2023 BENEFITS - YOUR BENEFITS. YOUR CHOICES. YOUR HEALTH. January 1, 2023 - December 31, 2023
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2023 BENEFITS YOUR BENEFITS. YOUR CHOICES. YOUR HEALTH. January 1, 2023 - December 31, 2023
Welcome
CONTENTS EASTERSEALS NORTHEAST CENTRAL FLORIDA strives to provide you with
comprehensive, valuable benefit plans as part of your total compensa-
3 Benefits Overview tion package, which we hope will assist you in planning for your financial
security now and in the future. We encourage you to learn about and
4 Medical understand your benefits so that you may use them wisely.
5 Medical Payroll UNITED HEALTHCARE
Deductions
Medical Customer Service 866.633.2446 MyUHC.com
6 Urgent Care vs.
METLIFE
Emergency Room
7 Wellness Customer Service for
Dental, Vision, Life &
8 UHC Mobile App 800.275.4638 MetLife.com
Disability
9 Flexible Spending
Account
MEDCOM
10 Dental Flexible Spending Account 800.523.7542 Medcombenefits.com
11 Vision AFLAC
12 Basic Life/AD&D Representative:
386.846.9087
Trisha Cuthbert
13 Voluntary Life/AD&D
14 Disability
We encourage you to take the time to review the benefit plans described
15 Employee Assistance in this guide and to choose the best options for you and your family.
Program If you have questions regarding any of the above benefits or the
16 Aflac Supplemental enrollment process, please contact your dedicated BenefitsVIP team at
866.284.2053 or email MyTeam@benefitsVIP.com
17 BenefitsVIP®
Monday—Friday, 8:30am—8:00pm (EST).
18 Disclosures
2 QUESTIONS? Call BenefitsVIP at 866.284.2053
Benefits Overview Following is a brief description of each benefit being offered to EASTERSEALS NORTHEAST CENTRAL FLORIDA employees for the plan year January 1, 2023 through December 31, 2023. MEDICAL Our medical and prescription drug coverage is offered through United Healthcare. DENTAL We offer two dental plans: A PPO & a DHMO dental plan through MetLife. VISION Our comprehensive vision plan is offered through MetLife. BASIC LIFE AND AD&D Basic Life/AD&D coverage is provided by EASTERSEALS NORTHEAST CENTRAL FLORIDA through MetLife. VOLUNTARY LIFE You will have the opportunity to purchase voluntary life coverage for yourself and your dependents. Coverage is offered through MetLife. SHORT-TERM DISABILITY Short-term disability coverage is provided by EASTERSEALS NORTHEAST CENTRAL FLORIDA through MetLife. LONG-TERM DISABILITY Long-term disability coverage is provided by EASTERSEALS NORTHEAST CENTRAL FLORIDA through MetLife. FLEXIBLE SPENDING ACCOUNT Our flexible spending account is offered through Medcom. VOLUNTARY SUPPLMENTAL BENEFITS Accident, Critical Illness and Hospital Insurance is offered through Aflac. QUESTIONS? Call BenefitsVIP at 866.284.2053 3
Medical
BXOO BXKB BWNL
NHP HMO NHP HMO Choice Plus PPO
Individual: $1,500 Individual: $1,000 Individual: $2,500
Plan Year Deductible
Family: $3,000 Family: $3,000 Family: $5,000
Individual: $4,500 Individual: $6,000 Individual: $6,000
Plan Year Out-of-Pocket Maximum
Family: $9,000 Family: $12,000 Family: $12,000
Preventive Care
Adult or Child Wellness Exam No Charge No Charge No Charge
Outpatient Care
Primary care physician office visits $25 Copay $25 Copay $25 Copay
Specialist office visits $45 Copay $45 Copay $50 Copay
Telemedicine (Family Physician) No Charge No Charge No Charge
Outpatient surgery (Ambulatory Surgical Center) Deductible, then 10% $250 Copay Deductible, then 20%
Independent Outpatient Lab & Diagnostics
Independent Clinical Lab (blood work) Deductible, then 10% No Charge No Charge
Freestanding Diagnostic Center (x-rays) Deductible, then 10% No Charge $60 Copay
Designated Network Imaging $350 Copay $200 Copay $200 Copay
Imaging (CT/PET Scans/MRIs) $750 Copay $750 Copay $750 Copay
Emergency Care
Ambulance when medically necessary Deductible, then 10% Deductible, then 20% Deductible, then 20%
At hospital emergency room Deductible, then 10% $350 Copay $350 Copay
Urgent Care $50 Copay $50 Copay $75 Copay
In-Patient Hospital
Facility fee Deductible, then 10% $250 Copay Deductible, then 20%
Physician/Surgeon fee Deductible, then 10% Deductible, then 20% Deductible, then 20%
Mental Health
Inpatient Deductible, then 10% $250 Copay per stay Deductible, then 20%
Outpatient $45 Copay $45 Copay $50 Copay
Prescription Drugs
Retail Pharmacy (30 day supply)
Generic $10 $10 $10
Preferred Brand $35 $50 $50
Non-Preferred Brand $70 $85 $85
Mail Order (90 day supply) $25 / $87.50/ $175 $25 / $125/ $212.50 $25 / $125/ $212.50
Out-of-Network Benefits
Plan Year Deductible (Individual/Family) Out of network coverage not Out of network coverage not $5,000 / $10,000
Out of Pocket Maximum (Individual/Family) available except for emergency available except for emergency $10,000 / $20,000
Coinsurance services services 40%
4 QUESTIONS? Call BenefitsVIP at 866.284.2053
Medical Payroll Deductions
26 Bi-Weekly Payroll Deductions
Coverage Tier BXOO BXKB BWNL
Employee Only $30.40 $44.80 $98.48
Employee & Spouse $411.74 $446.02 $573.78
Employee & Child(ren) $262.51 $289.02 $387.78
Employee & Family $616.22 $661.16 $828.64
22 Bi-Weekly Payroll Deductions
Coverage Tier BXOO BXKB BWNL
Employee Only $35.92 $52.95 $116.38
Employee & Spouse $486.60 $527.12 $678.10
Employee & Child(ren) $310.24 $341.57 $458.29
Employee & Family $728.26 $781.37 $979.30
QUESTIONS? Call BenefitsVIP at 866.284.2053 5
Urgent Care
vs. Emergency Room
of emergency department visits are
71% unnecessary or could have been avoided.
If you have a life-threatening illness or injury, go to the
ER or call 911 right away.
6 QUESTIONS? Call BenefitsVIP at 866.284.2053
Wellness
Employees enrolled in a UnitedHealthcare medical plan will have access
to the several health and wellness programs at no cost to you.
REAL APPEAL® UHC’s Rally® & SimplyEngaged® Plus, allows you to
complete specific health and wellness activities to earn
Real Appeal® is an online weight loss program that
financial incentives and rewards. You can track your ac-
provides personal coaching to help you and eligible
tivities and rewards through Rally®, a user-friendly digital
family members lose weight and keep it off.
experience that supports your program with online
• 1-on-1 coaching: Get help to stay on track to tools.
reach your goals with online coach-led group
sessions.
• No out‐of‐pocket expenses ELIGIBILITY
• Success kit: Get scales, recipes, fitness The program is open to all employees and spouses en-
equipment and more delivered to your door. rolled in a Company-sponsored medical plan. Participa-
tion in Rally and SimplyEngaged Plus is 100 percent
LEARN MORE AND START TODAY AT voluntary and confidential.
SUCCESS.REALAPPEAL.COM
RALLY® APP
UHC REWARDS
The Rally® app is designed to help you improve and
Eligible participants can earn up to $300 in gift cards for
maintain your health.
completing wellness activities through Rally and Simp-
• After taking a quick Health Survey, Rally will offer lyEngaged Plus (earnings are per person and include
personalized recommendations to help you move covered spouse).
more, eat better and stress less.
• Sync your tracking device, join a Challenge and
For each activity you complete, you’ll earn Rally Coins to
earn virtual coins that you can exchange for re-
enter additional sweepstakes plus gift cards. Rewards
wards for taking health steps every day.
will be delivered through UHC.
• Download the app from the App Store or Google
play
Examples of Health Actions:
• Complete the Health Survey and watch the video: $25
SIMPLY ENGAGED PLUS® + Rally Coins
Through Rally® you can access the Simply En- • Complete a Virtual Visit: $25 + Rally Coins
gaged® health and wellness activities that are availa- • Complete a coaching program: $200 + Rally Coins
ble to you.
• Complete a biometric screening: $50/metric
• For each Health Action you complete, you’ll earn
Rally coins which you can redeem for rewards. • Complete a gym check-in: $20/month + Rally Coins
• Rewards available for covered employees and
covered spouses. To get started, go to myuhc.com® > Health Resources
> Rally
QUESTIONS? Call BenefitsVIP at 866.284.2053 7
UHC Mobile App
HEALTHCARE IN YOUR HANDS
As a UnitedHealthcare member, you can now access your benefit and claim information when you’re
on-the-go from your mobile device. Just download the app on your iPhone or Android.
The app has you covered.
When you’re out and about, you can do everything from managing your
plan to getting convenient care. Just download the app to:
• Find nearby care options in your network.
• Estimate costs.
• Video chat with a doctor 24/7.
• View and share your health plan ID card.
• See your claim details and view progress toward your deductible.
Get the app and log on with Touch ID®.
The UnitedHealthcare app is available for download for iPhone®
or Android™.
8 QUESTIONS? Call BenefitsVIP at 866.284.2053Flexible Spending Account
EASTERSEALS NORTHEAST CENTRAL FLORIDA offers employees the option
of making deposits into separate spending accounts for eligible
healthcare (including Medical, Dental and Vision) expenses and depend-
ent care (including child care expenses.
HEALTHCARE REIMBURSEMENT DEPENDENT CARE FSA: Your deductions cannot be
FSA: changed or discontinued
The Dependent Care FSA enables
employees to use pre-tax dollars during the plan year unless
In addition to using this account to
to pay for eligible dependent care you experience a qualifying
make co-pays, co-insurance pay-
ments or deductible payments this expenses that are necessary for event.
program lets employees pay for cer- you (and your spouse) to work,
tain IRS approved medical care actively look for work, or attend You must enroll/re-enroll to
expenses. school full time. Dependent care
FSA can be used for the caring of participate
The annual maximum contribution children under the age of 13 or
to the Healthcare FSA account for dependent elders who live with
2023 is $3,050. you. The annual maximum contri-
In addition, you may roll over up to bution to the Dependent Care FSA
$570 into the next plan year. All oth- is $5,000 ($2,500 if married and
er monies will be forfeited. filing separately).
Some examples of reimbursable Examples of eligible expenses in-
expenses include: clude:
• Hearing exams, hearing aids • The cost of child or adult de-
• Vision expenses such as: laser
pendent care www.FSAStore.com is the only
eye surgery (Lasik), contact • The cost for an individual to one-stop-shop stocked
lenses, eye examinations, and provide care either in or out of exclusively with FSA-eligible
eyeglasses your house
products and services so there
• Orthodontia • Nursery schools and pre-
schools (excluding kindergar-
are no guessing games as to
• Chiropractic services what is and isn't reimbursable
ten)
• Acupuncture which is what consumers face
You should only contribute the
• Physical therapy amount of money you expect to every time they walk into a
• Diabetic Supplies pay out of pocket for eligible ex-
drugstore.
penses for the plan year. If you do
not use the money within the plan
year it will NOT be refunded to you
or carried forward to a future plan
year.
Use it or Lose it!
QUESTIONS? Call BenefitsVIP at 866.284.2053 9Dental
PPO PLAN DHMO PLAN
BENEFIT OUT-OF-
IN-NETWORK IN-NETWORK
NETWORK
Annual Deductible Individual: $50 Individual: $50
$0
Family: $150 Family: $150
SEARCHING FOR A DENTAL
Calendar Year Benefit
PROVIDER $1,250 None
Maximum
You may search for an in-network Diagnostic & Preventive
provider by accessing the website Services
Covered at *Covered at Fee Schedule
Prophylaxis (Cleanings); 100% 100%
STEP 1: Go to www.metlife.com
Oral Examinations; Topical
STEP 2: Click on “Find a Dentist” Fluoride; Bitewing X-Rays
Basic Services
STEP 3: Choose “PDP Plus” as
your network X-Rays; Fillings;
Extractions; Oral Surgery; Covered at *Covered at
STEP 4: Enter Location and click Endodontics; Periodontics; Fee Schedule
80% 80%
“Find a Dentist” Periodontal surgery; after Deductible after Deductible
Consultations; Sealants;
Space maintainers for
children
Once you are enrolled register at
Major Services
Metlife.com/MyBenefits to access Covered at *Covered at
Bridge and Dentures; Fee Schedule
your account information. 50% 50%
Crowns, Inlays, Onlays, after Deductible after Deductible
Major Services
Orthodontia No Coverage No Coverage Fee Schedule
Bi-Weekly 26 Bi-Weekly 22 Bi-Weekly 26 Bi-Weekly 22 Bi-Weekly
Contributions
Employee Only $10.97 $12.96 $7.05 $8.33
Employee + Spouse $21.54 $25.46 $12.34 $14.58
Employee + Child(ren) $23.55 $27.83 $14.80 $17.49
Employee + Family $33.63 $39.75 $20.79 $24.57
*PPO out-of-network fees are paid at the Maximum Allowable Charge (MAC). You will be
responsible to pay the difference in the provider’s actual charges and what the insurance
reimburses.
DHMO: Refer to fee schedule for exact costs for services. Amounts listed are approximate and do
not detail all services and fees offered
10 QUESTIONS? Call BenefitsVIP at 866.284.2053Vision
VISION PLAN
BENEFIT IN-NETWORK OUT-OF-NETWORK*
Eye Exam $10 Copay Reimbursed up to $45
Materials See below for
$10 Copay
(Frames and Lenses) Allowance amount NEED HELP FINDING AN
Frequency IN-NETWORK PROVIDER?
Exam Once every 12 months Once every 12 months
Lenses One pair every 12 months One pair every 12 months Follow the steps below to locate a
Frames One set every 24 months One set every 24 months
participating Doctor near you:
Contacts One pair every 12 months One pair every 12 months
Frames $130 Allowance Reimbursed up to $70 STEP 1: Go to www.metlife.com
Lenses Reimbursed up to:
Single Vision $10 Copay $30 STEP 2: Click on “Find a Vision
Bifocal Vision $10 Copay $50 Provider”
Trifocal Vision $10 Copay $65
Lenticular Vision $10 Copay $100
STEP 3: Choose “MetLife Vision
Contact Lenses PPO ” as your network
Reimbursed up to:
Medically Necessary** Covered in full $210
Elective Contact Lenses STEP 4: Enter Location and click
$130 Allowance $105
“Find a Vision Provider”
Bi-Weekly Contributions 26 Bi-Weekly 22 Bi-Weekly
Once you are enrolled register at
Employee Only $3.15 $3.72 Metlife.com/MyBenefits to access
Employee + Spouse $5.97 $7.06
Employee + Child(ren) $7.00
your account information.
$8.27
Employee + Family $9.84 $11.63
* For Out-of-Network services you will be required to pay the provider in full at the time of service. You must submit a
claim form to MetLife for reimbursement within 6 months of the date of service.
** When eyeglasses do not achieve the best visual potential, contact lenses may become medically necessary. This can be
due to keratoconus, corneal trauma, or post-surgical irregularity in the corneal surface. Medical necessity will be
reviewed on a case by case basis.
QUESTIONS? Call BenefitsVIP at 866.284.2053 11Basic Life & AD&D
BASIC GROUP LIFE AND ACCIDENTAL DEATH &
DISMEMBERMENT (AD&D)
EASTERSEALS NORTHEAST CENTRAL FLORIDA provides all benefit eligible
employees with Group Term Life and matching AD&D coverage at no
HOW BASIC LIFE/AD&D cost to you.
INSURANCE CAN HELP MAKE SURE TO UPDATE YOUR BENEFICIARY INFORMATION NOW!!
Life and AD&D insurance may A beneficiary is the person or entity you name in a life insurance policy
provide additional financial support to receive the death benefit.
by:
You can name:
• Assisting your family with the
• One person
cost of your funeral or medical
bills • Two or more people
• Covering household expenses • The trustee of a trust you’ve set up
• Relieving debt you might leave • Your estate
behind
If you don’t name a beneficiary, the death benefit will be paid to your
• Leaving an inheritance for your estate.
loved ones or an organization
Two “levels” of beneficiaries:
you are passionate about
Your Life Insurance policy should have both “primary” and “contingent”
beneficiaries. The primary beneficiary receives the death benefit upon
your passing, if they are found. Contingent beneficiaries receive the
death benefit if the primary beneficiary can’t be found. If no primary or
contingent beneficiaries can be found, the death benefit will be paid to
your estate.
As part of naming beneficiaries, you should identify them as clearly as
possible and include their Social Security numbers. This will make it
easier for the Life Insurance company to find them, and it will make it
less likely that disputes will arise regarding the death benefit.
12 QUESTIONS? Call BenefitsVIP at 866.284.2053Voluntary Life/AD&D
VOLUNTARY LIFE/AD&D
Employees may purchase voluntary life coverage through MetLife for
themselves, their spouse, and/or their dependent children. You must
elect coverage on yourself in order to cover your dependents.
THINGS TO REMEMBER:
COVERAGE GUIDELINES • Your spouse’s rate is based on
your age
MINIMUM GUARANTEE ISSUE MAXIMUM
• You pay just one payroll
5 x Annual Salary up to deduction for child coverage,
For You $10,000 $100,000
$500,000 no matter how many children
you are covering
50% of employee’s
Spouse $5,000 $30,000 • You must enroll in coverage in
benefit up to $100,000 order to elect coverage for your
dependents
Child(ren) $250
Age 14 days to 6 months • Payroll deductions may vary
Age 6 months to age 26 $10,000 due to rounding
Voluntary Life/AD&D Rate • AD&D coverage equals the life
How to calculate your supplemental life deduction insurance amount chosen is for
Monthly Cost per the employee and spouse.
Example: An employee who is 47 years old wishes to Age AD&D coverage is not available
$1,000 of coverage
elect $100,000 in coverage for child(ren).Disability
SHORT-TERM DISABILITY
EASTERSEALS NORTHEAST CENTRAL FLORIDA provides all benefit
eligible employees with Short-Term Disability. This coverage is designed
to replace a portion of your income should you become unable to work
PRE-EXISTING CONDITION EXCLUSION due to a non-work related injury or sickness. A brief summary of the
There is a 3/12 pre-existing plan is outlined in the following chart. Please refer to your MetLife
condition exclusion under the summary for additional details, including limitations and exclusions.
Long Term Disability plan. This
means any condition for which you
SHORT-TERM DISABILITY SCHEDULE OF BENEFITS
receive medical attention in the
three months prior to your effec- BENEFITS BEGIN 15th day for Accident / 15th day for Sickness
tive date of coverage that results in
BENEFIT DURATION / PAYABLE Up to 11 weeks
a disability during the first 12
months of coverage would not be PERCENTAGE OF INCOME REPLACED 60%
covered.
MAXIMUM WEEKLY BENEFIT $900
LONG-TERM DISABILITY
EASTERSEALS NORTHEAST CENTRAL FLORIDA also provides all benefit
eligible employees Long-Term Disability. This coverage is designed to
replace a portion of your income should you become unable to work for
an extended period of time. A brief summary of the plan is outlined in
the following chart. Please refer to your MetLife summary for additional
details, including limitations and exclusions.
LONG-TERM DISABILITY SCHEDULE OF BENEFITS
BENEFITS BEGIN 91st day
12 months
BENEFIT DURATION / PAYABLE if unable to perform you own occupation and
To Social Security Normal Retirement Age
PERCENTAGE OF INCOME REPLACED 60%
MAXIMUM MONTHLY BENEFIT $5,000
14 QUESTIONS? Call BenefitsVIP at 866.284.2053Employee Assistance
Program
15Aflac Supplemental
Benefit
HEALTH ADVOCATE ACCIDENT INSURANCE
If you enroll in the Accident, Criti- Accidents can happen in an instant affecting you or a loved one. Aflac is de-
cal Illness or Hospital Indemnity signed to help families plan for the health care bumps ahead and take some of
Plans you will have access to the uncertainty and financial insecurity out of getting better. After an accident,
Health Advocate. you may have expenses you’ve never thought about. Can your finances handle
Your Personal Health Advocate will them? It’s reassuring to know that an accident insurance plan can be there for
help you: you in your time of need to help cover expenses such as:
• Find doctors, dentists & hospi- • Ambulance rides
tals • Emergency room visits
• Schedule appointments • Surgery and anesthesia
• Resolve claims and billing is- • Prescriptions
sues • Major Diagnostic Testing
• Get help with eldercare issues • Burns
• Transfer medical records
Call 855-423-8585 24/7 to get CRITICAL ILLNESS INSURANCE
started The Aflac Group Critical Illness Plan provides cash benefits when an insured
person is diagnosed with a covered critical illness-and these benefits are paid
directly to you (unless otherwise assigned). The plan provides a lump-sum ben-
TELEMEDICINE efit to help with out-of-pocket medical expenses and the living expenses that
If you enroll in the Accident, Criti- can accompany a covered critical illness. Critical Illness Benefits are payable for:
cal Illness or Hospital Indemnity
Plans you will have access to • Cancer • Heart Attack (Myocardial Infarction)
MeMD telemedicine. • Stroke • Kidney Failure (End-Stage Renal Failure)
• Major Organ Transplant • Bone Marrow Transplant (Stem Cell Trans-
With MeMD, you or your family • Sudden Cardiac Arrest plant)
members can connect to a board- • Non-Invasive Cancer • Coronary Artery Bypass Surgery
certified, U.S.-licensed medical • Skin Cancer
provider from almost any location,
day and night, weekends and
holidays. All using your phone or HOSPITAL INDEMNITY
computer. You’ll get a confidential
diagnosis, along with a treatment Even a minor trip to the hospital can present you with unexpected expenses
plan and needed prescriptions for and medical bills. And even with major medical insurance, your plan may only
common medications – for just pay a portion of your entire stay. Hospital Indemnity provides financial assis-
$25 per visit. tance to enhance your current coverage. It may help avoid dipping into savings
or having to borrow to address out-of-pocket-expenses major medical insur-
PRIVATE CONSULTATIONS ance was never intended to cover. Benefits include:
WITH U.S. LICENSED MEDICAL
PROVIDERS.GET HELP 24/7 • Hospital Confinement Benefit
NEARLY ANYWHERE IN THE U.S. • Hospital Admission Benefit
CONNECT BY PHONE, • Hospital Intensive Care Benefit
WEB OR MOBILE APP • Intermediate Intensive Care Step-Down Unit
• Successor Insured Benefit
16QUESTIONS? Call BenefitsVIP at 866.284.2053BenefitsVIP
HELP STARTS HERE
BenefitsVIP is a powerful, one-stop contact center staffed by seasoned
professionals. Your dedicated team of employee benefits advocates is
ready to help you and your family members resolve your benefits issues.
For service that’s confidential and responsive, contact:
866.284.2053 WEBSITE
Stay informed with the latest
health news, biometric tools,
Monday—Friday calculators and information at
8:30am—8:00pm (EST) benefitsvip.com!
Fax: 856.996.2775
myteam@benefitsvip.com
QUESTIONS ANSWERED HERE
COMPLETELY CONFIDENTIAL! Your dedicated BenefitsVIP advocates
understand your benefit plans and are able to answer benefit questions
and quickly resolve claims and eligibility issues. A majority of inquiries
are resolved the same day and all calls adhere to privacy best practices.
BenefitsVIP.com
QUESTIONS? Call BenefitsVIP at 866.284.2053
17Disclosures
NEWBORNS’ AND MOTHERS’ HEALTH administrator of a group health plan is The continuation of coverage applies to to comply with the certification
PROTECTION ACT OF 1996 (NEWBORN’S required to determine, within a a dependent child’s leave of absence requirements of family and medical
ACT) reasonable period of time, whether a from (or other change in enrollment) a leave laws, or to information
Group health plans and health insurance medical child support order is qualified, postsecondary educational institution inadvertently obtained through lawful
issuers generally may not, under federal and to administer benefits in accordance (college or university) because of a inquiries under, for example, the
law, restrict benefits for any hospital with the applicable terms of each order serious illness or injury, while covered Americans with Disabilities Act,
length of stay in connection with that is qualified. In the event you are under a health plan. This would provided the employer does not use the
childbirth for the mother or newborn served with a notice to provide medical otherwise cause the child to lose information in any discriminatory
child to less than 48 hours following a coverage for a dependent child as the dependent status under the terms of the manner. In the event a covered employer
vaginal delivery, or less than 96 hours result of a legal determination, you may plan. Coverage will be continued until: lawfully (or inadvertently) acquires
following a cesarean section. However, obtain information from your employer genetic information, the information
federal law generally does not prohibit on the rules for seeking to enact such 1. One year from the start of the must be kept in a separate file and
the mother's or newborn's attending coverage. These rules are provided at no medically necessary leave of absence, or treated as a confidential medical record,
provider, after consulting with the cost to you and may be requested from 2. The date on which the coverage would and may be disclosed to third parties
mother, from discharging the mother or your employer at any time. otherwise terminate under the terms of only in very limited situations.
her newborn earlier than 48 hours (or 96 the health plan; whichever is earlier.
hours as applicable). In any case, plans
and issuers may not, under federal law, SPECIAL ENROLLMENT RIGHTS (HIPAA) CONSOLIDATED OMNIBUS BUDGET
require that a provider obtain If you have previously declined MENTAL HEALTH PARITY AND RECONCILIATION ACT (COBRA)
authorization from the plan or the issuer enrollment for yourself or your ADDICTION EQUITY ACT OF 2008 The Consolidated Omnibus Budget
for prescribing a length of stay not in dependents (including your spouse) This act expands the mental health Reconciliation Act of 1985 (COBRA)
excess of 48 hours (or 96 hours). because of other health insurance parity requirements in the Employee requires employers who provide medical
coverage, you may in the future be able Retirement Income Security Act, the coverage to their employees to offer
to enroll yourself or your dependents in Internal Revenue Code and the Public such coverage to employees and covered
THE WOMEN’S HEALTH AND CANCER this plan, provided that you request Health Services Act by imposing new family members on a temporary basis
mandates on group health plans that when there has been a change in
RIGHTS ACT OF 1998 (WHCRA, ALSO enrollment within 30 days after your circumstances that would otherwise
KNOWN AS JANET’S LAW) other coverage ends. In addition, if you provide both medical and surgical
benefits and mental health or substance result in a loss of such coverage [26 USC
Under WHCRA, group health plans, have a new dependent as a result of §4980B ] This benefit, known as
insurance companies and health marriage, birth, adoption, or placement abuse disorder benefits. Among the new
requirements, such plans (or the health “continuation coverage,” applies if, for
maintenance organizations (HMOs) for adoption, you may be able to enroll example, dependent children become
offering mastectomy coverage must also yourself and your dependents, provided insurance coverage offered in connection
independent, spouses get divorced, or
provide coverage for reconstructive that you request enrollment within 30 with such plans) must ensure that: employees leave the employer.
surgery in a manner determined in days after the marriage, birth, adoption, The financial requirements applicable to
consultation with the attending or placement for adoption. mental health or substance abuse
physician and the patient. Coverage disorder benefits are no more restrictive CHILDREN'S HEALTH INSURANCE
includes reconstruction of the breast on that the predominant financial PROGRAM REAUTHORIZATION ACT
which the mastectomy was performed, COVERAGE EXTENSION RIGHTS UNDER requirements applied to substantially all (CHIPRA)
surgery and reconstruction of the other THE UNIFORMED SERVICES medical and surgical benefits covered by
breast to produce a symmetrical Effective April 1, 2009 employees and
EMPLOYMENT AND REEMPLOYMENT the plan (or coverage), and there are no dependents who are eligible for
appearance, and prostheses and RIGHTS ACT (USERRA) separate cost sharing requirements that
treatment of physical complications at coverage, but who have not enrolled,
If you leave your job to perform military are applicable only with respect to have the right to elect coverage during
all stages of the mastectomy, including service, you have the right to elect to mental health or substance abuse
lymph edemas. the plan year under two circumstances:
continue your existing employer-based disorder benefits.
Call your Plan Administrator for more health plan coverage for you and your • The employee’s or dependent’s state
information. dependents (including spouse) for up to Medicaid or CHIP (Children's Health
24 months while in the military. Even if Insurance Program) coverage
GENETIC INFORMATION NON-
you do not elect to continue coverage terminates because the individual
DISCRIMINATION ACT (GINA)
during your military service, you have the cease to be eligible.
QUALIFIED MEDICAL CHILD SUPPORT GINA broadly prohibits covered
right to be reinstated in your employer’s employers from discriminating against
ORDER (QMCSO) health plan when you are reemployed, • The employee or dependent becomes
QMCSO is a medical child support order an employee, individual, or member eligible for a CHIP premium
generally without any waiting periods or because of the employee’s “genetic
issued under State law that creates or exclusions for pre-existing conditions assistance subsidy under state
recognizes the existence of an “alternate information,” which is broadly defined in Medicaid or CHIP (Children's Health
except for service-connected injuries or GINA to mean (1) genetic tests of the
recipient’s” right to receive benefits for illnesses. Insurance Program).
which a participant or beneficiary is individual, (2) genetic tests of family
eligible under a group health plan. An members of the individual, and (3) the Employees must request this special
“alternate recipient” is any child of a manifestation of a disease or disorder in enrollment within 60 days of the loss of
participant (including a child adopted by MICHELLE’S LAW family members of such individual. coverage and/or within 60 days of when
or placed for adoption with a participant Michelle’s Law permits seriously ill or eligibility is determined for the premium
injured college students to continue GINA also prohibits employers from subsidy.
in a group health plan) who is recognized requesting, requiring, or purchasing an
under a medical child support order as coverage under a group health plan
when they must leave school on a full- employee’s genetic information. This
having a right to enrollment under a prohibition does not extend to PREMIUM ASSISTANCE UNDER
group health plan with respect to such time basis due to their injury or illness
and would otherwise lose coverage. information that is requested or required MEDICAID AND CHILDREN’S HEALTH
participant. Upon receipt, the INSURANCE PROGRAM (CHIP)
QUESTIONS?
18 Call BenefitsVIP at 866.284.2053Disclosures
If you or your children are eligible for Email: hipp@dhcs.ca.gov KANSAS – Medicaid
Medicaid or CHIP and you’re eligible for
health coverage from your employer, COLORADO – Health First Colorado Website: https://www.kancare.ks.gov/ MONTANA – Medicaid
your state may have a premium (Colorado’s Medicaid Program) & Child
assistance program that can help pay for Health Plan Plus (CHP+) Phone: 1-800-792-4884 Website: http://dphhs.mt.gov/
coverage, using funds from their Health First Colorado Website: https:// MontanaHealthcarePrograms/HIPP
Medicaid or CHIP programs. If you or www.healthfirstcolorado.com/
your children aren’t eligible for Medicaid Phone: 1-800-694-3084
or CHIP, you won’t be eligible for these Health First Colorado Member Contact KENTUCKY – Medicaid
premium assistance programs but you Center: Email: HHSHIPPProgram@mt.gov
may be able to buy individual insurance Kentucky Integrated Health Insurance
coverage through the Health Insurance 1-800-221-3943/ State Relay 711 Premium Payment Program (KI-HIPP)
Marketplace. For more information, visit Website: https://chfs.ky.gov/agencies/
www.healthcare.gov. CHP+: https://www.colorado.gov/ dms/member/Pages/kihipp.aspx NEBRASKA – Medicaid
pacific/hcpf/child-health-plan-plus
Phone: 1-855-459-6328 Website: http://
CHP+ Customer Service: 1-800-359- www.ACCESSNebraska.ne.gov
If you or your dependents are already 1991/ State Relay 711 Email: KIHIPP.PROGRAM@ky.gov
enrolled in Medicaid or CHIP and you live Phone: 1-855-632-7633
in a State listed below, contact your Health Insurance Buy-In Program (HIBI): KCHIP Website: https://
State Medicaid or CHIP office to find out https://www.colorado.gov/pacific/hcpf/ kidshealth.ky.gov/Pages/index.aspx Lincoln: 402-473-7000
if premium assistance is available. health-insurance-buy-program
Phone: 1-877-524-4718 Omaha: 402-595-1178
HIBI Customer Service: 1-855-692-6442
Kentucky Medicaid Website: https://
If you or your dependents are NOT chfs.ky.gov
currently enrolled in Medicaid or CHIP, NEVADA – Medicaid
and you think you or any of your FLORIDA – Medicaid
dependents might be eligible for either Medicaid Website: http://dhcfp.nv.gov
of these programs, contact your State Website: https:// LOUISIANA – Medicaid
Medicaid or CHIP office or dial 1-877- www.flmedicaidtplrecovery.com/ Medicaid Phone: 1-800-992-0900
KIDS NOW or www.insurekidsnow.gov flmedicaidtplrecovery.com/hipp/ Website: www.medicaid.la.gov or
to find out how to apply. If you qualify, index.html www.ldh.la.gov/lahipp
ask your state if it has a program that Phone: 1-888-342-6207 (Medicaid
might help you pay the premiums for an Phone: 1-877-357-3268 NEW HAMPSHIRE – Medicaid
employer-sponsored plan. hotline) or 1-855-618-5488 (LaHIPP)
Website: https://www.dhhs.nh.gov/
If you or your dependents are eligible for programs-services/medicaid/health-
premium assistance under Medicaid or GEORGIA – Medicaid
CHIP, as well as eligible under your MAINE – Medicaid insurance-premium-program
employer plan, your employer must GA HIPP Website: https://
allow you to enroll in your employer plan medicaid.georgia.gov/health-insurance- Enrollment Website: https://
premium-payment-program-hipp www.maine.gov/dhhs/ofi/applications- Phone: 603-271-5218
if you aren’t already enrolled. This is forms
called a “special enrollment” Phone: 678-564-1162, Press 1
opportunity, and you must request Toll free number for the HIPP program: 1-
coverage within 60 days of being Phone: 1-800-442-6003 800-852-3345, ext 5218
determined eligible for premium GA CHIPRA Website: https://
assistance. If you have questions about medicaid.georgia.gov/programs/third- TTY: Maine relay 711
enrolling in your employer plan, contact party-liability/childrens-health-insurance
the Department of Labor at -program-reauthorization-act-2009-
www.askebsa.dol.gov or call 1-866-444- chipra NEW JERSEY – Medicaid and CHIP
Private Health Insurance Premium
EBSA (3272). Phone: (678) 564-1162, Press 2 Webpage:
Medicaid Website: http://
https://www.maine.gov/dhhs/ofi/ www.state.nj.us/humanservices/
If you live in one of the following states, applications-forms
you may be eligible for assistance paying INDIANA – Medicaid dmahs/clients/medicaid/
your employer health plan premiums. Phone: -800-977-6740.
The following list of states is current as Healthy Indiana Plan for low-income
adults 19-64 TTY: Maine relay 711 Medicaid Phone: 609-631-2392
of July 31, 2022. Contact your State for
more information on eligibility – Website: http://www.in.gov/fssa/hip/ CHIP Website: http://
ALABAMA – Medicaid Phone: 1-877-438-4479 MASSACHUSETTS – Medicaid and CHIP www.njfamilycare.org/index.html
Website: http://myalhipp.com/
Phone: 1-855-692-5447 All other Medicaid Website: https://www.mass.gov/ CHIP Phone: 1-800-701-0710
masshealth/pa
Website: https://www.in.gov/medicaid/
Phone: 1-800-862-4840
ALASKA – Medicaid Phone 1-800-457-4584
The AK Health Insurance Premium TTY: (617) 886-8102
Payment Program
Website: http://myakhipp.com/
Phone: 1-866-251-4861 IOWA – Medicaid and CHIP (Hawki)
Email: MINNESOTA – Medicaid
CustomerService@MyAKHIPP.com Medicaid Website:
Medicaid Eligibility: https:// Website: https://mn.gov/dhs/people-we-
health.alaska.gov/dpa/Pages/ https://dhs.iowa.gov/ime/members serve/children-and-families/health-care/
default.aspx health-care-programs/programs-and-
Medicaid Phone: 1-800-338-8366 services/other-insurance.jsp
ARKANSAS – Medicaid
Hawki Website: http://dhs.iowa.gov/ Phone: 1-800-657-3739
Website: http://myarhipp.com/ Hawki
Phone: 1-855-MyARHIPP (855-692-7447)
Hawki Phone: 1-800-257-8563
CALIFORNIA – Medicaid MISSOURI – Medicaid
HIPP Website: https://dhs.iowa.gov/ime/
Website: Health Insurance Premium members/medicaid-a-to-z/hipp Website: http://www.dss.mo.gov/mhd/
Payment (HIPP) Program http:// participants/pages/hipp.htm
dhcs.ca.gov/hipp HIPP Phone: 1-888-346-9562
Phone: 916-445-8322 Phone: 573-751-2005
Fax: 916-440-5676
19
QUESTIONS? Call BenefitsVIP at 866.284.2053Disclosures
NEW YORK – Medicaid Phone: 1-888-828-0059 Website: https://health.wyo.gov/ Administration, Office of Policy and
healthcarefin/medicaid/programs-and- Research, Attention: PRA Clearance
Website: https://www.health.ny.gov/ eligibility/ Officer, 200 Constitution Avenue, N.W.,
health_care/medicaid/ Room N-5718, Washington, DC 20210 or
TEXAS – Medicaid Phone: 1-800-251-1269
Phone: 1-800-541-2831 email ebsa.opr@dol.gov and reference
Website: http://gethipptexas.com/ the OMB Control Number 1210-0137.
Phone: 1-800-440-0493 To see if any other states have added a
NORTH CAROLINA – Medicaid premium assistance program since July OMB Control Number 1210-0137 (expires
Website: https://medicaid.ncdhhs.gov/ 31, 2022, or for more information on 1/31/2023)
UTAH – Medicaid and CHIP special enrollment rights, contact either:
Phone: 919-855-4100
Medicaid Website: https://
medicaid.utah.gov/
U.S. Department of Labor
NORTH DAKOTA – Medicaid CHIP Website: http://health.utah.gov/ Employee Benefits Security
chip Administration
Website: http://www.nd.gov/dhs/ www.dol.gov/agencies/ebsa
services/medicalserv/medicaid/ Phone: 1-877-543-7669 1-866-444-EBSA (3272)
Phone: 1-844-854-4825
VERMONT– Medicaid U.S. Department of Health and Human
Services
OKLAHOMA – Medicaid and CHIP Website: http://
Centers for Medicare & Medicaid
www.greenmountaincare.org/
Website: http:// Services
www.insureoklahoma.org Phone: 1-800-250-8427 www.cms.hhs.gov
1-877-267-2323, Menu Option 4, Ext.
Phone: 1-888-365-3742 61565
VIRGINIA – Medicaid and CHIP
OREGON – Medicaid Website: https://www.coverva.org/en/ PAPERWORK REDUCTION ACT
famis-select STATEMENT
Website: http://healthcare.oregon.gov/
Pages/index.aspx https://www.coverva.org/en/hipp According to the Paperwork Reduction
Act of 1995 (Pub. L. 104-13) (PRA), no
http://www.oregonhealthcare.gov/index Medicaid Phone: 1-800-432-5924 persons are required to respond to a
-es.html
CHIP Phone: 1-800-432-5924 collection of information unless such
Phone: 1-800-699-9075 collection displays a valid Office of
Management and Budget (OMB) control
number. The Department notes that a
WASHINGTON – Medicaid Federal agency cannot conduct or
PENNSYLVANIA – Medicaid sponsor a collection of information
Website: https://www.hca.wa.gov/
Website: https://www.dhs.pa.gov/ unless it is approved by OMB under the
Services/Assistance/Pages/HIPP- Phone: 1-800-562-3022 PRA, and displays a currently valid OMB
Program.aspx control number, and the public is not
required to respond to a collection of
Phone: 1-800-692-7462 WEST VIRGINIA – Medicaid and CHIP information unless it displays a currently
valid OMB control number. See 44 U.S.C.
Website: https://dhhr.wv.gov/bms/ 3507. Also, notwithstanding any other
RHODE ISLAND – Medicaid and CHIP provisions of law, no person shall be
http://mywvhipp.com/ subject to penalty for failing to comply
Website: http://www.eohhs.ri.gov/ with a collection of information if the
Medicaid Phone: 304-558-1700
collection of information does not
Phone: 1-855-697-4347, or 401-462-0311 CHIP Toll-free phone: 1-855-MyWVHIPP display a currently valid OMB control
(Direct RIte Share Line) (1-855-699-8447) number. See 44 U.S.C. 3512.
SOUTH CAROLINA – Medicaid WISCONSIN – Medicaid and CHIP The public reporting burden for this
Website: https://www.scdhhs.gov collection of information is estimated to
Website: https:// average approximately seven minutes
Phone: 1-888-549-0820 www.dhs.wisconsin.gov/ per respondent. Interested parties are
badgercareplus/p-10095.htm encouraged to send comments regarding
the burden estimate or any other aspect
Phone: 1-800-362-3002 of this collection of information,
SOUTH DAKOTA - Medicaid including suggestions for reducing this
Website: http://dss.sd.gov burden, to the U.S. Department of Labor,
WYOMING – Medicaid Employee Benefits Security
20
QUESTIONS? Call BenefitsVIP at 866.284.2053This benefit summary provides selected highlights of the employee benefits program available. It is not a legal document and shall not be construed as a guarantee of benefits nor of continued employment. All benefit plans are governed by master policies, contracts and plan documents. Any discrepancies between any information provided through this summary and the actual terms of such policies, contracts and plan documents shall be governed by the terms of such policies, contracts and plan documents. Our company reserves the right to amend, suspend or terminate any benefit plan, in whole or in part, at any time. The authority to make such changes rests with the Plan Administrator.
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