Tulsa County 2019 Benefits Guide by Tulsa County

Tulsa County Benefits Enrollment Guide

2019

This guide highlights the main features of many of the benefit plans sponsored by Tulsa County. Full details of these plans are contained in the legal documents governing the plans. If there is any discrepancy between the plan documents and the information described here, the plan documents will govern. In all cases, the plan documents are the exclusive source for determining rights and benefits under the plans. Participation in the plans does not constitute an employment contract. Tulsa County reserves the right to modify, amend or terminate any benefit plan or practice described in this guide. Nothing in this guide guarantees that any new plan provisions will continue in effect for any period of time.

Table of Contents Table of Contents.............................................................................................................................................3 Benefits Overview............................................................................................................................................4 How to Enroll for Benefits (Open Enrollment)................................................................................................8 Medical Plan â&#x20AC;&#x201C; CommunityCare....................................................................................................................10 IDEA Plus 1C ($750) HMO Plan Highlights.................................................................................................11 Telemedicine..................................................................................................................................................12 Prescription Drug Coverage - CommunityCare ............................................................................................13 Tobacco Free Premium Discount...................................................................................................................14 Employee Assistance Program - CommunityCare.........................................................................................15 Tulsa County Wellness Incentive Program....................................................................................................16 Dental Plan - Delta Dental.............................................................................................................................17 Vision Plan - VSP...........................................................................................................................................19 Life Plan - VOYA...........................................................................................................................................20 Optional Life Insurance - VOYA ..................................................................................................................22 AD&D Insurance - VOYA.............................................................................................................................23 Short-Term Disability (STD).........................................................................................................................24 Long-Term Disability (LTD).........................................................................................................................25 Accident Insurance - VOYA..........................................................................................................................26 Critical Illness Insurance - VOYA.................................................................................................................27 Cancer Insurance - Allstate Benefits .............................................................................................................28 Identity Theft Protection - IdentityForce.......................................................................................................30 457(b) & 401(a) Deferred Compensation Program ......................................................................................32 Post-Employment Health Plan (PEHP) ........................................................................................................33 Tulsa Countyâ&#x20AC;&#x2122;s Employee Retirement System (Pension Plan)......................................................................34 Employee General Notices ...........................................................................................................................35 Important Contacts.........................................................................................................................................45 Payroll Deduction Code.................................................................................................................................46

Benefits Overview

Tulsa Countyâ&#x20AC;&#x2122;s benefits allow you to select the plans that work best for you and your family Employee Paid Benefits Healthcare and Prescription Plan Dental Plan Vision Plan Basic Life Insurance (33% Paid) Optional Life Insurance Accidental Death & Dismemberment Short Term Disability Buy-Up Long Term Disability Cancer Insurance Accident Insurance Critical Illness Insurance Identity Theft Protection Plan 457 (b) Deferred Compensation Plan

Employer Paid Benefits Base Long Term Disability Post-Employment Health Plan 401 (a) Matching Plan Basic Life Insurance (67% Paid) Employee Assistance Program Wellness Incentive Retirement/Pension

Who Is Eligible? You are eligible to enroll in the Tulsa County benefit plans if you are a full-time employee who works 30 or more hours a week on a consistent basis. As a full-time employee, you are eligible for benefits on the first of the month following one month of continuous service.

Dependent Eligibility You may also cover your eligible dependents, including: • Your legal spouse. • Your eligible children up to age 26 for medical, dental and vision coverage. “Children” are defined as your natural children, stepchildren, legally-adopted children and children for whom you are the courtappointed legal guardian. • If a child is physically or mentally disabled, they may be covered at any age, with proof of disability from a Physician.

When Coverage Begins Initial Enrollment

All new hires will need to attend a new hire orientation. Employees will have 31 days (from their hire date), to enroll into benefits. Benefits information will be provided to them at the new hire orientation.

Annual Enrollment

Tulsa County’s Open Enrollment period takes place in the spring of each year. Coverage takes effect on July 1st of each year. Notes:

How to Enroll Dependents Eligible Dependents Are Defined As Follows:

Spouse: Your current legal spouse (including common-law marriage) as recognized by federal law and the state in which you reside. A legally separated or ex-spouse is not an eligible dependent. Children up to age 26: Your biological child, your legally adopted child, your stepchild, or a child that you or your spouse have been appointed as a legal guardian by a valid court order. Disabled Child: An unmarried child of any age who falls under one of the above listed dependent categories, and due to a mental or physical disability, is unable to earn a living.

How to submit the required dependent documentation requirements:

• Review the above definition of an eligible dependent to confirm your enrolled dependent(s) meets the eligibility requirements. • Obtain the required documentation for each dependent who is currently eligible for coverage. • Submit the required documents to familydocs@tulsacounty.org. • Retain a copy of all documents for your records.

Required Documentation:

• Spouse/Common-Law Spouse: Marriage Certificate OR Certificate of Common Law Marriage AND ONE of the following documents to support the marriage is still current (please note that the document must reflect an address, and the address must be the same as the employee’s address on file). • Page 1 and signature page of the employee’s most recent Federal Income Tax Return or email confirmation of certificate of filing listing the spouse. • A document dated within the past 6 months such as a mortgage statement, home equity loan, lease agreement, automobile registration, credit card or account statement, utility bill, or property tax document. • Child up to age 26: Birth Certificate (issued by state or vital records office) listing employee as parent. • Adopted Child up to age 26: Certificate of Adoption, Petition to Adopt (court documents) signed by a judge, AND birth certificate. • Legal Guardianship of Child up to age 26: Court order signed by a judge verifying legal custody of the child; OR Medical Support Order issued by a state agency. • Disabled Child: You must submit the required document(s) for one of the dependent categories above as proof that the dependent is your child or the child of your spouse/common law spouse.

Notes:

Making Changes to Coverage Once an employee has enrolled in the Tulsa County health plans, these enrollment selections remain in effect until the next annual open enrollment unless a qualifying event occurs. If an employee experiences a qualifying event, they can make changes to their benefit plans, outside of open enrollment. For all qualifying events, an employee has 31 days from the date of the event to submit documentation to Human Resources. In addition to the documentation to support the qualifying event, enrollment forms will need to be completed and submitted to Human Resources within 31 days of the date of the event. If the Human Resources office does not receive both the required documentation and the completed enrollment forms within 31 days of the qualifying event date, the request to make changes to the benefit plan will be denied. Qualifying event changes include, but are not limited to: • Change in number of eligible dependents due to: birth of a child, adoption of a child, or court appointed legal guardianship of a child. • Change in marital status: marriage, divorce, or death of a spouse. • Change in service area. • Change in insurance coverage: loss of coverage or gain of coverage through another insurance plan.

Special Enrollment Rules

If an employee declines health insurance through Tulsa County (and is enrolled in another health plan outside of Tulsa County), the employee (and eligible dependents) may become eligible to enroll in the Tulsa County health plans, if: • The employee or employee’s eligible dependents lose Medicaid or Children’s Health Insurance Program (“CHIP”) coverage as a result of a loss of eligibility. • If an employee or employee’s eligible dependents become eligible for a premium assistance subsidy under Medicaid or CHIP. • An employee will not be able to add themselves or their dependents to this coverage if the other coverage was terminated “for cause” (including failure to pay the required premiums on time).

Notes:

How to Enroll for Benefits (Open Enrollment) Please Note: If you are a new hire, you must complete a paper enrollment form.

Making Your Benefit Elections 1. Go to https://tulsacounty.munisselfservice.com/ and enter your user name and password to logon. Your user name is your first name, your middle initial, and your last name all one word. If you have never logged in before, your initial password is the last four digits of your social security number. If this is the first time you have signed into ESS, you will be asked to reset your password. Follow the guidelines for the password format that displays on the screen and enter a new password.

Example: Name: FredWFlintstone Password: 1234 2. Click on the “Employee Self Service” tab on the left side of the screen. 3. Click on the “Benefits” tab in the navigation menu. Employee Self Service Benefits Certifications Pay/Tax Information Personal Information Time Off

4. Click on Open Enrollment Link

Benefits Current Year Elections

You must complete your open enrollment before 6/4/2019

Benefit HEALTH COVERAGE VISION COVERAGE

5. All benefits must be reviewed by selecting Decline Benefit, No Changes, or Make New Election. Make Elections Make a selection for each benefit, then click “Continue”. You must submit this enrollment by 6/4/2019 PLEASE VERIFY YOUR MAILING ADDRESS AND EMAIL ADDRESS UNDER THE “PERSONAL INFORMATION” TAB ON THE LEFT BEFORE PROCEEDING.

Benefit

Current Election

New Election

HEALTH COVERAGE

CC - SELECT NETWORK - EMPLOYEE ONLY $95.28 | Details

Election Not Made

Decline benefit | No changes | Make New Election

6. If you wish to add eligible dependents into the health plans, social security number(s) and birth date(s) are required to enter into the employee self-service system. Please make sure that each dependent that you wish to cover under each plan is properly entered. 7. If you wish to add new dependents to the health plans, you will be required to submit dependent documentation (please refer to Tulsa County Enrollment Guide to review required dependent documentation requirements). If dependent documentation is not received for new dependents, enrollment into the health plans will be denied. • Please submit all required dependent documentation to familydocs@tulsacounty.org. 8. Once you have made your selection for each plan, click on the Continue Tab. 9. Review all benefit elections and click Submit. Congratulations! You have successfully completed your Benefit Elections! Confirmation Confirmation Your enrollment was submitted successfully. You can make changes until your choices have been approved. You may want to print this page for your records.

Thank you for logging onto ESS to complete your open enrollment, you will have until June 4th to make changes. HEALTH COVERAGE ELECTION - CC - SELECT NETWORK - EMPLOYEE ONLY

10. Print your confirmation so you have proof of enrollment. To do so, press CTRL + P on the keyboard. Notes:

Medical Plan – CommunityCare Tulsa County offers comprehensive major medical coverage through Community Care of Oklahoma. All of the medical plans offered cover the same type of health care expenses, such as doctor’s office visits, preventive care, hospitalization, and prescription drugs.

Medical Plans

Tulsa County offers the following plans: • IDEA PLUS 1C ($750) HMO: Tulsa County, Health Department, TAEMA, Drainage District 12, Public Defenders, Law Library & TCPFA (Expo Square).

Health Maintenance Organizations (HMOs)

With HMOs, the plan covers only those services you receive from HMO network providers. This means you and your covered dependents must use HMO providers to receive plan benefits. (The only exception is in the event of a life threatening emergency). If you receive non-emergency care outside of the HMO’s network, your care will not be covered. HMOs generally have lower out-of-pocket costs than other medical plans, and there are no claim forms to file. For more information on HMOs, refer to the Community Care booklet.

Notes:

IDEA Plus 1C ($750) HMO Plan Highlights Tulsa County, Health Department, TAEMA, Drainage District 12, Public Defenders, Law Library & TCPFA (Expo Square). Administered by Community Care Plan Provision Calendar Year Deductible Individual Family

Coverage $750 $1,500 $3,500 $7,000 Unlimited

Calendar Year Out-of-Pocket Maximum Annual Maximum (Combined Medical & Rx) Preventive Care Routine Adult physical examinations Well-woman exams by PCP or OB/GYN including mammogram Well Baby/Well Child, including immunizations Physician Services PCP office visit Specialist office visit Outpatient Care Emergency Room (copay waived if admitted inpatient) Urgent Care Center Outpatient Surgery Outpatient Diagnostic Services Laboratory Outpatient Radiology MRI, CT Scan & PET Scan Mental Health and Alcohol and Drug Services Inpatient Hospital Care

$0 copay per visit $0 copay per visit $0 copay per visit $25 copay per visit $50 copay per visit $150 copay per visit after deductible * $50 copay per visit $200 copay per visit after deductible * No additional copay No additional copay $150 copay per visit after deductible * $25 copay per visit $250 copay per day (maximum of $1,000 copay per admission) after deductible * $250 copay per day (maximum of $1,000 copay per admission) after deductible *

Surgical Services Mental Health and Alcohol and Drug Services

*You are responsible for this copay and if the deductible has not been completely satisfied, you are also responsible for payment for the balance of the services. These payments will count toward satisfying the deductible. As you get close to meeting the deductible requirement, a claim for services you receive could split between the remainder of the deductible and the copays for the beginning of the standard benefit level. If this occurs, you may be responsible for the copay required as part of the standard benefit level. This is a brief overview of benefits, not a guarantee of coverage. Please refer to your Member Handbook for detailed coverage information. 11

Telemedicine

T E L E M E DIC IN E Telemedicine allows healthcare professionals to evaluate, diagnose, and treat patients at a distance for minor illnesses through the use of telecommunications technology via mobile device and/or computer. MINOR ILLNESSES SUCH AS: • Colds • Flu • Sore Throat • Skin Rash • Bites • Other Minor Illnesses COPAYS General Medical Visit - $10 Behavioral Health - $45

You must be enrolled in the Tulsa County health plan to use this benefit. This includes any dependents enrolled in the plan. 12

Prescription Drug Coverage - CommunityCare Benefit Deductibles and Copayments

The HMO plans have a prescription deductible of $100 per member or $200 per family per calendar year. Please note that quantity limits or prior authorization rules may apply. Refer to your prescription drug formulary guide for additional information. If the cost of the prescription is less than the applicable copay, you will only be charged the cost of the prescription.

Retail Prescription Plan

The retail prescription plan uses a network of participating pharmacies. To receive the highest level of benefits, you must use a participating pharmacy. Prescriptions you fill at a non-participating pharmacy or prescriptions written by a non-network provider are generally not covered. If you have a chronic condition and take specialty medications, you may purchase up to a 30-day supply for each prescription. Refer to your formulary guide for a list of medications covered under the Specialty Pharmacy Plan. Specialty pharmacy drugs can be obtained from a contracted specialty pharmacy provider. Retail (30-day-supply)

Copay

Mail Order 90 Day Supply

Select Generic Drugs

Preferred Generic Drugs

$15

$30

Preferred Brand Drugs

$40

$80

Non-Preferred Brand or Generic Drugs

$85

$170

Specialty Drugs

$260

N/A

Notes:

Tobacco Free Premium Discount Tulsa County wants to encourage employees to live a healthier lifestyle. Tobacco use is a risk factor for a range of serious illnesses, including heart disease, emphysema and many types of cancer. Next year, effective July 1, 2020, Tulsa County will be providing employees covered on the Community Care Health Plan a tobacco free discount. Employees who are tobacco users will have a higher premium rate than the employees who are non-tobacco users. This also applies to your spouse enrolled in the Tulsa County medical plan.

Tobacco Use

For purposes of the medical plan, a tobacco user is a person who uses tobacco products. Tobacco products include, but aren’t limited to: • Cigarettes • Cigars • Pipe tobacco • Snuff • Chewing tobacco • Smokeless tobacco products such as e-cigarettes / vaping You will be asked to certify on a tobacco user attestation form whether or not you and/or your spouse are a tobacco user.

Tobacco Cessation Programs and Resources

• The Tulsa County Community Care medical plan covers all over-the-counter and prescription tobacco cessation products. A prescription is required for over-the-counter tobacco cessation products to be a covered benefit. There is a limit of two covered quit attempts per 365 days. Contact Member Services for more information at (918) 594-5200 or 1-800-278-7563. • Community Care members may access the Clear Direction tobacco cessation program offered at the Saint Francis Health Zone. The cost is a $25 deposit (refundable upon completion of the program) with a physician referral. Remember, those who seek assistance from their primary care physician are more successful at their quit attempt. For more information, please call (918) 494-8263. • Oklahoma Tobacco Helpline provides free tools and support to assist you with tobacco cessation. From free text and email support, phone and web coaching, and at least a FREE two week supply of nicotine patches, gum, or lozenges. Registered participants are four times more likely to quit tobacco than those quitting on their own. Call the helpline at 1-800-784-8669, 24 hours a day, seven days a week. Notes:

Employee Assistance Program - CommunityCare EAP helps employees find solutions to such issues as: • • • • •

Parenting/family concerns Emotional stress Alcohol and drug problems Job related issues Other issues

The program offers assistance for employees and dependents as long as they live in the same household. EAP Services Include: • Three face to face sessions per incident, per year, (covered by Community Care at 100%) • Confidential free assessment/referral/follow-up services • 24-hour, 365-day access for emergency situations • Face-to-face assessment interview • Master-level licensed counselors • Referrals to in network providers This program is provided for you and paid for by your employer. The program is completely confidential. The service is available by phone and in person. For assistance, call one of the numbers listed below, ask for the EAP representative and identify your place of employment. Community Care Employee Assistance Program (918) 594 - 5232 Tulsa (800) 221 - 3976 Toll Free Web site: www.ccok.com

Notes:

Tulsa County Wellness Incentive Program Tulsa County, TAEMA, Law Library Program Details

Tulsa County will be providing employees covered on the Community Care Health Plan a $20 incentive per month, if they have received a well woman exam, or a preventive exam from their physician.

Eligibility Requirements

• The participant must be a full-time, benefit eligible employee of Tulsa County. • The employee must be enrolled in the Community Care health plan sponsored by Tulsa County. • The employee must provide proof of a preventive exam from their physician. A well woman exam will be considered a preventive exam. • If the County employee has a spouse who also works full time at the County and is enrolled as a dependent spouse on the County health plan, the spouse will also be eligible for the incentive. • Dependent children are not eligible for the incentive. • Eligibility for the $5.00 incentive will continue from April, 2019 to Dec 31, 2019. A Preventative Exam Affidavit Form must be completed by the employees PCP to receive the incentive until December 31, 2019. • In order to receive the monthly $20.00 incentive, the employee must have their annual wellness exam completed between January 1, 2019 – December 31, 2019. • The incentive will go into effective on January 1, 2020. • Attending the annual biometric screening will no longer provide credit for the monthly incentive, as we encourage employees to be seen by their PCP. • Biometric screening will occur in the fall with flu shots and follow up with health coaching by Community Care.

Time Frame

• The employee will need to have completed preventive exam between January 1 – December 31, 2019 for the incentive to be paid starting January 1, 2020. • Effective January 1, 2020, the Wellness Incentive will increase from $5.00 to $20.00 per month for all employee that qualify on our health plan. Employees will be required to have an annual wellness exam completed through their Primary Care Physician (PCP) and signed by their PCP and submitted to Human Resources.

Dental Plan - Delta Dental Choosing a Dental Option Delta Dental PPO-Plus Premier Plan

The Delta Dental PPO-Plus Premier allows you the freedom to visit any in network dentist, without referrals, for your dental care. If you choose a non-participating dentist, your share of costs will generally be higher and you may need to file your own claims. To locate a Delta Dental provider, please visit: www.DeltaDentalOk.org.

Notes:

Dental Plan Highlights PPO Plus Premier Self-Insured Plan: Tulsa County, Law Library and Tulsa Health Department

PPO Plus Premier Fully Insured Plan: Public Defenders, TAEMA, Drainage District 12, Expo Square

$50 $150

Annual Maximum

$2,000

$1,500

Class I Services * (Oral evaluations, prophylaxis, x-rays, sealants)

100%

Class II Services (Basic restorative, fillings, endodontics, oral surgery, periodontics)

80%

Class III Services (Major restorative, prosthodontic, implants)

50%

Class IV Services (Orthodontics) Note: Benefits for orthodontic services are available only to eligible dependent children under the age of 19.

50%

$1,500

$1,000

Plan Feature

Annual Deductible Individual Family Note: The deductible applies only to Class II and Class III services.

Orthodontic Lifetime Maximum Per Child

Please note that if you are a late entrant, you will be limited to Class I services the first year of enrollment. This applies to the Self-Insured plan only. * Note: Benefits payable by the Plan for covered oral evaluations (examinations), procedure codes D0120-D0180, and routine prophylaxis (cleaning), procedure codes D1110-D1120, will not reduce the annual benefit year maximum for combined Class I, Class II, and Class III covered dental services. Note: Some benefits are subject to limitations such as age of patient, frequency of procedure, late enrollee etc., or excluded in some instances. Please review “LIMITATIONS” and “EXCLUSIONS” in your dental summary plan description or contact Delta Dental of Oklahoma’s Customer Service Department at (800) 522-0188 (toll free). 18

Vision Plan - VSP Vision Coverage If you enroll in vision coverage, you can go to any eye care provider you choose. However, if you choose providers who are part of the VSP network, you will receive a discount on services.

To find a VSP network provider, go to www.vsp.com. Certain cosmetic or elective eyewear is not covered under this plan through VSP, therefore you may incur out of pocket expenses. Always contact VSP to verify coverage amount, prior to making a purchase. Plan Feature

In-Network

Non-Network

Covered in full after $50 copay

Up to $50

$20 copay $20 copay $20 copay

Up to $50 Up to $75 Up to $100

Frames (once every 24 months)

Up to $120 allowance Plus, 20% off any out-of-pocket costs

Up to $70 N/A

Contact Lenses (once every 12 months) (in lieu of eye glasses)

$60 copay for Fitting & Evaluation fees $120 allowance for contacts

Up to $105

Eye Exam (once every 12 months) Lenses (once every 12 months) Single Vision: Bifocal Lenses: Trifocal Lenses:

Vision Plan Premiums Coverage Employee Family

Employer Portion $0.00 $0.00

Total Cost $3.60 $11.86

Notes:

Employee Portion $3.60 $11.86

Life Plan - VOYA Basic Life Insurance Tulsa County contributes 67% of the premium and Employees pay 33%. Basic Life Insurance coverage is equal to 2 times your annual base earnings, up to a maximum benefit of $50,000. Please note that the Basic Life insurance policy is only offered to employees.

Company Provided Benefits Benefit

Coverage

Paid By

Basic Life Insurance

2 times your annual base earnings, up to a maximum of $50,000

Employer 67% Employee 33%

Beneficiary Designation

You must designate a beneficiary for Basic and Optional Life Insurance benefits when you enroll. Your â&#x20AC;&#x153;beneficiaryâ&#x20AC;? is the person(s) who will receive the benefits from your life insurance in the event of your death. You can change your beneficiaries at any time during the year. If you do not name a beneficiary, or if your beneficiary passes away before you, your life insurance will be paid to your estate.

Benefits Reduce at Age 70

When you reach age 70, Basic and Optional Life Insurance benefits are reduced 50 percent. For more information, refer to your Group Life Insurance information. Please note that if you are a late entrant, you will be required to complete an Evidence of Insurability form (EOI) and send to VOYA. Notes:

Monthly Premiums Life Insurance (.175 per $1,000 of salary) two times annual salary, rounded to the next highest even $1,000. Example: $1,576 per month x 12 months = $18,912 x 2 = $37,824. Rounded to the next thousand = $38,000. Insurance Amount

Total Premium

County Portion

Employee Portion

$18,000

$3.15

$2.11

$1.04

$19,000

$3.33

$2.23

$1.10

$20,000

$3.50

$2.35

$1.16

$21,000

$3.68

$2.46

$1.21

$22,000

$3.85

$2.58

$1.27

$23,000

$4.03

$2.70

$1.33

$24,000

$4.20

$2.81

$1.39

$25,000

$4.38

$2.93

$1.44

$26,000

$4.55

$3.05

$1.50

$27,000

$4.73

$3.17

$1.56

$28,000

$4.90

$3.28

$1.62

$29,000

$5.08

$3.40

$1.67

$30,000

$5.25

$3.52

$1.73

$31,000

$5.43

$3.63

$1.79

$32,000

$5.60

$3.75

$1.85

$33,000

$5.78

$3.87

$1.91

$34,000

$5.95

$3.99

$1.96

$35,000

$6.13

$4.10

$2.02

$36,000

$6.30

$4.22

$2.08

$37,000

$6.48

$4.34

$2.14

$38,000

$6.65

$4.46

$2.19

$39,000

$6.83

$4.57

$2.25

$40,000

$7.00

$4.69

$2.31

$41,000

$7.18

$4.81

$2.37

$42,000

$7.35

$4.92

$2.43

$43,000

$7.53

$5.04

$2.48

$44,000

$7.70

$5.16

$2.54

$45,000

$7.88

$5.28

$2.60

$46,000

$8.05

$5.39

$2.66

$47,000

$8.23

$5.51

$2.71

$48,000

$8.40

$5.63

$2.77

$49,000

$8.58

$5.75

$2.83

$50,000

$8.75

$5.86

$2.89

Optional Life Insurance - VOYA The Optional Life Insurance policy is offered to employees, spouses and/or dependent children (up to the age of 26 years old) through Voya. Employees pay for the premiums on the Optional Life Insurance on a post-tax basis through payroll deductions. The combined coverage for the Basic and Optional Life Insurance policies on the employee cannot exceed $500,000. In order to enroll spouses and/or children in the Optional Life, the employee must be enrolled also. An employee must be enrolled in the Basic Life policy in order to enroll into the Optional Life policy. Coverage • The guaranteed issue amount (GI) is $250,000 or your annual earnings multiplied by 3 (whichever is the lesser of the two). • If you elect more than $250,000 or any amount in excess of your annual earnings multiplied by 3, you will be subject to completing an Evidence of Insurability (EOI) form. • Employees can enroll in increments of $10,000 to a maximum of $500,000 (includes the Basic life policy). • Coverage cannot exceed more than your annual earnings multiplied by 5. • Each year, you can increase your Optional life by $10,000 at Open Enrollment, without having to complete an EOI, to not exceed (GI) of $250,000. • Must submit beneficiary information. • Late Entrants must complete an EOI. • In order to enroll spouses in the Optional Life, the employee must be enrolled also. • Spouses can enroll in increments of $10,000 up to a $250,000 maximum (not to exceed 50% of the employee’s enrolled amount). • The Guaranteed issue amount for spouses is $20,000, as long as employee is enrolled in $40,000. • In order to enroll children in the Optional Life, the employee must be enrolled also. • Children (up to age 26) can enroll in increments of $2,000, up to a maximum of $10,000. • The Guaranteed issue amount for children is $10,000. The monthly premium rates for employee and spouse – per $10,000 of optional life coverage – are listed below. Please note that spouse rates are based on the age of the employee. Employee Age

Cost Per $10,000 of Coverage

Employee Age

Cost Per $10,000 of Coverage

Elected Child Coverage

Monthly Cost – The cost will remain the same regardless of number of children covered

<25

$0.60

50-54

$3.50

$2,000

$0.60

25-29

$0.60

55-59

$5.80

$4,000

$1.20

30-34

$0.80

60-64

$7.50

$6,000

$1.80

35-39

$0.90

65-69

$12.00

$8,000

$2.40

40-44

$1.10

70+

$21.00

$10,000

$3.00

45-49

$1.90

Waiver of Premium is included if approved prior to age 60 and ends at age 65. An Accelerated Death Claim can be submitted to Voya, in which up to 75% (with a maximum of $250,000) could be paid out to the employee, prior to death. 22

AD&D Insurance - VOYA Accidental Death and Dismemberment (AD&D) Insurance is for you and your family to help with expenses in the event you or a covered dependent passes away or becomes injured as a result of an accident. You pay for this coverage on a post-tax basis through payroll deductions. This coverage is administered through VOYA. If enrolling in the AD&D coverage, you must designate a beneficiary (person who would receive the benefits in the event of your death). Type of Coverage

Coverage

Employee

The minimum amount of coverage an employee can enroll in is $10,000. The maximum amount of coverage an employee can enroll in is $500,000, not to exceed five times basic annual earnings.

Employee + Spouse

Spouse receive 50% of coverage of the employees’ elected amount.

Employee + Children

Children receive 15% of coverage of the employees’ elected amount.

Employee + Family

Spouse receive 50% of coverage of the employees’ elected amount and each child receives 15% of coverage of the employees’ elected amount.

Principal Sum

Employee Only

Employee & Spouse

Employee & Children

Employee & Family

$10,000

$0.30

$0.45

$20,000

$0.60

$0.90

$30,000

$0.90

$1.35

$40,000

$1.20

$1.80

$50,000

$1.50

$2.25

$60,000

$1.80

$2.70

$70,000

$2.10

$3.15

$80,000

$2.40

$3.60

$90,000

$2.70

$4.05

$100,000

$3.00

$4.50

$150,000

$4.50

$6.75

$200,000

$6.00

$9.00

$300,000

$9.00

$13.50

$400,000

$12.00

$18.00

$500,000

$15.00

$22.50

Short-Term Disability (STD) • If you are enrolled in short-term disability and need time off work, due to a disability, you must complete disability claim paperwork and submit to Voya. Please note: There is never a guarantee of approval on a medical claim. All claims are subject to review by Voya’s medical underwriting department. • If the claim is approved by VOYA, the plan will pay benefits not to exceed 50% of your average monthly earnings. • Disability payments will be sent to the claimant in the amount of 50% of the normal rate of pay, up to a maximum of $1500 per week. • Benefits will begin to pay after 14 consecutive days of disability (elimination period). • You may use your personal and/or vacation hours during the elimination period. • Once you begin to receive your disability payments, you may continue to use your personal leave and vacation hours, not to exceed 100% of your gross pay. • Benefit payments will cover up to 11 weeks of disability. • If you are a late entrant, VOYA will require that you complete an Evidence of Insurability (EOI). • For late entrants, if you were diagnosed with a condition three months prior to your effective date of coverage, the condition will not be covered for the first 12 months.

Calculating Premium To calculate your monthly payroll deduction, use the formula indicated below: 1. Enter your average monthly income, not to exceed $13,333 on line 1

Line 1: _________

2. Multiply line 1 with the STD rate of $0.0051

Line 2: x .0051

3. Line 3 is the monthly cost for STD coverage

Line 3: _________

Notes:

Long-Term Disability (LTD) There are two different levels of long-term disability coverage. Both plans are designed to help protect your income in the event you are unable to work due to a disability. The first option, called the Base LTD Plan, replaces up to 50% of your base pay up to a maximum of $3,000 per month, has a 24-month benefit duration, and is fully paid by Tulsa County. The Buy-Up LTD Plan premiums are paid by the employee, and the duration of coverage is longer (up to age 65 years old). All benefit eligible employees are automatically enrolled into the Base LTD plan. Please refer to plan documents for plan limitations and exclusions. Base LTD Plan

Buy-Up LTD Plan

50%

Maximum monthly LTD benefit

$3,000.00

Minimum monthly LTD benefit

$100.00

24 Months

*SSNRA/To Age 65

Percentage of monthly pre-disability earnings

Benefit Duration * Social Security normal retirement age.

How Does LTD Coverage Work?

• The minimum eligibility requirement to submit a LTD claim to VOYA is to have been off work (for medical reasons) 90 consecutive days or more. • There are two options of long term disability benefits (Base LTD and Buy-Up LTD). • The Base LTD is paid by Tulsa County at 100%. • The Buy-Up LTD is paid by the employee. • The only difference between the two is that under the Base LTD, coverage would last for up to two years of disability. Coverage under the Buy-Up LTD would last up to age 65 years old. • If you are a late entrant into this plan, you will be required to complete an Evidence of Insurability form (EOI) and submit to VOYA. • For late entrants, if you were diagnosed with a condition three months prior to your effective date of coverage, the condition will not be covered for the first 12 months.

Buy-Up LTD Plan Premium Rates

If you elect the Buy-Up LTD Plan, your monthly premium rate for this plan is indicated in the table below. If you do not enroll in the Buy-Up LTD Plan, you will automatically be insured under the Base LTD Plan with no premium cost to you. To calculate your estimated monthly premium for the Buy-Up LTD plan, use the formula below: 1. Enter your average monthly income, not to exceed $6,000 on line 1

Line 1: _________

2. Multiply line 1 by LTD rate of .00279

Line 2: x .00279

3. Line 3 is the monthly cost for LTD Buy-up

Line 3: _________

Accident Insurance - VOYA Accident Insurance pays benefits for specific injuries and events resulting from a covered accident while off the job. In order to enroll spouses/and or children into the Accident Plan, the employee must be enrolled also. These benefits can be used for any purpose, such as:

Benefits are available, but not limited to:

Copay/deductibles/coinsurance

Dislocations/Fractures

Childcare expenses

Lacerations/Burns

Mortgage/rent/utilities

Urgent/Emergency Facility Treatment

Home healthcare costs

Ambulance transport

House-cleaning expenses

Surgery

Everyday expenses like groceries

Hospital admission/confinement Transportation/Lodging Physical Therapy

Accident Monthly Rates Employees Only

$6.59

Employee + Spouse

$10.93

Employee + Children

$13.20

Family

$17.54

Claim example: John slid into home base while playing in a summer softball league. The good news is he was safe and they won the game. The bad news is he tore his ACL in the process, requiring a trip to the emergency room and a surgical repair. Out of pocket medical expenses incurred: Deductible

$1,500

Emergency Room CoPay

$800

6 Physical Therapy visits

$180

Total out of pocket expenses

$3480

Total benefit paid under Accident Policy

$2600

Critical Illness Insurance - VOYA Critical Illness Insurance pays a lump-sum benefit if you are diagnosed with a covered illness or condition after the effective date of coverage. In order to enroll spouses and/or children in the Critical Illness Plan, the employee must be enrolled also. Your Critical Illness benefit can be used for any purpose, such as: • Lost time from work • Mortgage/rent/utilities • Co-pays/deductibles/coinsurance • Home health care costs • Childcare expenses A critical illness benefit is payable for each of the conditions outlined below: • Heart attack • Stroke • End stage renal (kidney) failure • Coronary artery bypass (25%) • Coma • Major organ failure • Permanent paralysis Recurrence Benefit • Allows you to receive a benefit for the same condition a second time • A second benefit for the same condition is payable following a period of 12 consecutive months during which both of the following are true: • You are free of the condition (s) for which benefits were previously paid. • You have had no occurrence of any other critical illness covered under the policy. Employee Rates

Spouse Rates*

Age Band

$10,000

$20,000

$30,000

Age Band

$5,000

$10,000

$15,000

Under 30

$6.00

$12.00

$18.00

Under 30

$2.85

$5.70

$8.55

30-39

$6.30

$12.60

$18.90

30-39

$3.10

$6.20

$9.30

40-49

$9.90

$19.80

$29.70

40-49

$5.30

$10.60

$15.90

50-59

$18.60

$37.20

$55.80

50-59

$10.20

$20.40

$30.60

60-64

$26.10

$52.20

$78.30

60-64

$14.25

$28.50

$42.75

65-69

$32.40

$64.80

$97.20

65-69

$17.00

$34.00

$51.00

70+

$42.90

$85.80

$128.70

70+

$26.00

$52.00

$78.00

Children Rates Age Band

$2,500

$5,000

$10,000

N/A

$1.00

$2.00

$4.00

* Spouse rates are based on the age of the Employee

Cancer Insurance - Allstate Benefits Benefit Coverage Highlights

Coverage is for cancer and 29 other specified diseases. Coverage is offered for employees and/or spouses and child dependents (up to age 26 years old). Benefits are paid directly to you or your insured family members unless assigned elsewhere. Premiums do not increase with age. A waiver of premium benefit allows you to forego payment of your premiums after 90 days of continuous disability due to cancer for as long as disability lasts (applicable only to the policyholder). • Late Entrants: Employees that elect cancer coverage during open enrollment that previously declined coverage (when initially eligible), will be required to complete an Evidence of Insurability form and send to Allstate Benefits. • Allstate Benefits does not pay any benefit due to or caused by a pre-existing condition during the 12 month period beginning on the date that coverage goes into effect. • • • • •

Coverage provides you and your covered family members with: • Benefits pay for treatment, hospital stays, transportation, and much more. • Affordable premiums that are payroll deducted. • A wellness benefit is included for certain screenings and early detection test and exams. • Pays for hospice care and extended care facilities. • Cancer initial diagnosis level benefit is a one-time benefit that will be paid for each insured member when diagnosed for the first time with cancer (expect for skin cancer). • A daily benefit for intensive care and a benefit for ambulance transportation are included on Option 2 only. Notes:

Cancer Insurance â&#x20AC;&#x201C; Monthly Premium Plan Design See Brochure for additional benefits

Employee

Employee + Employee + Employee + Spouse Child Family

Option 1 Initial Diagnosis $3,000 Yearly/12 month benefits: Wellness Benefit - $100 Radiation/Chemo - $10,000 Surgery Benefits - $3,000

$24.30

$37.76

$33.95

$47.40

Option 2 Initial Diagnosis $5,000 Yearly/12 month benefits: Wellness Benefit - $100 Radiation/Chemo - $10,000 Surgery Benefits - $4,500 Air/Surface Ambulance Intensive Care Benefits

$31.51

$49.66

$44.69

$62.82

Call for answers to your questions about the Cancer Insurance: Allstate Benefits Customer Care Center: (800) 521-3535 For additional details request an Allstate Benefits brochure from Human Resources. Notes:

Identity Theft Protection - IdentityForce Identity theft is one of the fastest growing crimes in the U.S. with more than 11 million victims last year alone. Identity theft can impact anyone, anywhere, at any time - which is why it is important that you protect yourself and your family. IdentityForce provides the best identity, privacy, and credit protection. They have protected millions of people for nearly 40 years and you can trust theyâ&#x20AC;&#x2122;ll do the same for you â&#x20AC;&#x201C; Rest assured with IdentityForce.

Monitor

As carefully as you plan for the unexpected, it is impossible to anticipate the theft of your identity, credit, or personal information. Innovative technology and on-going monitoring keep your personal information and identity secure.

Control

You insure your home, cars, and health. Your credit and personal information is even more at risk of unexpected disaster. With IdentityForce protection, you are in control. You will see and can improve your credit score, protect your personal information online and keep your keystrokes, pin numbers, and credit card information safe.

Alert

11 million U.S. residents have their identities stolen each year with financial losses close to a whopping $50 billion. On a more personal level, that is 1 out of every 4 adults, averaging losses of $3,500. IdentityForce provides an early warning system with prompt notification on your computer, phone or tablet allowing you to take action before the damage is done.

Relax

If your information is compromised, what is the next step? Certified Protection Experts offer comprehensive, 24/7 recovery services. Let IdentityForce do the work for you. We will make the phone calls, complete the paperwork, and handle every detail in restoring your identity. Plus, IdentityForceâ&#x20AC;&#x2122;s $1 million Identity Theft insurance coverage gives you an additional layer of protection. Notes:

IdentityForce Plans PLAN OPTIONS IdentityForce service payroll deduction pricing - Monthly

Ultra Secure Plan

UltraSecure

UltraSecure+ Credit

The UltraSecure plan provides continuous monitoring of your personal information, rapid alerts, comprehensive recovery services and $1 million identity theft insurance policy.

UltraSecure+ Credit Plan TM

This plan includes all services in the UltraSecure Plan plus robust credit report monitoring and credit reports and scores from all 3 bureaus.

Easy to Enroll 1. Enroll along with other voluntary benefits through your employer.

2. Receive confirmation email. If you do not receive the email, please check your spam folder.

Employee Only

$9.95

$16.95

Employee + Spouse/Domestic Partner

$19.90

$33.90

+Children*

FREE

* Children are defined as dependents 26-years-old and under living in your household. If you enroll in the plan, your children will receive a tailored identity protection product - ChildWatch. Change of Address Monitoring

■

Court Record Monitoring

■

Fraud Alert Reminders

■

Fraud Monitoring

■

Identity Monitoring

■

Identity Threat Alerts

■

Junk Mail Opt-Out

■

Medical ID Fraud Protection

■

Online PC Protection Tools

■

Pay Day Loan Monitoring

■

Sex Offender Monitoring

■

Three Bureau Credit Report Monitoring

■

3. Click on link in confirmation

Three Bureau Credit Report & Scores

Quarterly

email to complete registration and access your identity Protection Dashboard.

Credit Score Tracker

Monthly

Credit Score Simulator

■

Lost Wallet

■

Identity Restoration Specialist

■

Identity Theft Insurance ($1 Million)

■

457(b) & 401(a) Deferred Compensation Program BOK FINANCIAL - StartRight.RetireRight 457 (b) Deferred Compensation

With BOK Financial, your plan provides you with added advantages not found in traditional supplemental retirement programs. Why you should participate in the 457(b) Deferred Compensation Program: • The money you contribute to deferred comp comes out of your paycheck on a pretax basis. This lowers your taxable income and can provide higher growth potential because of the tax deferral. • Participating in the plan is easy - contributions are automatically deducted from your paycheck before taxes are taken and sent automatically to your account. You decide how much to contribute, what to invest it in, and how to use the money when you leave employment or retire from your employment. • It’s flexible - increase or decrease contributions and change investment options at any time • You can withdraw your money upon separation of service, whether you retire or not, without penalty. (Withdrawals will be subject to ordinary income tax.) • You will receive personal attention from BOSC, Inc.’s Senior Financial Consultants up, to, and throughout retirement. BOSC, Inc. is a subsidiary of BOK Financial. The 457(b) Deferred Compensation plan is a simple approach to enjoy the benefits of long term investing. The 457(b) plan is a tax deferred retirement plan that Tulsa County offers so you can put even more money toward retirement directly from your pay. It is designed to be a supplement to your pension.

401(a) Matching Plan Tulsa County will match up to $50.00 each pay period of the deferred amount that you make to the 457(b) Deferred Compensation Plan. The money in this program is managed by you and has the same tax advantages as the 457(b) Deferred Compensation Program. Call for answers to your questions about deferred compensation: BOKF Financial’s Participant Services Group 1 (800) 876-9557 Web site: www.startright.bokf.com Notes:

Post-Employment Health Plan (PEHP) The Post Employment Health Plan (PEHP) is a unique benefit plan designed to allow Tulsa County employees to set aside money for healthcare costs, after they separate employment with Tulsa County. This benefit will reimburse medical insurance premiums as well as the out-of-pocket cost of qualified medical expenses such as prescription drugs, physician co-pays, dental and vision expenses. After an employee has completed twelve months of employment as a full time employee, Tulsa County contributes $40 per month into the Universal Account and 2% of an employeeâ&#x20AC;&#x2122;s base salary into the Medical Premium account of the PEHP. Employees can invest the funds in their PEHP accounts and may do so through Bank of Oklahoma. The principal advantage to the employee, their spouse and their qualified dependents is that the amounts contributed to the program by the employer, investment earnings on the contributions, and the amounts distributed to them for the reimbursement of qualified medical expenses (as determined by IRC213(d) are free from federal income tax and FICA taxes. TASC administers the Post-Employment Health Plan (PEHP) claims for Tulsa County. Their contact information is listed in the directory of this benefits guide if you wish to obtain more information on the PEHP claims process.

Notes:

Tulsa Countyâ&#x20AC;&#x2122;s Employee Retirement System (Pension Plan) Membership in the Retirement System is mandatory for all eligible employees, including elected officials. An employee becomes eligible on the first day of employment as a regular, full-time employee. Tulsa County contributes 14% of an employeeâ&#x20AC;&#x2122;s base pay and employees contribute 2.5% of their base pay on a monthly basis into the Retirement System. Employees are vested after five years of service.

Yrs. Of Credited Service

Benefits %

Yrs. Of Credited Service

Benefits

1 2 3 4 5 6 7 8 9 10

2% 4% 6% 8% 10% 12% 14% 16% 18% 20%

11 12 13 14 15 16 17 18 19 20

22% 24% 26% 28% 30% 34% 38% 42% 46% 50%

Notes:

Employee General Notices Initial Notice of your HIPAA Special Enrollment Rights Our records show that you are eligible to participate in Tulsa County Group Benefits (to actually participate, you must complete an enrollment form and pay part of the premium through payroll deduction). A federal law called HIPAA requires that we notify you about an important provision in the plan - your right to enroll in the plan under its “special enrollment provision” if you acquire a new dependent, or if you decline coverage under this plan for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons.

Loss of Other Coverage (Excluding Medicaid or a State Children’s Health Insurance Program).

If you decline enrollment for yourself or for an eligible dependent (including your spouse) while other health insurance or group health plan coverage is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward you or your dependents’ other coverage). However, you must request enrollment within 30 days after you or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

Loss of Coverage for Medicaid or a State Children’s Health Insurance Program.

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

New Dependent by Marriage, Birth, Adoption, or Placement for Adoption.

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

Eligibility for Medicaid or a State Children’s Health Insurance Program.

If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children’s health insurance program with respect to coverage under this plan, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days after you or your dependents’ determination of eligibility for such assistance. *If you decline enrollment for yourself or for an eligible dependent, you must submit a signed statement to decline coverage. You are required to state that coverage under another group health plan or other health insurance coverage (including Medicaid or a state children’s health insurance program) is the reason for declining enrollment. If you do not complete the form, you and your dependents will not be entitled to special enrollment rights upon a loss of other coverage as described above. To request special enrollment or to obtain more information about the plan’s special enrollment provisions, contact your HUMAN RESOURCES DEPARTMENT. 35

Women’s Health and Cancer Rights Act (WHCRA) 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 states of reconstruction of the breast on which the mastectomy was performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more information on WHCRA benefits, call your Human Resources Department.

Dependents to Age 26

Due to a change in the laws governing your employer’s Group Health Plan, your children generally can be covered under the Plan until they attain age 26, regardless of their student or marital status and regardless of whether your home is their principal place of abode or whether you support them. The dependents are eligible for coverage regardless of eligibility on another employer group health plan.

Mental Health Parity

According to the Mental Health Parity Act of 1996, the lifetime maximum and annual maximum dollar limits for mental health benefits under the Tulsa County Group Health Plan are equal to the lifetime maximum and annual maximum dollar limits for medical and surgical benefits under this plan. However, mental health benefits may be limited to a maximum number of treatment days per year or series per lifetime.

Genetic Information Nondiscrimination Act (GINA)

The Genetic Information Nondiscrimination Act (GINA) applies to the Tulsa County Group Health Plan. This new law establishes a basic uniform national standard to protect the public from discrimination based on genetic information.

Newborns’ and Mothers’ Health Protection Act (NMHPA)

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

General Notice of COBRA Continuation Coverage Rights Introduction

You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-ofpocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

What is COBRA continuation coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event”. Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary”. You, your spouse and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct. If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan as the result of any of the following qualifying events: • • • • •

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

When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment. • Death of the employee. • COBRA coverage can be extended beyond 18 months: • If Commencement of a proceeding in bankruptcy with respect to the employer. • If the employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs.

How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. • If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. • If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period”. Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov. If you have questions: Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.healthcare.gov.

Keep your Plan informed of address changes:

To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan contact information Benefit Specialist 633 West Third Street Tulsa, OK 74127 918-596-5095 Notes:

Medicare Part D Notice 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 Tulsa County coverage will not be affected. You can keep this coverage if you elect Part D, but the group health plan will not coordinate with Part D coverage. If you do decide to join a Medicare drug plan and drop your current Community Care of Oklahoma coverage, be aware that you and your dependents will be able to get this coverage back only during open enrollment or a special enrollment event.

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

For More Information About Your Options Under Medicare Prescription Drug Coverage More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage: Visit www.medicare.gov

Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help.

Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Contact: Benefits Specialist 633 W Third Street Tulsa OK 74127 918-596-5095

Notes:

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office at 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in Oklahoma, you may be eligible for assistance paying your employer health plan premiums. Contact your State for more information on eligibility.

Oklahoma - Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1.888.365.3742

To see if any other states have added a premium assistance program since January 31, 2019, or for more information on special enrollment rights, contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol. gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 42

Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

Disclaimers

Some plans may not offer out of network benefits. If your plan offers out of network benefits, the amount the plan pays for covered services provided by non-network providers is based on a maximum allowable amount for the specific service rendered. Although your plan stipulates an out-of-pocket maximum for out-of-network services, please note the maximum allowed amount for an eligible procedure may not be equal to amount charged by your out-of-network provider. Your out of-network provider may bill you for the difference between the amount charged and the maximum allowed amount. This is called balance billing and the amount billed to you can be substantial. The out-of-pocket maximum outlined in your policy will not include amounts in excess of the allowable charge and other non-covered expenses as defined by your plan. The maximum reimbursable amount for non-network providers can be based on a number of schedules such as a percentage of reasonable and customary or a percentage of Medicare. The plan document or carrierâ&#x20AC;&#x2122;s master policy is the controlling document, and this Benefit Highlight does not include all of the terms, coverage, exclusions, limitations, and conditions of the actual plan language. Contact your claims payer or insurer for more information. This booklet gives you an overview of the main features of your benefit plans. The plans are administered according to legal plan documents and insurance contracts. Although we have tried to summarize the provisions of these legal documents clearly and accurately, if any information contained herein conflicts with the legal documents, the legal documents will govern. For more detailed information on the plans and your legal rights under the plans, be sure to read the summary plan descriptions or request a copy of the plan documents. All benefits are subject to change from time to time and Tulsa County reserve the right to amend or cancel any benefits described in this booklet, with or without notice.

IMPORTANT: This benefit guide is an outline of the coverages proposed by the carrier(s) based upon the information provided by your company. It does not include all the terms, coverages, exclusions, limitations, and conditions of the actual contract language. See the policies and contracts for actual language. This benefit guide is not a contract and offers no contractual obligation on behalf of GBS. Policy forms for your reference will be made available upon request. The intent of this booklet is to provide you with general information regarding the status of, and/or potential concerns related to your current employee benefits environment. It should not be construed as, nor is it intended to provide, legal advice. Laws may be complex and subject to change. This information is based on current interpretation of the law and is not guaranteed. Questions regarding specific issues should be addressed by legal counsel who specializes in this practice area.

Notes:

Important Contacts Contact Tulsa County â&#x20AC;&#x201C; Human Resources

Tulsa County

(918) 596-5095

Tulsa County â&#x20AC;&#x201C; Retirement/PEHP

Tulsa County

(918) 596-5854

Community Care

(918) 594-5242 (Member Services) (877) 293-8628 (Pharmacy Helpdesk) www.ccok.com

Community Care

(918) 594-5232 (Local) (800) 221-3976 (Toll Free) www.ccok.com

Delta Dental

(800) 522-0188 www.DeltaDentalOK.org

VSP

(800) 877-7195 www.vsp.com

VOYA

Customer Service Team (877) 236-7564 www.voya.com

Allstate Benefits

Customer Care Center: (800) 521-3535 Spanish: (800) 211-5533 Claims: (800) 348-4489 www.allstatebenefits.com

IdentityForce

(877) 694-3367 (Member Services) www.identityforce.com

TASC

(800) 422-4661 www.tasconline.com

TASC

(866) 678-8322 https://mybenefitsportal.tasconline.com

Bank of Oklahoma (BOK)

(800) 876-9557 www.startright.bokf.com

Medical Plan Member Services Prescription Drug Plan Pharmacy Helpdesk Employee Assistance Program

Delta Dental Customer Service Line VSP Vision Member Service Line Life Insurance Accidental Death & Dismemberment Short & Long Term Disability Plans, Critical Illness and Accident Plans

Cancer Insurance

Identity Theft

Flexible Spending Account (FSA)

Post-Employment Health Plan (PEHP) Deferred Compensation Program 457(b) and 401(a)

Payroll Deduction Code Payroll Deduction Code

Long Description

1000

FICA - SOCIAL SECURITY

1100

MEDICARE

2308

CORE DISABILITY

2309

LONG TERM DISABILITY

2310

SHORT TERM DISABILITY

2312

FOP DUES

2313

SAFETY SHOES

2314

CLOTHING

2317

UNITED WAY

2322

OPTIONAL LIFE

2323

LONG TERM CARE

2324

PEHP 05 $40

2325

PEHP 06 2%

2326

PEHP 06 1%

2327

EMPLOYEE ASSISTANCE PROGRAM

2331

ACCIDENT INSURANCE

2333

IDENTITY PROTECTION

2334

SUPPLEMENTAL LIFE/SPOUSE

2335

SUPPLEMENTAL LIFE/CHILD

2336

CRITICAL ILLNESS INSURANCE

2337

CRITICAL ILLNESS INSURANCE/SP

2338

CRITICAL ILLNESS INSURANCE/CH

2339

AD&D/SINGLE

2341

AD&D/FAMILY

2350 thru 2362

PARKING

2400

BASIC LIFE PRE TAX

2401

HEALTH - HMO PRETAX

2403

VISION SERVICE PLAN PRE TAX

2404

DELTA DENTAL (SI) PRE TAX

2408

FLEX PLAN MEDICAL

2409

FLEX PLAN CHILD CARE

2410

ALLSTATE CANCER

2432

DELTA DENTAL (FI) PRE TAX

2900

DEFERRED COMPENSATION 457

2901

401(A) EMPLOYER MATCH

2950 thru 2964

WORKERS COMPENSATION

3000

FEDERAL INCOME TAX

4000

STATE INCOME TAX

7000

RETIREMENT EE

7002

RETIREMENT ER

Notes:

ENROLLMENT GUIDE 2019 This guide highlights the main features of many of the benefit plans sponsored by Tulsa County. Full details of these plans are contained in the legal documents governing the plans. If there is any discrepancy between the plan documents and the information described here, the plan documents will govern. In all cases, the plan documents are the exclusive source for determining rights and benefits under the plans. Participation in the plans does not constitute an employment contract. Tulsa County reserves the right to modify, amend or terminate any benefit plan or practice described in this guide. Nothing in this guide guarantees that any new plan provisions will continue in effect for any period of time. In all events, the terms of the Plan as set forth in the Plan document govern and, as a result, no statements made outside of the Plan document, whether verbal or written, change or modify the terms of the Plan. The Plan can be amended only in writing and only by the Tulsa County Board of County Commissioners. Other than the Tulsa County Board of Commissioners or its authorized designee, no individual or entity has the authority to change the terms of the Plan or to commit to any benefit or benefit provisions not set forth in the terms of the Plan, including, but not limited to, changing the eligibility criteria for any benefit. Printed by Tulsa County Administrative Services