20 20 Your Benefits Overview - Easterseals

 
20 20 Your Benefits Overview - Easterseals
January 1, 2020 -December 31, 2020

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Your Benefits Overview
20 20 Your Benefits Overview - Easterseals
General Information

                                                                          What is a “Copayment”?

                                                                              •    A copayment is a pre-determined amount you must pay out-of-
                                                                                   pocket when seeing a service provider. It is paid directly to the
                                                                                   provider and is due at the time services are rendered.

                                                                          What is a “Deductible”?

                                                                              •    A deductible is a pre-determined amount that is paid by you
                                                                                   before the insurer begins to pay.

                                                                          What is “Coinsurance”?

                                                                              •    Coinsurance is the percentage paid by the insurer and the
                                                                                   percentage paid by you after you have met the deductible.

                                                                          What is “Precertification”?

                                                                              •    Certain services, such as hospitalization or outpatient surgery,
                                                                                   may require prior authorization with your insurer to verify
                                                                                   coverage for those services. When required, your participating
                  TABLE OF CONTENTS                                                physician must obtain a precertification for you prior to your
                    Qualifying Life Events                    3                    treatment.

                    Helpful Tools                            4-6          Where can I find an in-network provider?

                    Medical Coverage                         7-9              •    Directories of participating service providers may be found on
                                                                                   your insurer’s website. If you do not have internet access, you
                    Cost Savings Tools                        10
                                                                                   may call member services to find an in-network provider near
                    FSA                                       11                   you.

                    Dental Coverage                           12          Should I use a Convenient Care Center, an Urgent Care Center, or the
                                                                          Emergency Room?
                    Vision Coverage                           13
                                                                              •    Convenient Care Centers (found in many CVS and Walgreens
                    Disability Coverage                       14                   stores) are a great way to address the common cough, cold, and
                    Life Coverage                           15-16                  sore throat. The cost is normally the same co-payment as seeing
                                                                                   your doctor. Urgent Care Centers are another great alternative
                    MetLaw                                  17-18                  to the Emergency Room when your doctor’s office is closed.
                    Aflac                                     19                   The co-payments are normally a lot less than an Emergency
                                                                                   Room visit.
                    Important Notices                       20-23

This Benefits-At-A-Glance booklet is designed to provide basic informa on to employees on benefit plans and programs available January 01, 2020 – December 31,
2020. It does not detail all of the provisions, restric ons and exclusions of the various benefit programs documented in the carrier contract or the Summary Plan
Descrip on (SPD). This booklet does not cons tute an SPD or Plan Document as defined by the Employee Re rement Income Security Act (ERISA).               2
20 20 Your Benefits Overview - Easterseals
Qualifying Life Events
 If you experience any of the below qualifying life events, you must contact Human Resources within 30 days of the
 event to be able to make changes to your benefits. Proof of the event is required in order to successfully make the
 requested changes to your plans.

   •     Marriage                                                                 •     Divorce or legal separation (subject to State
                                                                                        regulations)

   •     Death of spouse, child or other qualified                                •     Birth or adoption of child
         dependent

   •     Loss of other group coverage                                             •     Change in employment status for employee,
                                                                                        spouse or dependent

   •     Change in residence due to an employment                                 •     Change of dependent status
         transfer

Lower your out-of-pocket
When you see a provider who participates in the FHCP HMO Network(s) or Florida Blue Bluecare/Blue
Options networks, your expenses for covered services will be lower. Under your PPO plans, when you use out-
of-network providers, your out-of-pocket costs for covered services may be higher and you could be balance
billed for any charges that are over the Florida Blue eligible charges.
Directories of participating network providers may be found on your insurer’s website. If you do not have
internet access, you may call the member services telephone number (located at the top of each benefit overview
page) to find an in-network provider near you.

This Benefits-At-A-Glance booklet is designed to provide basic informa on to employees on benefit plans and programs available January 01, 2020 – December 31,
2020. It does not detail all of the provisions, restric ons and exclusions of the various benefit programs documented in the carrier contract or the Summary Plan
Descrip on (SPD). This booklet does not cons tute an SPD or Plan Document as defined by the Employee Re rement Income Security Act (ERISA).               3
20 20 Your Benefits Overview - Easterseals
HELPFUL
                                   H e l p f u l TOOLS
                                                  To o l s-F H C P

By being a Florida Health Care Plans member, you automatically receive services that are free for you and your covered dependents to
use. Below are some of these services. For more information, log on to your member portal at www.fhcp.com.
           Find a Provider/Facility
           Health Care Reform Information
           Member Portal Login
           Member Wellness Programs
           Glossary of Health Coverage and Medical Terms
           Summary of Benefits Coverage
           Case Management
           Utilization Management
 Florida Health Care Member Portal available 24 hours a day, 7 days a week, 365 days a year. The Member
Portal has three main sections, Health Portal, Documents Portal and Member Resources. See below for a de-
scription of each portal.
The Health Portal: Here you will find the “Welcome to Wellness” Health Risk assessment and Health Management Tool. After you
register, you have the opportunity to complete a personalized health risk assessment that will provide insight on different areas of im-
provement concerning members health. This also allows access to a database of thousands of articles, programs and news related to
health and health conditions.
If you utilize a FHCP staff physician, you can access the Patient Portal which will allow you to communicate directly with your FHCP staff
physician, make an appointment or request prescription refills.
The Documents Portal: Here you will be obtain view and print your Certificate of Coverage (Member Handbook) which describes your
rights and obligations along with FHCP rights and obligations with respect to the coverage and benefits provided. You will also be able to
view and print your benefit summary and any applicable benefit riders.
Member Resources: Provides access to common FHCP programs, contacts, resources and forms.
Member Wellness Programs As a FHCP member, you have access information on:
        Smoking Cessation                                                             Acute Low Back and Neck Pain

        Weight Management                                                             Nutrition Program

        Diabetes                                                                      Exercise

     Matter of Balance - a program designed to manage falls and increase activity levels and balance.
Doctor on Demand See a board certified doctor or licensed psychologist or psychiatrist through live, face-to-face video visits from any-
where. Physicians can diagnose, treat and write prescriptions for most non-emergency medical conditions.* Copays apply.
Nurse Advice Line FHCP has partnered with Carenet Healthcare Services to provide members with access to highly skilled, registered
nurses 24 hours a day, 7 days a week, 365 days a year to assist with their health concerns. If you need help understanding a condition or
symptom, want to ask a Registered Nurse a confidential health question or wondering where to go for care, the Nurse Advice Line is
available to you at no cost. It also has a 24 hour Audio Health Library that contains over 1, 500 English and Spanish topics as well as
current community health concerns and announcements. Contact the Nurse Advice Line at 866-548-0727.

  This Benefits-At-A-Glance booklet is designed to provide basic informa on to employees on benefit plans and programs available January 01, 2020 – December 31,
  2020. It does not detail all of the provisions, restric ons and exclusions of the various benefit programs documented in the carrier contract or the Summary Plan
  Descrip on (SPD). This booklet does not cons tute an SPD or Plan Document as defined by the Employee Re rement Income Security Act (ERISA).               4
20 20 Your Benefits Overview - Easterseals
HELPFUL
                                 H e l p f u l TOOLS
                                               To o l s

You also have access to Florida Health Care Healthy Living Preferred Fitness Program. The facilities on the authorized list are
authorized to perform a Fitness Evaluation for a small fee. The evaluation consists of Health & weight measurements, blood pressure/
pulse rate, body fat percentage, flexibility and range of motion measures, balance and V02 Max– a measure of Oxygen consumption
during aerobic exercise. To find the most current gym list please visit https://www.fhcp.com/documents/FHCP-Gym-List.pdf

                                                             ORMOND BEACH/ HOLLY HILL
                                                                            Ormond Beach YMCA                    Perfect Storm Hardcore         Sky Active Strength
    Anytime Fitness           Bodez Fitness Express           Gold’s Gym
                                                                               (386) 673-9622                         Training Gym                    Studio
    (386) 677-8600               (386) 672-6464              (386) 677-4949
                                                                                Pool Available                       (386) 681-8361               (386) 947-7642
                                                                                                                    Holly Hill YMCA             Ability Health Ser-
      Planet Fitness               Pro Bodies                Revive Fitness            The Body Exchange
                                                                                                                     (386) 253-5675               vices & Rehab
     (386) 677-4000              (386) 676-2377              (386) 676-0009              (386) 679-7446
                                                                                                                      Pool Available              (386) 898-0443
                              DAYTONA BEACH/SOUTH DAYTONA                                                                        PORT ORANGE
                              Elite Muay Thai and
Ability Health Services **                              Club Fitness of Daytona        Curves For Women               4 Ever Fitness             Anytime Fitness
                                     Fitness
      (386) 763-0084                                        (386) 763-9250               (386) 760-2855               (386) 788-5678             (386) 243-5640
                                 (386) 589-1373
    Halifax Health                                                                Green Acres/Iron
                               Planet Fitness                Greater Fitness
   Wellness Center **                                                                   Mike’s
                              (386) 253-4300                 (386) 310-7857                                                 Port Orange Family YMCA
    (386) 254-4031                                                                  (386) 258-9502
                                                                                                                               (386) 760-9622 Pool
             Total Nutrition Gym                             Workout Anytime Daytona Beach Shores
                (386) 238-0244                                         (386) 281-3231
   ST. AUGUSTINE/ST. JOHNS COUNTY                                                      EDGEWATER/ NEW SMYRNA BEACH
    Anytime Fitness           St. Augustine YMCA          Blue Water Therapy         Edgewater Fitness Club Heartland Rehabilitation           Nautilus By The Sea
    (904) 297-2300             (904) 471-9622 Pool        (386) 426-7885 Pool            (386) 847-3269         (386) 427-4866                   (386) 426-0079
Solomon Calhoun Com-          Ponte Vedra YMCA
  munity Center Pool            (904) 543-9622                                                                                                  Southeast Volusia
  (904) 824-6770, Pool           Pool Available             Vision Fitness 24           NSB Athletic Club              Snap Fitness
                                                                                                                                                  Family YMCA
                                                             (386) 506-9415              (386) 423-4267               (386) 423-8995
                   Planet Fitness                                                                                                              (386) 409-9622 Pool
                  (386) 283-4973

                                                          DELAND/ DELTONA/ ORANGE CITY
Ability Health Services **   Brooks Rehabilitation      Crunch Fitness Deltona       DeLand Family YMCA                      Florida Fitness World
      (386) 851-0901            (386) 775-7488              (386) 259-5551            (386) 736-6000 Pool                        (386) 775-1313
  Four Townes Family                                                                                                    Latow’s
                               Next Level Fitness        Planet Fitness Deland
         YMCA                                                                                                     Fitness & Nutrition
                                (386) 734-9900              (386) 873-4911
   (386) 532-9622 Pool                                                                                              (386) 228-2444
                                                                   PALM COAST/BUNNELL
                               Belle Terre Swim &       East Coast Gym of Flag-         Fitness One, Inc.         Frieda Zamba Aquatics
    Anytime Fitness                                                                                                                             Just Train Fitness
                                  Racquet Club                     ler                   (386) 439-7707               (386) 986-4741
    (386) 445-4945                                                                                                                                (386) 264-6706
                               (386) 446-6717 Pool           (386) 866-1152               Pool Available               Pool Available
                               Palm Coast Sports          Thriv Fitness Center,                  Silver Synergy With Artie G
    MPower Fitness                                                                                                                               Studio Z Fitness
                                    Med **                        LLC                            St. Thomas Episcopal Church
    (386) 445-2508                                                                                                                                (386) 446-4333
                                (386) 445-5555              (386) 446-7462                             (386) 931-3485

     Please check with the facility for the ages accepted. Facili es with ** by their name require a Fitness Evalua on before use.

 This Benefits-At-A-Glance booklet is designed to provide basic informa on to employees on benefit plans and programs available January 01, 2020 – December 31,
 2020. It does not detail all of the provisions, restric ons and exclusions of the various benefit programs documented in the carrier contract or the Summary Plan
 Descrip on (SPD). This booklet does not cons tute an SPD or Plan Document as defined by the Employee Re rement Income Security Act (ERISA).               5
20 20 Your Benefits Overview - Easterseals
H eHELPFUL
                               l p f u l ToTOOLS
                                            o l s-F L BLU E

MyBlueService™: MyBlueService™ is a personalized web portal designed to help provide answers to some of your most common health
needs. Your unique and confidential user identification code and password gives you access to your personal benefit information 24 hours
a day, 7 days a week. With MyBlueService™ you can:
 Check the status of any claims
 Get details on your plan’s benefits
 Order a replacement identification card
 Request a benefits booklet
 Access claim forms and other frequently requested forms
 Search for a participating hospital or provider
 Access a map with detailed directions to participating providers and hospitals

Blue365™:
Florida Blue offers its members a program of products and services called Blue365™ to help offset the rising costs associated with
healthcare by offering discounts on a variety of products and services. Some of these programs and discounts include:
 Enhanced vision care discount program
 Weight management programs
 Family health & wellness facilities
 Fitness centers
 Contact lens mail order service
 Hearing aid discount programs
 Alternative Medicines, and much more….

For more information on Blue365™, visit www.blue365deals.com

Healthy Resources
As a Florida Blue member, health-related information and support is available to you at no cost, 24 hours a day, 7 days a week. Infor-
mation and support is provided through:
 Health Coaches — You can speak privately with experienced, licensed, health care professionals, including RN’s, dieticians, and respirato-
    ry therapists 24 hours a day, 7 days a week.
 Web-based information tools where you can search over 27,000 pages of up-to-date, easy to understand information on more than 1,900
    clinical topics including medical tests and medications.
 Audio tapes — Via the telephone, you may listen to audiotapes on more than 300 health care topics.

Florida Blue Mobile
A mobile website designed for everyone, that works on any Smartphone—just type in bcbsfl.com from your mobile browser. On Florida
Blue Mobile you can access health information, get a snapshot of your benefits and accumulators such as deductible and out of pocket
maximum. You can also access and see an image of your ID card. You can find a doctor, hospital or specialist in the provider directory
customized to your plan. Get details and map it using your GPS location.

 This Benefits-At-A-Glance booklet is designed to provide basic informa on to employees on benefit plans and programs available January 01, 2020 – December 31,
 2020. It does not detail all of the provisions, restric ons and exclusions of the various benefit programs documented in the carrier contract or the Summary Plan
 Descrip on (SPD). This booklet does not cons tute an SPD or Plan Document as defined by the Employee Re rement Income Security Act (ERISA).               6
20 20 Your Benefits Overview - Easterseals
M e d i c a l I n s u r a n c e C ove r a ge O p t i o n s

       Provided by FHCP                                                  1 (800) 352 - 2583
                                                                            www.fhcp.com                                             1 (877) 615 - 4022

               Plan Name                                FHCP HMO T 70                            FHCP HMO T 72                          FHCP HMO T 60

           Name of Network                                      HMO                                      HMO                                    HMO

  Calendar Year Deductible
  Individual                                                    $1,500                                  $2,500                                   $500
  Family                                                        $4,500                                  $7,500                                  $1,500
  Annual Out-of-Pocket Maximum                 (Includes deductible, copays, coinsurance)
  Individual                                                    $4,500                                   $6,500                                 $3,000
  Family                                                        $9,000                                  $13,000                                 $6,000

  Coinsurance (Coins)                          (Amount paid after deductible is met)
You pay…..                                                       20%                                      20%                                    10%
  Physician Services
Office Visit                                              $30 Copay                                $35 Copay                               $20 Copay
Specialist                                                $55 Copay                                $65 Copay                               $35 Copay
Chiropractic Care                                         $30 Copay                         Deductible + Coinsurance                Deductible + Coinsurance
Telemedicine (medical)                            $10(Primary) /$30(Specialist)            $10(Primary) /$30(Specialist)           $10(Primary) /$30(Specialist)

Adult and Child Wellness Exams                             100% Covered                             100% Covered                           100% Covered
Hospital Services
Inpatient Hospital Per Admission                    Deductible + Coinsurance                 Deductible + Coinsurance               Deductible + Coinsurance
Emergency Room                                            $250 Copay                               $350 Copay                             $100 Copay
Urgent Care                                                $60 Copay                                $85 Copay                              $50 Copay

Prescription Drugs

Retail (30 day supply):                                                                      FHCP/Walgreens
  Preferred Generic                                                                         $3 Copay/$15 Copay
  Non Preferred Generic                                                                    $10 Copay/$15 Copay
  Preferred Brand                                                                           $30 Copay/35 Copay
  Non-preferred Brand                                                                      $55 Copay/$60 Copay
  Preferred Specialty                                                                   15% Coinsurance/Not Covered
  Non Preferred Specialty                                                               25% Coinsurance/Not Covered
  Mail Order (90 day supply)-no specialty                                                    $6/$27/$87/$162
Non-Network

Calendar Year Deductible Ind/(Fam.)                              N/A                                      N/A                                    N/A
Out of Pocket Max Ind/( Family)                                  N/A                                      N/A                                    N/A
Coinsurance                                                      N/A                                      N/A                                    N/A

  This Benefits-At-A-Glance booklet is designed to provide basic informa on to employees on benefit plans and programs available January 01, 2020 – December 31,
  2020. It does not detail all of the provisions, restric ons and exclusions of the various benefit programs documented in the carrier contract or the Summary Plan
  Descrip on (SPD). This booklet does not cons tute an SPD or Plan Document as defined by the Employee Re rement Income Security Act (ERISA).               7
20 20 Your Benefits Overview - Easterseals
M e d i c a l I n s u r a n c e C ove r a ge O p t i o n s

       Provided by Florida Blue                                         1 (800) 352 - 2583
                                                                        www.floridablue.com                                         1 (800) 352 - 2583

                                                BlueOptions 05904 PPO                        BlueCare 68 HMO                         BlueCare 46 HMO
               Plan Name                                                                 Lake County Residents                   Lake County Residents
                                                                                                 Only                                    Only
         Name of Network                                 BlueOptions                           BlueCare (HMO)                          BlueCare (HMO)

  Calendar Year Deductible

  Individual                                                  $2,500                                   $1,000                                  $2,000
  Family                                                      $7,500                                   $3,000                                  $6,000

  Annual Out-of-Pocket Maximum                (Includes deductible, copays, coinsurance)
  Individual                                                  $6,000                                   $4,500                                  $5,000
  Family                                                     $12,000                                   $9,000                                 $10,000

  Coinsurance (Coins)                          (Amount paid after deductible is met)
You pay…..                                                     20%                                      20%                                     10%
  Physician Services
Office Visit                                                $35 Copay                               $35 Copay                               $35 Copay
Specialist                                                  $65 Copay                               $60 Copay                               $65 Copay
Chiropractic Care                                           $65 Copay                               $60 Copay                               $65 Copay
Telemedicine                                                $10 Copay                               $10 Copay                               $10 Copay

Adult and Child Wellness Exams                           100% Covered                             100% Covered                            100% Covered
Hospital Services
Inpatient Hospital Per Admission                  Deductible + Coinsurance                   $500/day up to $1,500                 Deductible+ Coinsurance
Emergency Room                                    Deductible+ Coinsurance                        $500 Copay                             $300 Copay
Urgent Care                                              $70 Copay                                $65 Copay                              $70 Copay
Prescription Drugs

Retail (30 day supply):
  Generic                                                   $10 Copay                               $10 Copay                               $10 Copay
  Preferred Brand                                           $50 Copay                               $50 Copay                               $50 Copay
  Non-preferred Brand                                       $80 Copay                               $80 Copay                               $80 Copay
Mail Order (90 day supply):                                2.5x’s Copay                            2.5x’s Copay                            2.5x’s Copay
Non-Network
Calendar Year Deductible Ind/(Fam.)                 $5,000 ($15,000 Family)                             N/A                                     N/A
Out of Pocket Max Ind/( Family)                     $8,000 ($20,000 Family)                             N/A                                     N/A
Coinsurance                                                  40%                                        N/A                                     N/A

 This Benefits-At-A-Glance booklet is designed to provide basic informa on to employees on benefit plans and programs available January 01, 2020 – December 31,
 2020. It does not detail all of the provisions, restric ons and exclusions of the various benefit programs documented in the carrier contract or the Summary Plan
 Descrip on (SPD). This booklet does not cons tute an SPD or Plan Document as defined by the Employee Re rement Income Security Act (ERISA).               8
20 20 Your Benefits Overview - Easterseals
C o s t S av i n gs To o l s

Prescription Drug cost comparison:
Use GoodRx's drug price search to compare prices (just like you do for travel or
electronics on other sites) for your prescription at pharmacies near you. GoodRx
does not sell the medications, the free website and mobile app tells you where you
can get the best deal on them. If you have insurance, your co-pay might not be the
best price. Hundreds of generic medications are available for $4 or even free without
insurance. Every week GoodRx collects millions of prices and discounts from
pharmacies, drug manufacturers and other sources. GoodRx will show you prices, coupons, discounts and savings tips for your
prescription at pharmacies near you. Please visit the website at www.goodrx.com or download the app on your smartphone.

Please note: amounts paid for prescriptions using GoodRx’s discount card do not apply toward your medical plan’s deductible or
annual out of pocket maximum.

Pharmacy Discount Programs:
Before you pay for your next prescription, check to see if they are available for free or at a lower cost than traditional copays.
Pharmacies such as Wal-Mart, CVS/Target, and Costco offer prescription discount programs that allow you to purchase medications
for as low as $4 for a 30 day Supply. Publix pharmacies also provide a list of free maintenance medications as well as antibiotics that
they offer for free (with a prescription from your physician). If your local pharmacy is not listed please check with them to see if they
offer any discounts.

 Urgent Care/Walk-In-Clinics Vs. Emergency:
 Do not pay more than you have to for medical care. The Emergency room is meant for true
 emergencies such as life threating illnesses and injuries. Walk-in-clinics are designed to treat
 common ailments and provide basic primary health care and are typically staffed by nurse
 practitioners and sometimes a physician’s assistant. They are used for common ailments such as:
 flu/strep throat, allergies, cold and cough. Urgent care facilities are designed to serve patients who
 are suffering from acute illnesses and injuries which are beyond the capacities of a regular walk-in-
 clinic, are typically open for extended hours, and are used to treat non-life threating injuries and
 illnesses. To maximize savings use in-network facilities.

 Above are potential ways to save money on the cost of medical care and prescriptions. Actual results may vary.

This Benefits-At-A-Glance booklet is designed to provide basic informa on to employees on benefit plans and programs available January 01, 2020 – December 31,
2020. It does not detail all of the provisions, restric ons and exclusions of the various benefit programs documented in the carrier contract or the Summary Plan
Descrip on (SPD). This booklet does not cons tute an SPD or Plan Document as defined by the Employee Re rement Income Security Act (ERISA).               10
20 20 Your Benefits Overview - Easterseals
F l e x i bl e S p e n d i n g A c c o u n t

      Provided by Medcom                                               www.medcombenefits.com                                         1 (800) 523 - 7542

WHAT IS A FLEXIBLE SPENDING ACCOUNT: An FSA is a pre-tax benefit account that is used to pay for
eligible medical, dental, and vision care expenses that are not covered by your health care plan. With an FSA you
use pre-tax dollars to pay for qualified out-of-pocket health care expenses.
WHAT ARE THE BENEFITS OF A FLEXIBLE SPENDING ACCOUNT (FSA):
There are a variety of different benefits of using a Flexible Spending Account (FSA), including the following:
      •     It saves you money. Allows you to put aside money tax-free that can be used for qualified medical ex-
            penses.
      •     It’s a tax saver. Since your taxable income is decreased by your contributions, you’ll pay less in taxes
      •     You can use it for a variety of expenses. Use your FSA for qualified medical, dental, or vision expenses.
            (Remember to keep your receipts for audit purposes).
You cannot stockpile your money in your FSA. If you do not use it, you lose. You should only contribute the
amount of money you expect to pay out of pocket that year. The maximum you can contribute each year is
$2,750.
WHAT IS A DEPENDENT CARE FSA: Dependent care FSAs allow you to contribute pre-tax dollars to pay
for qualified dependent care. The maximum amount you may contribute each year is $5,000 (or $2,500 if mar-
ried and filing separately). The dependent care FSA is also use it or lose it.
FSA CASE STUDY: Because FSAs provide you with an important tax advantage that can help you pay for
health care expenses on a pre-tax basis, due to the personal tax savings you incur, your spendable income will
increase. The example that follows illustrates how an FSA can save you money.

                                                                        Without FSA                                              With FSA
 Gross income                                                               $45,000                                               $45,000
 FSA contributions                                                             $0                                                 (-$2,700)
 Gross income                                                               $45,000                                               $42,300
 Estimated taxes                                                           (-$5,532)*                                            (-$4,999)*
 After-tax earnings                                                         $39,468                                               $37,301
 Eligible out-of-pocket expenses                                           (-$3,000)                                               (-$300)
 Remaining spendable income                                                 $36,468                                               $37,001
 Spendable income increase                                                      --                                                  $533
*Assumes standard deductions, amounts can vary and are for illustrative purposes only.
Please note, the above example is for illustrative purposes only. Each situation varies and it is recommended you consult a tax advisor for all tax
advice

This Benefits-At-A-Glance booklet is designed to provide basic informa on to employees on benefit plans and programs available January 01, 2020 – December 31,
2020. It does not detail all of the provisions, restric ons and exclusions of the various benefit programs documented in the carrier contract or the Summary Plan
Descrip on (SPD). This booklet does not cons tute an SPD or Plan Document as defined by the Employee Re rement Income Security Act (ERISA).               11
D i s a b i l i t y C ove r a ge

            Provided by Lincoln                                                  www.lfg.com                                           1 (800) 487-1485

You count on your income to provide the things you need today and to achieve the dreams you have for tomorrow. But, what
would happen if you were suddenly unable to earn a living because of an unexpected accident or illness?

                                               Short-Term Disability
                                               If you become disabled because of a non-occupational illness or injury and
                                               cannot work, you can be covered by the short-term disability insurance policy.
                                               Benefits can begin on the 15th day following an accident and the 15th day of a
                                               sickness. The short-term disability plan replaces up to 60% of your basic weekly
                                               earnings, with a maximum weekly benefit of $900. You can receive short-term
                                               disability benefits for up to 11 weeks.
                                               The cost of this coverage is paid entirely by your employer.

                                                                                                                Long-Term Disability
   If you become unable to perform your regular job duties for an extended period of time due to sickness, or
   accidental injury, you can be covered by the long-term disability (LTD) policy.
   Your income replacement benefit would equal 60% of your basic monthly earnings. The maximum monthly
   benefit you can receive is $5,000. Benefits begin after you have been unable to work for 90 days due to a
   covered sickness or accident and will continue to be paid for up to one year if you are disabled in your own
   occupation. If you are disabled in any occupation, benefits will be paid until Social Security Normal Retirement
   Age.
   Your LTD benefit will be reduced by any disability income you receive for other sources, such as Social Security,
   worker’s compensation, and/or state disability plans, to provide you with a combined monthly benefit equal to
   60% of your basic monthly earnings.
   The LTD plan contains a pre-existing condition exclusion. The exclusion applies only to conditions for which
   medical advice, diagnosis, care or treatment was recommended or received or for which a reasonably prudent
   person would have sought care within the 3 month period prior to the effective date of coverage and the
   disability begins within 12 months of the effective date of coverage.
   The cost of this coverage is paid entirely by your employer.
  This Benefits-At-A-Glance booklet is designed to provide basic informa on to employees on benefit plans and programs available January 01, 2020 – December 31,
  2020. It does not detail all of the provisions, restric ons and exclusions of the various benefit programs documented in the carrier contract or the Summary Plan
  Descrip on (SPD). This booklet does not cons tute an SPD or Plan Document as defined by the Employee Re rement Income Security Act (ERISA).               14
L i f e C ove r a ge
        Provided by Lincoln                                                 www.lfg.com                                              1 (800) 487-1485

          Life insurance protects your family or other beneficiaries in the
          event of your death. The death benefit helps replace the
          income you would have provided and can help meet important
          financial needs. It can help pay your mortgage, rent, run your
          household, send your children to college, pay off debts, etc.
          Easterseals Northeast Central Florida, Inc. provides you with
          basic term life insurance and accidental death and
          dismemberment, based on your employment class, covered
          through Lincoln. The cost of this coverage is paid entirely by
          your employer.
          Easterseals Northeast Central Florida, Inc. also offers eligible
          employees the opportunity to purchase voluntary life insurance
          and accidental death and dismemberment with Lincoln at a
          group rate.

          Summary of Voluntary Life Insurance
          If you chose to enroll in voluntary life insurance, you may also insure your spouse and eligible dependent children
          up to the age of 26. A summary of your life insurance coverage is listed in the table below, if you should have
          questions on this policy see your Lincoln Certificate of Benefits, or visit www.lfg.com.

              Summary of Insurance
              Guaranteed Issue                                 $100,000
              Minimum Benefit Amount                           $10,000
              Maximum Benefit Amount                           Lesser of 5x Salary of $500,000
              Increments of…                                   $10,000

              Spouse Coverage
              Spouse Guarantee Issue                           $30,000
              Increments of…                                   $5,000
              Maximum Benefit Amount                           $100,000 (not to exceed 50% of employee amount)

              Child(ren) Coverage
              Age 14 days to 6 months                          $250
              Age 6 months up to 26 years                      $10,000

This Benefits-At-A-Glance booklet is designed to provide basic informa on to employees on benefit plans and programs available January 01, 2020 – December 31,
2020. It does not detail all of the provisions, restric ons and exclusions of the various benefit programs documented in the carrier contract or the Summary Plan
Descrip on (SPD). This booklet does not cons tute an SPD or Plan Document as defined by the Employee Re rement Income Security Act (ERISA).               15
Voluntary Life Costs

  Employee/Spouse                                                                  Additional Information
                                                                                      •    Age-bracketed premiums: Premiums increase
    Monthly Cost:                                                                          on plan anniversary after you enter next 5 year
                                                                                           age group
   If your age is...             Your cost for each $1,000 of
                                 supplemental life and ad&d
                                 is...                                                •    Evidence of Insurability form Is required for
Aflac-Supplemental Benefits
                                                                         1 (800) 352 - 2583
Provided by : Aflac                                                                                        Contact: Trisha Cuthbert (386) 846-9087

                                                               Accidents Happen. Help protect yourself with a policy that will pay
                                                               you cash benefits to help with any unexpected expenses. Aflac
                                                               Accident Insurance pays accidental injuries which occur on or off
                                                               the job.
              Accident Insurance

                                                               A serious health event comes with serious costs. Aflac Critical Illness
                                                               Insurance helps with treatment costs when you need it most, so you
                                                               can focus less on your wallet and more on getting better. This
                                                               benefit pays upon diagnosis of critical illness such as: heart attack,
                                                               stroke, and major organ failure.

         Critical Illness Insurance

                                                              Get coverage that can help with deductibles, copayments, and other
                                                              out-of-pocket costs if you’re out of work for a hospital stay. Aflac
                                                              Hospital Insurance helps with the expenses not covered by major
                                                              medical, which can help prevent high deductibles and out‐of‐pocket
                                                              expenses from derailing your life plans. Pays for hospitalization due to
                                                              sickness or injury.
          Hospital Insurance

   This Benefits-At-A-Glance booklet is designed to provide basic informa on to employees on benefit plans and programs available January 01, 2020 – December 31,
   2020. It does not detail all of the provisions, restric ons and exclusions of the various benefit programs documented in the carrier contract or the Summary Plan
   Descrip on (SPD). This booklet does not cons tute an SPD or Plan Document as defined by the Employee Re rement Income Security Act (ERISA).               19
N OT ENotices
                     Important  S

Special Enrollment Rights Notice                                                          Health Insurance Portability and Accountability Act (HIPAA) Notice
If you are declining enrollment for yourself or your dependents (including your           Federal law requires that group health plans allow certain employees and dependents
spouse) because of other health insurance or group health plan coverage, you may be       special enrollment rights when they previously declined coverage and when they have
able to enroll yourself and your dependents in this plan if you or your dependents        new dependents. This law, the Health Insurance Portability and Accountability Act
lose eligibility for that other coverage (or if the employer stops contributing towards
your or your dependents' other coverage). However, you must request enrollment            (HIPAA) also addresses the circumstances under which treatment for medical
within 30 days after your or your dependents' other coverage ends (or after the           condition may be excluded from health plan coverage.
employer stops contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption, or     This Information in this notice is intended to inform you, in a summary fashion, of
placement for adoption, you may be able to enroll yourself and your dependents.           your rights and obligations under these laws. You, your spouse and any dependents
However, you must request enrollment within 30 days after the marriage, birth,            should all take the time to read the entire notice carefully.
adoption, or placement for adoption.
Special enrollment rights also may exist in the following circumstances:                  Special Enrollments: If you decline enrollment for yourself or your dependents
              If you or your dependents experience a loss of eligibility for             (including your spouse) because of having other health insurance coverage at the time
                   Medicaid or a state Children’s Health Insurance Program (CHIP)         of your eligibility to participate, you may enroll yourself or your dependents at a
                   coverage and you request enrollment within 60 days after that          future point, provided that you request enrollment within 30 days after your other
                   coverage ends; or                                                      coverage ends. In addition, if you have a new dependent as a result of a marriage,
              If you or your dependents become eligible for a State premium              birth, adoption or placement for adoption, you may be able to enroll yourself and
                   assistance subsidy through Medicaid or a state CHIP with respect to    your dependents, provided that you request enrollment within 30 days of such an
                   coverage under this plan and you request enrollment within 60 days
                                                                                          event.
                   after the determination of eligibility for such assistance.
              If you or your dependents lose eligibility for coverage under              If you or your dependents lose eligibility for coverage under Medicaid or the
                   Medicaid or the Children’s Health Insurance Program (CHIP) or          Children’s Health Insurance Program (CHIP) or become eligible for a premium
                   become eligible for a premium assistance subsidy under Medicaid or
                                                                                          assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and
                   CHIP, you may be able to enroll yourself and your dependents. You
                   must request enrollment within 60 days of the loss of Medicaid or      your dependents. You must request enrollment within 60 days of the loss of Medicaid
                   CHIP coverage or the determination of eligibility for a premium        or CHIP coverage or the determination of eligibility for a premium assistance
                   assistance subsidy.                                                    subsidy.
Note: The 60 day period for requesting enrollment applied only in these last two
listed circumstances relating to Medicaid and state CHIP. As described above, a 30- Obtaining Additional Information: If you need assistance in determining your rights
day period applied to most special enrollments.                                     under ERISA or HIPAA, you may contact your Plan Administrator or the U.S.
                                                                                    Department of Labor by writing to the Chicago Regional office at 200 W. Adams
Women’s Health & Cancer Rights Act of 1998                                          Street, Suite 1600, Chicago, IL 60606, or by calling the Department at (312)353-
The Women’s Health and Cancer Act (WHCRA) requires group health plans to 0900.
provide participants with notices of their rights under WHCRA, to provide certain If you have any questions about this notice or the law, please contact your Plan
benefits in connection with a mastectomy, and to provide other protections for Administrator at the number or location provided in your benefits booklet or
participants undergoing mastectomies. If you have had or are going to have a Summary Plan Description.
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 Also, if you have changed marital status, or if you, your spouse or any other qualified
benefits, coverage will be provided in a manner determined in consultation with the dependents have changed addresses, please notify your local Human Resources
attending physician and the patient, for:                                           Representative.

            All stages of reconstruction of the breast on which the mastectomy Notice of Privacy Practices: Plan administrators, clearinghouses, business associates,
                                                                             and health care providers that transmit health information electronically or use
                 was performed;
                                                                             electronic health records may not redistribute or unlawfully use electronic health
                Surgery and reconstruction of the other breast to produce a records without permission from the insured. The insured may request information
                 symmetrical appearance;                                     on how their electronic records are distributed, how frequently they are distributed,
                                                                             and who they are distributed to by contacting the U.S. Department of Health and
                Prostheses; and                                             Human Services.

            Treatment of physical complications of the mastectomy, including Health Insurance Marketplace Coverage Notice
                 lymphedema.
                                                                                          The Health Insurance Marketplace is available to assist you as you evaluate health
            These benefits will be provided subject to the same deductibles and          insurance options for you and your family.        This notice provides some basic
                 coinsurance amounts applicable to other medical and surgical             information about the new Marketplace and employment based health coverage
                 benefits provided under the health plan offered by your employer.        offered by your employer. The Marketplace is designed to help you find private health
                                                                                          insurance and compare private health insurance options. You may also be eligible for
            Please keep this information with your other group health plan               a new kind of tax credit under section 36B of Internal Revenue Code that could
                 documents. If you have any questions about the Plan’s coverage of        potentially lower your monthly premium. If you purchase a qualified health plan
                 mastectomies and reconstructive surgeries, please contact the            through the Marketplace, you may lose the employer contribution (if any) to any
                 Human Resources Department.                                              health benefit plan offered by your employer and all or a portion of that contribution
                                                                                          may be excludable from income for federal income tax purposes . More information
                                                                                          on the health insurance Marketplace may be found at https://www.healthcare.gov.
N OT ENotices
                       Important  S

Notice of Rescission                                                                        Mental Health Parity & Addiction Equity Act 2008 (MHPAEA)

(a) Prohibition on rescissions - (1) A group health plan, or a health insurance             Under the MHPAEA, the financial requirements and treatment limits that group
issuer offering group or individual health insurance coverage, must not rescind             health plans and health insurance issuers apply to mental health or substance use
coverage under the plan, or under the policy, certificate, or contract of insurance,        disorder benefits generally cannot be more restrictive than those applicable to medical
with respect to an individual (including a group to which the individual belongs or         and surgical benefits. If a plan covers mental health and substance use disorder,
family coverage in which the individual is included) once the individual is covered         MHPAEA provides medical and surgical benefits and mental health and substance
under the plan or coverage, unless the individual (or a person seeking coverage on          use disorder benefits. MHPAEA it must comply with the federal parity requirements.
behalf of the individual):                                                                  The MHPAEA contains the following parity requirements:

I.     performs an act, practice, or omission that constitutes fraud                      The financial requirements (such as deductibles, copayments, coinsurance and out-of-
                                                                                          pocket limits) applicable to mental health and substance use disorder benefits cannot
II.    makes an intentional misrepresentation of material fact,
                                                                                          be more restrictive than the predominant financial requirements applied to
 as prohibited by the terms of the plan or coverage. A group health plan, or a health substantially all medical and surgical benefits.
insurance issuer offering group or individual health insurance coverage, must provide Treatment limitations (such as frequency of treatment, number of visits, days of
at least 30 days advance written notice to each participant (in the individual market, coverage or other similar limits on the scope or duration of coverage) must also
primary subscriber) who would be affected before coverage may be rescinded under comply with the MHPAEA’s parity requirements. Non-quantitative treatment
this paragraph (a)(1), regardless of, in the case of group coverage, whether the limitations (such as medical management standards, formulary design and
coverage is insured or self-insured, or whether the rescission applies to an entire group determinations of usual, customary or reasonable amounts) are subject to a separate
or only to an individual within the group. (The rules of this paragraph (a)(1) apply parity requirement.
regardless of any contestability period that may otherwise apply.) A rescission is a
                                                                                          If medical and surgical benefits are offered on an out-of-network basis, a plan or issuer
cancellation or discontinuance of coverage that has retroactive effect. For example, a
                                                                                          must also offer mental health and substance use disorder benefits on an out-of-
cancellation that treats a policy as void from the time of the individual's or group's
                                                                                          network basis.
enrollment is a rescission. As another example, a cancellation that voids benefits paid
up to a year before the cancellation is also a rescission for this purpose.               Newborns’ and Mothers’ Health Protection Act

A cancellation or discontinuance of coverage is not a rescission if -                       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
I.     The cancellation or discontinuance of coverage has only a prospective effect;        the mother or newborn child to less than 48 hours following a vaginal delivery, or less
II.     The cancellation or discontinuance of coverage is effective retroactively, to the   than 96 hours following a cesarean section. However, Federal law generally does not
       extent it is attributable to a failure to timely pay required premiums or            prohibit the mother's or newborn's attending provider, after consulting with the
       contributions (including COBRA premiums) towards the cost of coverage;               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,
III. The cancellation or discontinuance of coverage is initiated by the individual (or      require that a provider obtain authorization from the plan or the insurance issuer for
    by the individual's authorized representative) and the sponsor, employer, plan,         prescribing a length of stay not in excess of 48 hours (or 96 hours).
    or issuer does not, directly or indirectly, take action to influence the individual's
                                                                                          COBRA (Consolidated Omnibus Budget Reconciliation Act)
    decision to cancel or discontinue coverage retroactively or otherwise take any
    adverse action or retaliate against, interfere with, coerce, intimidate, or threaten Cobra provides eligible individuals and their dependents who would otherwise lose
    the individual; or                                                                    group health coverage as a result of a qualifying life event with an opportunity to
                                                                                          continue group health coverage for a limited time period under certain circumstances
IV. The cancellation or discontinuance of coverage is initiated by the exchange
                                                                                          such as:
    pursuant (the insured).
                                                                                            •     Voluntary or involuntary job loss
Michelle’s Law

Michelle’s Law protects a postsecondary student from losing full-time student status
                                                                                       •     Reduction in the hours worked
under an employer’s medical coverage if the student is (i) a dependent child of a
                                                                                       •     Transition between jobs
participant or beneficiary under the terms of the plan; and (ii) enrolled in a plan on
the basis of being student at a postsecondary educational institution immediately •          Death
before the first day of a medically necessary leave of absence from school. A
dependent covered under the law is entitled to the same benefits as if the dependent •       Divorce
continued to be enrolled as a full-time student. The law also recognizes that changes
in coverage (whether due to plan design or a subsequent annual enrollment election) •        And other qualifying life events
pass through to the dependent for the remainder of the medically necessary leave of If you are entitled to elect COBRA coverage, you will have 60 days (starting on the
absence.                                                                               date you are furnished the election notice or the date you would lose coverage) to
                                                                                       choose whether or not to elect continuation coverage.
Important Notices

Qualified individuals may be required to pay the entire premium for coverage up to out if premium assistance is available.
102 percent of the cost to the plan.
                                                                                       If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and
COBRA generally requires that group health plans sponsored by groups with 20 or you think you or any of your dependents might be eligible for either of these
more employees in the prior year offer employees and their families the opportunity programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or
for a temporary extension of health coverage (called continuation coverage) in certain www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it
instances where coverage under the plan would otherwise end.                           has a program that might help you pay the premiums for an employer-sponsored
                                                                                       plan.
The duration of COBRA extends from the date of the qualifying event for a limited
period of 18 or 36 months. The length of time depends on the type of qualifying life If you or your dependents are eligible for premium assistance under Medicaid or
event that gave rise to the COBRA rights. A plan, however, may provide longer CHIP, as well as eligible under your employer plan, your employer must allow you to
periods of coverage beyond the maximum period required by law.                         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
COBRA Continuation coverage may be terminated earlier than the end of the
                                                                                       determined eligible for premium assistance. If you have questions about enrolling
maximum period for any of the following reasons:
                                                                                       in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or
• Premiums are not paid in full on a timely basis                                      call 1-866-444-EBSA (3272).

•    The employer ceases to employ any group health plan

•    A qualified beneficiary begins coverage under another group health plan after
     electing continuation coverage;

•    A qualified beneficiary becomes entitled to Medicare benefits after electing
     continuation coverage;

•    A qualified beneficiary engages in conduct that would justify the plan in
     terminating coverage of a similarly situated participant or beneficiary not
     receiving continuation coverage (such as fraud).

If continuation coverage is terminated early, the plan must provide the qualified
beneficiary with an early termination notice. The notice must be given as soon as
practicable after the decision is made, and it must describe the date coverage will
terminate, the reason for termination, and any rights the qualified beneficiary may
have under the plan or applicable law to elect alternative group or individual
coverage.

If you decide to terminate your COBRA coverage early, you generally won't be able
to get a Marketplace plan outside of open enrollment period. For more information
on alternatives to COBRA coverage reach out to your HR Representative or Plan
administrator.

 Contact your plan administrator or Human Resources to determine how COBRA is
administered at your workplace.

CHIP Model Notice

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 on the following page, contact your State Medicaid or CHIP office to find
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following
   list of states is current as of July 31, 2019. Contact your State for more information on eligibility –
                               ALABAMA – Medicaid                                                                    ARKANSAS – Medicaid
Website: http://myalhipp.com/                                                            Website: http://myarhipp.com/
Phone: 1-855-692-5447                                                                    Phone: 1-855-MyARHIPP (855-692-7447)
                                ALASKA – Medicaid                                            COLORADO – Health First Colorado & Child Health Plan Plus (CHP+)
The AK Health Insurance Premium Payment Program                                          Health First Colorado Website: https://www.healthfirstcolorado.com/
Website: http://myakhipp.com/ Phone: 1-866-251-4861                                      Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711
Email: CustomerService@MyAKHIPP.com                                                      CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus
Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx             CHP+ Customer Service: 1-800-359-1991 / State Relay 711
                               FLORIDA – Medicaid                                                                      GEORGIA – Medicaid
Website: http://flmedicaidtplrecovery.com/hipp/                                          Website: https://medicaid.georgia.gov/health-insurance-premium-payment-program-
                                                                                         hipp
Phone: 1-877-357-3268
                                                                                         Phone: 678-564-1162 ext. 2131
                               INDIANA – Medicaid                                                                        IOWA – Medicaid
Healthy Indiana Plan for low-income adults 19-64                                         Website: http://dhs.iowa.gov/Hawki
Website: http://www.in.gov/fssa/hip/         Phone: 1-877-438-4479                       Phone: 1-800-257-8563
Other Medicaid: Website: http://www.indianamedicaid.com Phone 1-800-403-0864
                             KANSAS – Medicaid                                                                          KENTUCKY – Medicaid
Website: http://www.kdheks.gov/hcf/   Phone: 1-785-296-3512                              Website: https://chfs.ky.gov       Phone: 1-800-635-2570
                             LOUISIANA – Medicaid                                                                       MAINE – Medicaid
Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331                              Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html
Phone: 1-888-695-2447                                                                    Phone: 1-800-442-6003 TTY: Maine relay 711
                    MASSACHUSETTS – Medicaid and CHIP                                                               MINNESOTA – Medicaid
Website: http://www.mass.gov/eohhs/gov/departments/masshealth/                           Website: http://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-
                                                                                         programs/programs-and-services/other-insurance.jsp     Phone: 1-800-657-3739
Phone: 1-800-862-4840
                              MISSOURI – Medicaid                                                                    MONTANA – Medicaid
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm                           Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
Phone: 573-751-2005                                                                      Phone: 1-800-694-3084
                             NEBRASKA – Medicaid                                                                       NEVADA – Medicaid
Website: http://www.ACCESSNebraska.ne.gov                                                Medicaid Website: https://dhcfp.nv.gov
Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-1178                      Medicaid Phone: 1-800-992-0900
                         NEW HAMPSHIRE – Medicaid                                                              NEW JERSEY – Medicaid and CHIP
Website: https://www.dhhs.nh.gov/oii/hipp.htm                                            Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/
Phone: 603-271-5218                                                                      Medicaid Phone: 609-631-2392
Toll Free number for the HIPP program - 1-800-852-3345, ext. 5218                        CHIP Website: http://www.njfamilycare.org/index.html Phone: 1-800-701-0710
                             NEW YORK – Medicaid                                                                  NORTH DAKOTA – Medicaid
Website: https://www.health.ny.gov/health_care/medicaid/                                 Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 1-800-541-2831                                                                    Phone: 1-844-854-4825
                         NORTH CAROLINA – Medicaid                                                             OKLAHOMA – Medicaid and CHIP
Website: https://medicaid.ncdhhs.gov/          Phone: 919-855-4100                       Website: http://www.insureoklahoma.org         Phone: 1-888-365-3742
                               OREGON – Medicaid                                                                  PENNSYLVANIA – Medicaid
Website: http://healthcare.oregon.gov/Pages/index.aspx                                   Website: http://www.dhs.pa.gov/provider/medicalassistance/
                                                                                         healthinsurancepremiumpaymenthippprogram/index.htm         Phone: 1-800-692-7462
http://www.oregonhealthcare.gov/index-es.html          Phone: 1-800-699-9075
                           RHODE ISLAND – Medicaid                                                               SOUTH CAROLINA – Medicaid
Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347 or 401-462-0311                    Website: https://www.scdhhs.gov         Phone: 1-888-549-0820
                             SOUTH DAKOTA - Medicaid                                                                    TEXAS – Medicaid
Website: http://dss.sd.gov                  Phone: 1-888-828-0059                        Website: http://gethipptexas.com/           Phone: 1-800-440-0493
                          UTAH – Medicaid and CHIP                                                                   VERMONT– Medicaid
Medicaid Website: https://medicaid.utah.gov/                                             Website: http://www.greenmountaincare.org/
CHIP Website: http://health.utah.gov/chip       Phone: 1-877-543-7669                    Phone: 1-800-250-8427
                         VIRGINIA – Medicaid and CHIP                                                              WASHINGTON – Medicaid
Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm                 Website: http://www.hca.wa.gov/
CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm                     Phone: 1-800-562-3022 ext. 15473
Medicaid Phone: 1-800-432-5924          CHIP Phone: 1-855-242-8282
                          WEST VIRGINIA – Medicaid                                                             WISCONSIN – Medicaid and CHIP
Website: http://mywvhipp.com/                                                            Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf
Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)                                         Phone: 1-800-362-3002
                              WYOMING – Medicaid
Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531
        To see if any other states have added a premium assistance program since July 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 (1-866-444-3272)                                 www.cms.hhs.gov (1-877-267-2323) , menu opt 4, ext 61565
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