifetime Orthodontic Maximum $1,000 $1,000
Up to age 26 50% Coinsurance Coinsurance subject to balance billing*
In-Network Out-of-Network
Exams, Cleanings, Bitewing X Rays, Full mouth of Panoramic X rays, Fluoride up to age 18, Sealants up to age 18
$1,000 Per Person
50%
Amalgam & Composite fillings, Oral Surgery, Endodontics, Periodontics Coinsurance
20%
*Balance billing may occur when using out of network dentists that charge more than usual, customary and reasonable (UC&R) charges for their services. The “balance” of the bill that remains after the dentist has been paid by the insurance carrier will be billed to the patient.
Space Maintainers up to age 18
$50
Calendar Year Deductible
DENTAL (COMPANY NAME) Benefits Guide 16
Crowns, Onlays, Veneers, Dentures, Bridges Coinsurance
Calendar Year Maximum Applies to Preventative, Basic and Major services $1,000 Per Person
Orthodontics
Staying healthy includes obtaining quality dental care for you and your family. Our dental benefits, administered by Anthem, provide a wide range of dental services including preventive care, fillings, and x Yourays.have
0% Coinsurance subject to balance billing*
Waived for Preventive Services Individual | $150 Family $50 Individual | $150 Family
Out of Network Reimbursement N/A 90th UC&R
50%
the freedom of choice to utilize in network or out of network providers. For a list of in network providers, visit www.anthem.com. When you visit an in network dentist, your out of pocket expenses are lower because there is no balance billing. In network dentists will file the claim for you and services are paid at the Anthem negotiated rate.
A waiting period may apply for basic, major and orthodontic services for those that enroll after their initial eligibility period.
20% Coinsurance subject to balance billing*
Dental Plan Benefits
VISION 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
employees may elect coverage for themselves, a spouse and eligible dependent children. Dependent children are covered up to age 26, regardless of student status. (COMPANY NAME) Benefits Guide 17 Vision Plan Benefits In Network Out of Network Exam $10 copay $42 allowance Frames $130 allowance then 20% off remaining balance $45 allowance Lenses SingleTrifocalBifocalVision $25 copay $25 copay $25 copay Up to $40 Up to $60 Up to $80 Contact Lenses Disposable Lenses Medically Necessary Lenses $130100%allowancecovered $105 allowance $210 allowance Frequency Exam Lenses (Contacts OR Eyeglass) Frames 12 months 12 months 24 months Please review your plan summaries or policy for out of network coverage information and full plan details. To find an In-Network Provider visit www.anthem.com or call 866-723-0512
Eligible
in network providers, visit www.anthem.com. When you visit an in network vision provider, your out of pocket expenses are lower.
Dependent Child coverage is available in $1,000 increments up to $10,000 subject to child’s age:
• From 23 years to 25 years if a full time student = $10,000
Supplemental Life Insurance Employee Paid
*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.
• Child From birth to 15 days = $500 14 days to 23 years: = $10,000
• Employee Age 15 64 = $100,000 Age 65 69 = $50,000 Age 70+ = $10,000
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, with a maximum amount of $500,000, subject to the guaranteed issue schedule*.
Spouse coverage is available in $5,000 increments, with a maximum amount of $500,000 subject to the guaranteed issue schedule*.
Basic Life Insurance Company Paid
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.
LIFE
• Spouse Age 15 64 = $30,000 Age 65+ = $10,000
• From birth to 15 days = $500
GuaranteedINSURANCEIssueSchedule*
JBBG provides a life and accidental death & dismemberment (AD&D) benefit at no cost to you. Your life insurance death benefit amount is 1.5 times your annual salary up to $100,000.
• 14 days to 23 years = $10,000
Life insurance death benefit reduces to 65% at age 65 and 50% at age 70
Short Term Disability is provided to you through Guardian. This coverage will pay up to 60% of your weekly salary up to a maximum of $2,000 per week for nonwork related illnesses, injuries and maternity, so you can focus on getting better, and worry less about keeping up with your bills. Benefits begin on the 8th day of an illness, injury or maternity. Benefits are payable up to a maximum of 12 weeks.
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.
Weekly Benefit Maximum Up to $2,000
DISABILITY INSURANCE
Long-Term Disability Company Paid
Monthly Benefit Maximum Up to $8,000
Pre-existing condition limitation
• The disability begins in the first 12 months after the effective date of coverage.
Plan Highlights Short-Term Disability
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: and
Short-Term Disability – Employee Paid
NEW for 2022
Plan Highlights Long-Term Disability
Waiting Period 8 days Benefit Percentage 60%
Benefit Duration Up to 12 weeks
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.
Waiting Period 90 days Benefit Percentage 60%
Serious illnesses or accidents can come out of nowhere. They can interrupt your life and your ability to work for months even years. Long Term Disability coverage is available to you through Guardian. This benefit pays 60% of your monthly earnings in the event of a disability after 90 days for an injury or illness up to a maximum monthly benefit of $8,000 per month. The Long Term Disability benefit pays up to your Social Security Normal Retirement Age (SSNRA).
Benefit Duration Retirement Age
19
EMPLOYEE ASSISTANCE PROGRAM - EAP
(COMPANY NAME) Benefits Guide 20
EMPLOYEE PAYROLL DEDUCTIONS (COMPANY NAME) significantly contributes to the cost of the employee benefits package for employees. For an additional premium employees can add dependent coverage. Please refer to the chart below for your payroll deductions.(COMPANY NAME) Benefits Guide 21 Payroll Deductions – Semi Monthly (24/yr) EmployeeOnly Employee & Spouse Employee Child(ren)& Family $2,500 Deductible PPO Plan $20.00 $385.60 $335.74 $701.34 $3,500 Deductible PPO Plan $10.00 $336.22 $291.73 $617.95 $3,500 Deductible HSA $0.00 $302.30 $261.08 $563.37 Dental $0.00 $15.90 $25.42 $45.10 Vision (Monthly) 6.72 $13.44 $13.78 $20.50 Voluntary STD Premiums based on benefit amount and your age. Premiums located in Paylocity. Basic Life/AD&D Long Term Disability (LTD) 100% Company Paid Supplementary Life / AD&D
Premiums based on benefit amounts selected and your age. Premiums located in Paylocity.
Company Phone Website/Email Benefits/Human Resources (COMPANYNAME) 478 749 9963 csimmons@jamesbatesllp.com Medical Allied Benefit 877 438 5479 www.alliedbenefit.com/members Surgery & Imaging Service KISx Card 877 438 5479 www.getkisx.com Healthcare(Telemedicine)Concierge HealthJoy 877 500 3212 www.healthjoy.com Pharmacy Coverage SmithRx 877 559 2055 www.portal.mysmithrx.com Specialty Drug SmithRx Connect 844 454 5201 www.lportal.mysmithrx.com $0 Brand Copay Program SmithRx Connect 844 454 5201 www.portal.mysmithrx.com Dental Anthem 855 397 9267 www.anthem.com Vision Anthem 866 723 0512 www.anthem.com Life/AD&D Guardian 888 482 7342 www.guardiananytime.com Short & Long Term Disability Guardian 888 482 7342 www.guardiananytime.com EAP EmployeeProgramAssistance Guardian 800 386 7055 www.lbhworklife.comUsername:MattersPassword:wlm70101 Your SupportEmployeeContact KEY CONTACTS & RESOURCES Questions on your benefits or need assistance with claims, contact Sterling Seacrest Pritchard: (COMPANY NAME) Benefits Guide 22 CHARLOTTE CONNER CLIENT SERVICE EXECUTIVE 404 832 cconner@sspins.com8642 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)
administrator.(COMPANY NAME) Benefits Guide 23
IMPORTANT INFORMATION
COBRA Continuation of Coverage
Premium Assistance under Medical and CHIP
Special Enrollment Events
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
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.
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 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
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.
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
Compliant Plan Notice
USERRA 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.
"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.
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.
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 to continue the coverage that you (and your covered dependents, if any) had under the (COMPANY NAME) plan.
Definitions
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.
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 NAME) 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.
IMPORTANT INFORMATION
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 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.
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.
"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.
PPACAGINA
(COMPANY NAME) Benefits Guide 24
IMPORTANT INFORMATION
Notice of Privacy Provision
• The provision of health care to you; or
• The past, present, or future payment for the provision of health care to you.
This Notice of Privacy Practices (the "Notice") describes the legal obligations of (COMPANY NAME) 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.
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 from your Human Resources department.
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.
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:
Duration of USERRA Coverage
• Your past, present, or future physical or mental health or condition;
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:
(COMPANY NAME) Benefits Guide 25
To request special enrollment or obtain more information, please contact HR.
General Notice of the Cobra Continuations Rights
This guide provides a summary of your employee benefits rights and regulations as determined by Federal and State Laws. Information included in this guide includes the following:
Break Time for Nursing Mothers Under the Fair Labor Standards Acts (FLSA) Women’s Health & Cancer Rights Act
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 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).Ifyouoryour
Affordable Care Act (ACA) Preventive Services for Non grandfathered Plans Newborns’ and Mothers’ Health Protection Act of 1996
SPECIAL OPEN ENROLLMENT RIGHTS
Health Insurance Marketplace Coverage Options and Your Group Health Coverage
Medicaid or CHIP
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.
Loss of Other Coverage
HIPAA Privacy Rules
(COMPANY NAME) Benefits Guide 26
Children’s Health Insurance Program (CHIP) Premium Assistance
The Generic Information Nondiscrimination Act of 2008 (GINA)
IMPORTANT INFORMATION
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.
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 31 days after the marriage, birth or placement for adoption.
Marriage, Birth or Adoption
Special Open Enrollment Rights
Affordable Care Act (ACA) Insurance Mandate
HEALTH INSURANCE MARKETPLACE
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.
Does Employer Health Coverage Affect Eligibility for Premium Savings Through the Marketplace?
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.
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 after tax basis.
You may qualify to save money and lower your monthly premium, but only if your 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.
What is the Health Insurance Marketplace?
PART A: GENERAL INFORMATION
For more information about your coverage offered by your employer, please check your summary plan description or contact Human Resources.
!
Can I Save Money on my Health Insurance Premiums in the 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 1st through December 15th for coverage starting as early as January 1st
(COMPANY NAME) Benefits Guide 27
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.
How Can I Get More Information?
If you decide to shop for coverage in the Marketplace, Healthcare.gov will guide you through the process. Above is the employer information you’ll enter when you visit to find out if you can get a tax credit to lower your monthly premiums.
Here is some basic information about health coverage offered by this employer: As your employer, we offer a health plan to:
9. Zip Code 31201
11. Phone Number (if different from above)
All employees. Eligible employees are:
Some employees. Eligible employees are:
** 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.
6. Employer Phone Number 478 749 9963
8. State GA
Active full time employees working 30 or more hours a week.
Spouses and children up to age 26.
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.
HEALTH INSURANCE MARKETPLACE
PART B: INFORMATION ABOUT HEALTH COVERAGE OFFERED BY YOUR EMPLOYER
7. City Macon
We do offer coverage. Eligible dependents are:
5. Employer Address 231 Riverside Drive
10. Who can we contact about health coverage at this job? Christi Simmons
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.
We do not offer coverage.
csimmons@jamesbatesllp.com(COMPANYNAME)Benefits Guide 28
12. Email Address
4. Employer Identification Number (EIN) 58 2472336
3. Employer Name (COMPANY NAME), LLP
With respect to dependents:
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
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).
• 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.
CREDITABLE
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 (COMPANY NAME) changes. You also may request a copy of this notice at any time.
When Can You Join a Medicare Drug Plan?
(COMPANY NAME) Benefits Guide 29
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.
If you decide to join a Medicare drug plan, your current (COMPANY NAME) coverage will not be affected. Please review prescription drug coverage plan provisions/options under the certificate booklet provided by Allied. 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 (COMPANY NAME) coverage, be aware that you and your dependents may not be able to get this coverage back.
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).
Forjoin.more
information about this notice or your current prescription drug coverage, contact your PBM
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with (COMPANY NAME) 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
• (COMPANY NAME) has determined that the prescription drug coverage offered by the non HSA 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.
IMPORTANT NOTICE ABOUT YOUR PRESCRIPTION DRUG COVERAGE & MEDICARE
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with (COMPANY NAME) 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.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
NON - CREDITABLE
IMPORTANT NOTICE ABOUT YOUR PRESCRIPTION DRUG COVERAGE & MEDICARE
Since the coverage under the HSA 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 (COMPANY NAME), 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.
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with (COMPANY NAME) 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.
When Can You Join a Medicare Drug Plan?
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.
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.
• You can keep your current coverage from the 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 Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
EMPLOYER GROUP PLAN
• (COMPANY NAME) has determined that the prescription drug coverage offered by the HSA 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 HSA 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.
(COMPANY NAME) Benefits Guide 30
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
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”.
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).
Coinsurance
To better understand your health insurance, be aware of the following terms:
You can purchase either group or individual health insurance. Group health insurance is typically acquired through your employer and covers many people.
HEALTH INSURANCE TERMINOLOGY
Deductible
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.
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).
Out of pocket maximum (OOPM)
Individual insurance, on the other hand, is usually purchased by an individual or a family and is not tied to a job.
Participant
Copayment
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.
20% 80% You Pay Health Plan Pays (COMPANY NAME) Benefits Guide 31
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.
Premium
