EMPLOYEE 2018-2019 BENEFITS INFORMATION GUIDE - Understanding your Options - Playworks
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EMPLOYEE 2018-2019 BENEFITS INFORMATION GUIDE Understanding your Options
HELLO!
To Our Valued Employees,
We recognize how important your peace of mind is. That’s why, at Playworks, we’re providing
you and your dependents with access to a quality employee benefits program to support your
long-term health and wellness. Each year when we reevaluate our benefits offering, we keep in
mind what’s most important to you and hope you find a plan option that will meet your needs.
This Benefits Information Guide is a great tool to help you understand the plans and programs
that you and your family can enroll in for the plan year. Enclosed you will find details about:
• Your medical, dental and vision benefit options, as well as additional benefits such as
life and disability insurance, employee assistance program and even more
• The cost of each plan
• Additional voluntary plans available to you
• Directory and contact information, in case you have questions
• Tips and tricks on how to spend your health care dollars wisely
• And much more!
Here at Playworks we value the health and well-being of our employees and their families. For
this reason, we’re doing our part to care for you and develop an environment in which we can
all flourish together.
To your health in 2018 and beyond,
Playworks
GETTING STARTED 4
4 Enrollment
YOUR HEALTH 7
7 Medical
8 Prescription Drug Coverage
15 Dental Plan
16 Vision Plan
LIFE & DISABILITY 17
17 Basic Life and AD&D
18 Voluntary Life and AD&D
19 Short & Long Term Disability
WORK/LIFE 20
20 Flexible Spending Accounts (FSA)
21 Employee Assistance Program (EAP)
22 Retirement Program
COSTS & DIRECTORY 23
23 Cost Breakdown
24 Directory & Resources
REQUIRED NOTICES 25
25 Plan Guidelines and Evidence of Coverage
26 Medicare Part D Notice
27 Legal Information Regarding Your Plans
The Children’s Health Insurance Program (CHIP)
31
Premium Assistance Subsidy Notice
GETTING STARTED
ENROLLMENT
Who can Enroll?
If you are a full time employee regularly working a minimum of 30 hours per week, you are eligible to participate in the
benefits program. Eligible employees may also choose to enroll family members, including a legal spouse/registered
domestic partner (as legally defined under state and local law) (hereinafter referred to as “registered domestic partner”)
and/or eligible children.
Children are considered eligible if they are:
You or your spouse’s / state-registered domestic partner’s biological children, stepchildren, adopted children or
foster child up to age 26
You or your spouse’s / state-registered domestic partner’s children of any age if they are incapable of self-support
due to a physical or mental disability
When Does Coverage Begin?
Your enrollment choices remain in effect through the end of the benefits plan year, (August 1, 2018 – July 31, 2019).
Benefits for eligible new hires will commence as outlined below:
ELIGIBILITY DATE BENEFIT PLAN
The first day of the month following 30days of employment All new employees
The first day of the month following your date of hire Rehires
(you must enroll within 30 days of becoming eligible)
If you miss the enrollment deadline, you may not enroll in a benefit plan unless you have a change in
TIP status during the plan year. Please review details on IRS qualified change in status events for more
information.
ULTIPRO:
Access UltiPro by logging into Salesforce and clicking the UltiPro tile from the App Launcher tab. Go to Menu: Myself: Life
Events. Find the Life Event titled “I am a new employee.” This will walk you through all your benefit options. There is no need
to complete other Life Events. You will see a list of benefit options on the left that will act as a guide for you.
JELLYVISION – ANY OTHER QUESTIONS? JUST ASK ALEX!
Don’t forget to sign up for your benefits, and don’t forget to talk to ALEX, your personal benefits
counselor. ALEX explains all your options in plain English, and even makes recommendations that
help you choose the plans that make the most sense for you and your family.
Meet ALEX at: https://www.myalex.com/playworks/2018
4. Playworks 2018 Benefits Information Guide
GETTING STARTED
WHAT IF MY NEEDS CHANGE DURING THE YEAR?
You are permitted to make changes to your benefits outside of the open enrollment period if you have a qualified change in
status as defined by the IRS. Generally, you may add or remove dependents from your benefits, as well as add, drop, or
change coverage if you submit your request for change within 30 days of the qualified event. Change in status examples
include:
Marriage, divorce or legal separation.
Birth or adoption of a child.
Death of a dependent.
You or your spouse’s/registered domestic partner’s loss or gain of coverage through our organization or another
employer.
Change in employment status where you have a reduction in hours to an average below 30 hours of service per week,
but continue to be eligible for benefits, and you intend to enroll in another plan. The plan must provide Minimum
Essential Coverage that is effective no later than the first day of the second month following the date of revocation of
your employer sponsored coverage.
You enroll, or intend to enroll, in a Qualified Health Plan (QHP) through the State Marketplace or Federal Exchange and
it is effective no later than the day immediately following the revocation of your employer sponsored coverage.
If your change during the year is a result of the loss of eligibility or enrollment in Medicaid, Medicare or state health
insurance programs, you must submit the request for change within 60 days. For a complete explanation of qualified status
changes, please refer to the “Legal Information Regarding Your Plans” contents.
Please contact Human Resources if you have a qualifying event.
DO I HAVE TO ENROLL?
Please Note: This notice is effective from August 1, 2018 – December 31, 2018.
Most U.S. citizens and legal residents are subject to a federal tax penalty if they do not have minimum essential health
coverage. To avoid paying the penalty, you can obtain health insurance through our benefits program or purchase coverage
elsewhere, such as a State or Federal Health Insurance Exchange.
For information regarding Health Care Reform and the Individual Mandate, please contact Human Resources or visit
www.cciio.cms.gov. You can also visit www.coveredca.com to review information specific to the Covered California State
Health Insurance Exchange.
You may elect to “waive” coverage if you have access to coverage through another plan. If you choose not to enroll, we ask
that you indicate that choice through the “waive” option. You must also provide HR with evidence of other coverage. It is
important to note that if you waive our medical coverage, you must maintain minimum essential health insurance through
another source. It is also important to note that if coverage is waived, the next opportunity to enroll in our group benefit
plans would be on August 1, 2019 or if a qualifying status change occurs.
Playworks 2018 Benefits Information Guide 5.
GETTING STARTED
BENEFITS INFORMATION ON THE GO
iBenefits
Available for iOS and Android mobile devices, the iBenefits app makes checking your
benefits information easier than ever!
With iBenefits, you can:
View our company’s benefit plans, 24/7.
Access group numbers and review detailed plan information.
Quickly contact an insurance company.
Keep up with important benefit plan announcements such as open enrollment dates,
deadlines, and more.
Store images of your ID cards directly in the app.
Download it now from the App Store or Google Play and use our Company Code Playworks18
to login to the app.
Aetna
With Aetna’s mobile app, you can:
Search for a doctor, dentist, hospital, or pharmacy
Use the “Urgent Care Finder” tool to quickly find urgent care centers and walk-in clinics
Register for your secure member site to view claims, coverage details, your ID card and your
personal Health record
Contact Aetna by phone or email
Search for Aetna’s mobile app in the App Store or Google Play to get started!
KP Preventive Care App!
As a Northern California Kaiser Permanente member, important personalized health reminders
and information are available for you and your family members on the go. With this app, you are
able to:
Get alerts when you or your family members are due for routine health screenings, tests and
immunizations.
Receive appointment reminders for scheduled visits.
See details of your upcoming appointments.
Contact your doctor.
Store medical record numbers in one convenient place.
Visit the App Store or Google Play to download the KP Preventive Care app today!
6. Playworks 2018 Benefits Information Guide
YOUR HEALTH
MEDICAL
What are my Options?
Use the chart below to help compare medical plan options and determine which would be the best for you and your family.
PPO HMO – CA ONLY
Aetna Kaiser
Required to select No Yes
and use a Primary
Care Physician (PCP)
Seeing a Specialist No referral required PCP referral required in most cases
Deductible Required Yes, in most cases Yes, in most cases
Finding a Provider www.aetna.com/docfind Northern CA:
Network: Choice POS II https://healthy.kaiserpermanente.org/northern-
california/doctors-locations#/search-form
Southern CA:
https://thrive.kaiserpermanente.org/care-near-
you/southern-california/find-a-doctor/
Claims Process Typically handled by providers PPO providers will submit claims
You submit claims for other services
Compatible with your No No
Health Savings
Account (HSA)
Other Important Tips This plan requires that you see a doctor in You may choose in or out of network care,
a specific network to receive coverage. however in-network care provides you a
Out-of-Network services without proper
higher level of benefit.
PCP referral will not be covered. Emergencies covered worldwide.
Emergencies covered worldwide. Out of network providers will bill the balance
to the member for amounts not covered by
Aenta
Please note the above examples are used for general illustrative purposes only. Please consult with your Human Resources
Department for more specific information as it relates to your specific plan. For a detailed view of your medical plan
summaries, visit www.aetna.com or www.kp.org.
Playworks 2018 Benefits Information Guide 7.
YOUR HEALTH
PRESCRIPTION DRUG COVERAGE
Many FDA-approved prescription medications are covered through the benefits program. Important information regarding
your prescription drug coverage is outlined below:
Tiered prescription drug plans require varying levels of payment depending on the drug’s tier and your copayment or
coinsurance will be higher with a higher tier number.
The Aetna plans include a four-tier prescription benefit and the Kaiser Permanente plan(s) includes a two-tier
prescription benefit.
Tier 1 prescriptions offer the greatest value compared to other drugs that treat the same conditions and are often the
lowest cost.
Tier 2 drugs are generally brand name with a moderate copayment. Some drugs may also be Tier 2 because they are
“preferred” among other drugs that treat the same conditions.
Tier 3 drugs are a higher copayment compared to the lower tiers, as they are higher cost drugs. Some drugs on this list
may have a generic counterpart in Tier 1 or Tier 2.
Many drugs on Tier 4 are “specialty” drugs used to treat complex, chronic conditions, and may require special storage
or close monitoring.
For a current version of the prescription drug list(s), go to www.kp.org or www.aetna.com.
WHY PAY MORE?
There are a few ways you can save money when using the Prescription Drug Plan:
8. Playworks 2018 Benefits Information Guide
PLAN HIGHLIGHTS AETNA PPO PLATINUM
In-network Out-of-network
Annual Deductible
Individual None $250
Family None $500
Annual Maximum Out-of-pocket (1)
Individual $4,000 $8,000
Family $8,000 $16,000
Lifetime Maximum
Individual Unlimited Unlimited
Professional Services
Primary Care Physician (PCP) $20 Copay 30% Coinsurance
Specialist $20 Copay 30% Coinsurance
Preventive Care Exam No Charge Not Covered
Diagnostic X-ray and Lab 10% Coinsurance 30% Coinsurance
Chiropractic $20 Copay 30% Coinsurance
Hospital Services
Inpatient $250 per day up to 5 days 30% Coinsurance after $600 Copay
Outpatient Surgery 10% Coinsurance 30% Coinsurance
Emergency Room (Waived if Admitted) $150 Copay 30% Coinsurance
Maternity Care
Physician Services (prenatal) No Charge Covered as any other claim
Inpatient Hospital Services $250 per day up to 5 days 30% Coinsurance after $600 Copay
Mental Health & Substance Abuse
Inpatient $250 per day up to 5 days 30% Coinsurance after $600 Copay
Outpatient $20 Copay 30% Coinsurance
Retail Prescription Drugs (30-day supply)
Tier 1 $15 Copay
Member pay In-network Copay, plus 30%
Tier 2 $30 Copay
of the Allowable Amount
Tier 3 $50 Copay
Specialty Drugs 30% up to $200 Maximum Not Covered
Mail Order Prescription Drugs (90-day supply)
Tier 1 $30 Copay
Tier 2 $60 Copay
Not Covered
Tier 3 $100 Copay
Specialty Drugs Not Covered
(1) Out-of-pocket maximum is based on the maximum allowable charge the carrier allows. This does not include any balance billing that may occur
when using an out-of-network provider.
The above information is a summary only. Please refer to your Evidence of Coverage for complete details of Plan benefits, limitations and exclusions.
Playworks 2018 Benefits Information Guide 9.
YOUR HEALTH
PLAN HIGHLIGHTS AETNA PPO GOLD
In-network Out-of-network
Annual Deductible
Individual $250 $500
Family $500 $1,000
Annual Maximum Out-of-pocket (1)
Individual $6,350 $10,000
Family $12,700 $20,000
Lifetime Maximum
Individual Unlimited Unlimited
Professional Services
Primary Care Physician (PCP) $30 Copay 40% Coinsurance
Specialist $30 Copay 40% Coinsurance
Preventive Care Exam Covered in Full 40% Coinsurance
Diagnostic X-ray and Lab 20% Coinsurance 40% Coinsurance
Chiropractic $30 Copay 40% Coinsurance
Hospital Services
Inpatient $600 per day up to 5 days 40% Coinsurance after $600 Copay
Outpatient Surgery 20% Coinsurance 40% Coinsurance
Emergency Room (Waived if Admitted) 20% Coinsurance after $250 Copay
Maternity Care
Physician Services (prenatal) No Charge Covered as any other claim
Inpatient Hospital Services $600 per day up to 5 days 40% Coinsurance after $600 Copay
Mental Health & Substance Abuse
Inpatient $600 per day up to 5 days 40% Coinsurance after $600 Copay
Outpatient 20% Coinsurance 40% Coinsurance
Retail Prescription Drugs (30-day supply)
Tier 1 $15 Copay
Member pay In-network Copay, plus 30%
Tier 2 $30 Copay
of the Allowable Amount
Tier 3 $50 Copay
Specialty Drugs 30% up to $200 Maximum Not Covered
Mail Order Prescription Drugs (90-day supply)
Tier 1 $30 Copay
Tier 2 $60 Copay
Not Covered
Tier 3 $100 Copay
Specialty Drugs Not Covered
(1) Out-of-pocket maximum is based on the maximum allowable charge the carrier allows. This does not include any balance billing that may occur
when using an out-of-network provider.
The above information is a summary only. Please refer to your Evidence of Coverage for complete details of Plan benefits, limitations and exclusions.
10. Playworks 2018 Benefits Information GuideYOUR HEALTH
PLAN HIGHLIGHTS AETNA PPO SILVER
In-network Out-of-network
Annual Deductible
Individual $2,000 $2,000
Family $4,000 $4,000
Annual Maximum Out-of-pocket (1)
Individual $6,350 $10,000
Family $12,700 $20,000
Lifetime Maximum
Individual Unlimited Unlimited
Professional Services
Primary Care Physician (PCP) $45 Copay 40% Coinsurance
Specialist $45 Copay 40% Coinsurance
Preventive Care Exam No Charge 40% Coinsurance
Diagnostic X-ray and Lab $45 Copay 40% Coinsurance
Chiropractic $45 Copay 40% Coinsurance
Hospital Services
Inpatient 20% Coinsurance 40% Coinsurance after $600 Copay
Outpatient Surgery 20% Coinsurance 40% Coinsurance
Emergency Room 20% Coinsurance after $250 Copay
Maternity Care
Physician Services (prenatal) No Charge Covered as any other claim
Inpatient Hospital Services 20% Coinsurance 40% Coinsurance after $600 Copay
Mental Health & Substance Abuse
Inpatient 20% Coinsurance 40% Coinsurance after $600 Copay
Outpatient 20% Coinsurance 40% Coinsurance
Retail Prescription Drugs (30-day supply)
Tier 1 $15 Copay
Member pay In-network Copay, plus 30%
Tier 2 $30 Copay
of the Allowable Amount
Tier 3 $50 Copay
Specialty Drugs 30% up to $200 Maximum Not Covered
Mail Order Prescription Drugs (90-day supply)
Tier 1 $30 Copay
Tier 2 $60 Copay
Not Covered
Tier 3 $100 Copay
Specialty Drugs Not Covered
(1) Out-of-pocket maximum is based on the maximum allowable charge the carrier allows. This does not include any balance billing that may occur
when using an out-of-network provider.
The above information is a summary only. Please refer to your Evidence of Coverage for complete details of Plan benefits, limitations and exclusions.
Playworks 2018 Benefits Information Guide 11.YOUR HEALTH
KAISER HMO PLATINUM
PLAN HIGHLIGHTS CA ONLY
In-Network Only
Annual Deductible
Individual None
Family None
Annual Maximum Out-of-pocket (1)
Individual $3,000
Family $6,000
Lifetime Maximum
Individual None
Professional Services
Primary Care Physician (PCP) $20 Copay
Specialist $20 Copay
Preventive Care Exam No Charge
Well-baby Care No Charge
Most Diagnostic X-ray and Lab $10 per Encounter
Acupuncture $20 Copay w/ Referral
Chiropractic Not Covered
Hospital Services
Inpatient $100 per Day
Outpatient Surgery $100 per Procedure
Emergency Room (Waived if Admitted) $100 per Visit
Maternity Care
Physician Services (prenatal or postnatal) No Charge
Inpatient Hospital Services $100 per Day
Mental Health & Substance Abuse
Inpatient $100 per Day
Outpatient $20 Copay
Retail Prescription Drugs (30-day supply)
Tier 1 $10 Copay
Tier 2 $30 Copay
Mail Order Prescription Drugs (31 to 100-day supply)
Tier 1 $20 Copay
Tier 2 $60 Copay
(1) Out-of-pocket maximum is based on the maximum allowable charge the carrier allows. This does not include any balance billing that may occur
when using an out-of-network provider.
The above information is a summary only. Please refer to your Evidence of Coverage for complete details of Plan benefits, limitations and exclusions.
12. Playworks 2018 Benefits Information GuideYOUR HEALTH
KAISER HMO GOLD
PLAN HIGHLIGHTS
CA ONLY
In-Network Only
Annual Deductible
Individual $1,000
Family $2,000
Annual Maximum Out-of-pocket (1)
Individual $3,000
Family $6,000
Lifetime Maximum
Individual None
Professional Services
Primary Care Physician (PCP) $20 Copay
Specialist $20 Copay
Preventive Care Exam No Charge
Well-baby Care No Charge
Most Diagnostic X-ray and Lab $10 per Encounter after Plan Deductible
Acupuncture $20 Copay w/ Referral
Chiropractic Not Covered
Hospital Services
Inpatient 20% Coinsurance after Plan Deductible
Outpatient Surgery 20% Coinsurance after Plan Deductible
Emergency Room 20% Coinsurance after Plan Deductible
Maternity Care
Physician Services (prenatal or postnatal) No Charge
Inpatient Hospital Services 20% Coinsurance after Plan Deductible
Mental Health & Substance Abuse
Inpatient 20% Coinsurance after Plan Deductible
Outpatient $20 per Visit
Retail Prescription Drugs (30-day supply)
Tier 1 $10 Copay
Tier 2 $30 Copay
Mail Order Prescription Drugs (31 to 100-day supply)
Tier 1 $20 Copay
Tier 2 $60 Copay
(1) Out-of-pocket maximum is based on the maximum allowable charge the carrier allows. This does not include any balance billing that may occur
when using an out-of-network provider.
The above information is a summary only. Please refer to your Evidence of Coverage for complete details of Plan benefits, limitations and exclusions.
Playworks 2018 Benefits Information Guide 13.YOUR HEALTH
KAISER HMO SILVER
PLAN HIGHLIGHTS
CA ONLY
In-Network Only
Annual Deductible
Individual $1,500
Family $3,000
Annual Maximum Out-of-pocket (1)
Individual $4,000
Family $8,000
Lifetime Maximum
Individual None
Professional Services
Primary Care Physician (PCP) $40 Copay
Specialist $40 Copay
Preventive Care Exam No Charge
Well-baby Care No Charge
Most Diagnostic X-ray and Lab $10 per encounter after Plan Deductible
Acupuncture $40 Copay w/ Referral
Chiropractic Not Covered
Hospital Services
Inpatient 30% Coinsurance after Plan Deductible
Outpatient Surgery 30% Coinsurance after Plan Deductible
Emergency Room (Waived if Admitted) 30% Coinsurance after Plan Deductible
Maternity Care
Physician Services (prenatal or postnatal) No Charge
Inpatient Hospital Services 30% Coinsurance after Plan Deductible
Mental Health & Substance Abuse
Inpatient 30% Coinsurance after Plan Deductible
Outpatient $40 Copay
Retail Prescription Drugs (30-day supply)
Tier 1 $10 Copay
Tier 2 $30 Copay
Mail Order Prescription Drugs (31 to 100-day supply)
Tier 1 $20 Copay
Tier 2 $60 Copay
(1) Out-of-pocket maximum is based on the maximum allowable charge the carrier allows. This does not include any balance billing that may occur
when using an out-of-network provider.
The above information is a summary only. Please refer to your Evidence of Coverage for complete details of Plan benefits, limitations and exclusions.
14. Playworks 2018 Benefits Information GuideYOUR HEALTH
DENTAL PLAN
Your Dental PPO Plan
This year, you and your eligible dependents have the opportunity to enroll in a Dental Preferred Provider Organization (PPO)
plan offered by Aetna.
Using the Plan
The Dental PPO plan is designed to give you the freedom to receive dental care from any licensed dentist of your choice.
Keep in mind, you’ll receive the highest level of benefit from the plan if you select an in-network PPO dentist versus an out-
of-network dentist who has not agreed to provide services at the negotiated rate. Additionally, no claim forms are required
when using in-network PPO dentists.
AETNA DENTAL PPO
PLAN HIGHLIGHTS
NETWORK: CHOICE POS II
In-Network Out-of-Network(1)
Annual Deductible
Individual $50
Family $150
Annual Maximum $1,500
Preventive 0% Coinsurance; Deductible Waived
Basic Services 20% Coinsurance 40% Coinsurance
Major Services 50% Coinsurance 60% Coinsurance
Orthodontia Services
Adult & Child 50% Coinsurance
Lifetime Maximum $1,500
Out-of-network coinsurance is based on the maximum allowable charge the carrier allows. This does not include any balance billing that may occur
(1)
when using an out-of-network provider
The above information is a summary only. Please refer to your Evidence of Coverage for complete details of Plan benefits, limitations and exclusions.
Choose your Primary Care Dentist
TIP When using a Dental PPO plan, you can receive services from dental providers both in and out of your
insurance network. However, you’ll receive better coverage when you use an in-network dentist. To
determine whether your dentist is in or out of your insurance network, go to www.aetna.com and search
the provider network, or call Aetna.
Playworks 2018 Benefits Information Guide 15.YOUR HEALTH
VISION PLAN
Your Vision Plan
Vision coverage is offered by VSP as a Preferred Provider Organization (PPO) plan.
Using the Plan
As with a traditional PPO, you may take advantage of the highest level of benefit by receiving services from in-network vision
providers and doctors. You would be responsible for a copayment at the time of your service. However, if you receive
services from an out-of-network doctor, you pay all expenses at the time of service and submit a claim for reimbursement up
to the allowed amount.
To locate an in-network vision provider, visit www.vsp.com.
VSP VISION PPO
PLAN HIGHLIGHTS
NETWORK: VSP CHOICE NETWORK
In-Network Out-of-Network
Exam – Every 12 months $20 Exam Copay Covered to a Maximum of $45
Lenses – Every 24 months $20 Materials Copay
Single Covered at 100% after Copay Covered to a Maximum of $30
Bifocal Covered at 100% after Copay Covered to a Maximum of $50
Trifocal Covered at 100% after Copay Covered to a Maximum of $65
Frames – Every 24 months Covered to a Maximum of $130 Covered to a Maximum of $70
Contacts – Every 24 months
Contact Lens Exam Covered to a
In lieu of lenses & frames Maximum of $60; Covered to a Maximum of $105
Materials Covered to a Maximum of $130
The above information is a summary only. Please refer to your Evidence of Coverage for complete details of Plan benefits, limitations and exclusions.
Five Tips for Superior Vision
TIP Don’t take your eyes for granted! The following pointers can help you keep your vision strong:
Eat lots of leafy greens and dark berries.
Get regular eye exams.
Give your eyes a rest from staring into the computer screen.
Wear sunglasses to protect your eyes from bright light.
Wear safety eyewear whenever necessary.
16. Playworks 2018 Benefits Information GuideLIFE AND DISABILITY
BASIC LIFE AND AD&D
Protect your loved ones
In the event of your death, Life Insurance will provide your family members or other beneficiaries with financial protection
and security. Additionally, if your death is a result of an accident or if you become dismembered, your Accidental Death &
Dismemberment (AD&D) coverage may apply.
Your coverage
Paid for in full by Playworks, the benefits outlined below are provided by MetLife:
Basic Life Insurance of 1x annual earnings up to $250,000.
AD&D of 1x annual earnings up to $250,000.
Please note, benefits may reduce when you reach age 65.
IRS Regulation: Employees can receive employer paid life insurance up to $50,000 on a tax-free basis and do not have to
report the payment as income. However, an amount in excess of $50,000 will trigger taxable income for the “economic
value” of the coverage provided to you.
Required! Are Your Beneficiaries Up to Date?
TIP Beneficiaries are individuals or entities that you select to receive benefits from your policy.
You can change your beneficiary designation at any time.
You may designate a sole beneficiary or multiple beneficiaries to receive payment in the percent
allocated.
You can select or change your beneficiary through UltiPro or contact Human Resources.
Playworks 2018 Benefits Information Guide 17.LIFE AND DISABILITY
VOLUNTARY LIFE AND AD&D
If you would like to supplement your employer paid insurance, additional Life and AD&D coverage for you and/or your
dependents is available for purchase.
For employees: Increments of $10,000 up to a maximum of 5x your salary to $500,000. Guarantee Issue: $100,000.
For your spouse / state registered domestic partner: Increments of $5,000 up to a $100,000 maximum. Guarantee
Issue: $25,000.
For your child(ren): Minimum flat benefit of $1,000; up to a $10,000 maximum. Additional limits on infants under six
months old may apply. Guarantee Issue $10,000.
Optional AD&D: No requirements for a medical questionnaire and coverage is available for purchase in the same
amounts as optional life insurance amount above.
Any amounts of insurance over the guarantee issue benefit are subject to review of good health by the insurance company.
Insurance amounts subject to review will not be effective until the insurance company approves.
If you do not enroll in the plan within the initial enrollment period, any amount of supplemental life insurance will require
proof of good health, which is subject to approval by the insurance company before the insurance is effective. For more
information regarding this plan, review the plan summary detail.
Please note: Benefits coverage may reduce when you reach age 65. Restrictions may apply if you and/or your dependent(s) are confined in the
hospital or terminally ill. Please refer to your Summary Plan Description for exclusions and further detail.
COST OF EMPLOYEE & SPOUSAL VOLUNTARY
COVERAGE DEPENDENT CHILD COVERAGE
Age of Insured Monthly Rate per $1,000 Benefit Amount Monthly Premium
Less than 25 $0.09 $1,000 $0.29
25–29 $0.09 $2,000 $0.58
30–34 $0.10 $4,000 $1.16
35–39 $0.12 $5,000 $1.46
40–44 $0.16 $10,000 $2.91
45–49 $0.24 AD&D Included
50–54 $0.36
55–59 $0.55
60–64 $0.82
65–69 $1.30
70–74 $2.43
AD&D Included
18. Playworks 2018 Benefits Information GuideLIFE AND DISABILITY
SHORT & LONG TERM DISABILITY
Added protection
Should you experience a non-work related illness or injury that prevents you from working, disability coverage acts as
income replacement to protect important assets and help you continue with some level of earnings. Benefits eligibility may
be based on disability for your occupation or any occupation.
YOUR PLANS COVERAGE DETAILS
Short Term Disability (STD) Administered by MetLife, STD coverage provides a benefit equal to 60% of
This benefit is not available for employees your earnings, up to $1,104 per week for a period up to 12 weeks.
in the following states: CA, HI, NY, NJ, RI, The plan begins paying these benefits at the time of disability/after you have
PR been absent from work for7 consecutive days.
Long Term Disability Coverage (LTD) If your disability extends beyond 90 days, the LTD coverage through MetLife
can replace 60% of your earnings, up to maximum of $7,000 per month.
Your benefits may continue to be paid until you reach social security normal
retirement age as long as you meet the definition of disability.
State Disability Insurance The state you reside in may provide a partial wage-replacement disability
insurance plan.
Applies to employees who reside in: CA, NY, NJ, RI, HI as of 7/1/2018
For more information regarding statutory disability programs, contact Human
Resources.
Disability Facts and Figures
TIP One in every 7 people will become disabled for five years or more in their lifetime.
30% of people use disability coverage.
Nearly half (46%) of all foreclosures are caused by financial hardship due to a disability.
Source: www.affordableinsuranceprotection.com/disability_facts
Tax considerations
Because disability coverage is an employer-paid benefit and is available for employees at no cost, any disability payments
made to you will be taxable.
Please note: Consult your tax advisor for additional taxation information or advice.
Playworks 2018 Benefits Information Guide 19.WORK/LIFE
FLEXIBLE SPENDING ACCOUNTS (FSA)
A flexible spending account lets you use pre-tax dollars to cover eligible health care, dependent care, and transit/parking
expenses. There are different types of FSAs that help to reduce your taxable income when paying for eligible expenses for
yourself, your spouse, and any eligible dependents, as outlined below:
FSA TYPE DETAIL
Can reimburse for eligible health care expenses not covered by your
Health Care FSA medical, dental and vision insurance.
Maximum contribution for 2018 is $2,650.
Can be used to pay for qualified child care and/or caregivers for a disabled
Dependent Care FSA family member in the household, who is unable to care for themselves.
Maximum contribution for 2018 is $5,000.
Can be used to cover qualified transit passes, vanpooling, payments for
Commuter Spending transportation in a commuter highway vehicle, and qualified parking costs.
Account Parking maximum contribution for 2018 is $260 per month.
Transit maximum contribution for 2018 is $260 per month.
What are the benefits?
Your taxable income is reduced and your spendable income increases!
Save money while keeping you and your family healthy.
How do I use it?
You must enroll in the FSA program within 30 days of your hire date or during annual open enrollment. At this time, you must
establish an annual contribution amount within the maximum limit. Once enrolled, you will have online access to view your
FSA balance, check on a reimbursement status, and more. Visit www.discoverybenefits.com to access Discovery’s online
portal.
Receiving Reimbursements
You will have until March 31, 2019 to submit a reimbursement request for claims incurred between January 1 and
December 31, 2018. If you do not receive automatic reimbursement by using your debit card, you can submit a manual
reimbursement request by contacting Discovery Benefits. Any unclaimed funds remaining in your account after March 31,
2019 will be forfeited.
A few rules you need to know:
A Health Care FSA can reimburse for health care expenses that are not covered, or are only partially covered, by your
medical, dental and vision insurance plans including other eligible expenses. You will have immediate access to the
entire annual contribution amount from the first day of the benefit year, before all scheduled contributions have been
made. Only those who are eligible to participate in the Playworks’ major medical coverage are eligible to participate in
the Health Care FSA
The Dependent Care FSA can be used to pay for qualified child care/or caregivers for a disabled family member living in
the household who is unable to care for themselves. Unlike the Health Care FSA, you can only access the money that is
currently in the account.
With regards to the FSA types available:
The plan administrator is Discovery Benefits.
Contributions are deducted from your paycheck in equal amounts during the year before federal, state and social
security taxes are taken out.
Since you are not paying federal, state or social security taxes on the contributions, your taxable income is reduced and
your spendable income actually increases
Additionally, Commuter Benefit plans such as a Mass Transit and Parking benefit can be reimbursed for eligible commuting
expenses also on a pre-tax basis.
20. Playworks 2018 Benefits Information GuideWORK/LIFE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
Playworks understands that you and your family members might experience a variety of personal or work-related challenges.
Through the EAP, you have access to resources, information, and counseling that are fully confidential and no cost to you.
PROGRAM COMPONENT COVERAGE DETAILS
Who Can Utilize All employees, dependents of employees, and members of your household
Topics May Include Childcare.
Eldercare.
Legal services.
Identity theft.
Marital, relationship or family problems.
Bereavement or grief counseling.
Substance abuse and recovery.
Financial support.
Educational materials.
How to Access:
TIP By Phone: 888.319.7819.
Online: metlifeeap.lifeworks.com.
Website user name: metlifeeap
Website password: eap
Playworks 2018 Benefits Information Guide 21.WORK/LIFE
RETIREMENT OPTIONS
Your 401(k) Plan Option
Administered by Fidelity, the 401(k) plan allows you to plan for your future by investing a portion of each paycheck. Once you
become eligible, you may elect to have a percentage of your paycheck withheld and invested in your 401(k) account, subject
to federal law and plan guidelines. See Human Resources to confirm eligibility and enrollment dates.
Enrollment & Account Access
To enroll in the 401(k) plan, please visit www.401k.com to enroll online or contact Human Resources
Check your 401(k) account balance, view your contributions, change your investments and more by visiting
www.401k.com. For login or password assistance please contact Fidelity at 800.343.3548.
Additional 401(k) Information
Contribution Limits: For 2018 the IRS annual contribution limits are $18,500 for everyone under age 50 or $24,500 for
anyone that is age 50 or over prior to December 31, 2018. If you have multiple employers during the year, these limits are
combined for all plans that you contribute to during the year. Restrictions may apply to these limits based on plan
documents and annual testing requirements.
Contribution Changes: Check with Human Resources for frequency and process for changing your contributions. You may
also stop your contribution entirely at any time. Requests to change or stop your contributions must be made through the
provider website or in writing to Human Resources.
Employer Contributions: Check with Human Resources for current status of any employer contributions to the plan.
Loans & Hardship Withdrawals: If allowed by the plan document, please see Human Resources for information and
requirements for either option.
Rollover Contributions: If you have an outside qualified retirement plan or account such as a 401(k), 403(b), 457(b) or IRA,
you may be able to transfer that account into your new plan. Please contact Fidelity or Human Resources for additional
information.
Termination of Employment: Upon termination of employment from our organization, regardless of reason, you will be
entitled to request a full distribution of your vested account balance. This may be done as a rollover to another plan or IRA.
You may also request a lump-sum cash payment to yourself. Please be aware of possible taxes and penalties which may
apply to any payment other than a rollover.
Your Target Retirement
TIP Are you wondering how much you should save for retirement? Learn more by accessing a free retirement
planning calculator at http://www.mmaretirement.com/calculators.cfm
Marsh & McLennan Insurance Agency LLC does not serve as advisor, broker-dealer or registered investment advisor for this plan. All of the terms and
conditions of your plan are subject to applicable laws, regulations and policies. In case of a conflict between your plan document and this
information, the plan documents will always govern.
22. Playworks 2018 Benefits Information GuideCOSTS & DIRECTORY
COST BREAKDOWN
The rates below are effective August 1, 2018 – July 31, 2019.
COVERAGE LEVEL TOTAL COST CONTRIBUTION PAYROLL DEDUCTION
Employee Payroll
Employee Monthly
Monthly Cost Deduction per Pay
Cost
Period
Aetna Platinum Plan
Employee Only $407.46 $125.34 $62.67
Employee and Spouse/Registered Domestic Partner $855.66 $390.99 $195.50
Employee and Child(ren) $774.17 $342.69 $171.35
Employee and Family $1,222.37 $608.34 $304.17
Aetna Gold Plan
Employee Only $331.91 $49.79 $24.90
Employee and Spouse/Registered Domestic Partner $397.01 $232.34 $116.17
Employee and Child(ren) $630.63 $199.15 $99.58
Employee and Family $995.72 $381.69 $190.85
Aetna Silver Plan
Employee Only $274.11 $13.71 $6.86
Employee and Spouse/Registered Domestic Partner $575.62 $164.46 $82.23
Employee and Child(ren) $520.80 $137.05 $68.53
Employee and Family $822.32 $287.81 $143.91
Kaiser Platinum Plan (CA Only)
Employee Only $563.27 $281.15 $140.58
Employee and Spouse/Registered Domestic Partner $1,239.19 $774.52 $387.27
Employee and Child(ren) $1,126.54 $695.06 $347.53
Employee and Family $1,689.81 $1,075.78 $537.89
Kaiser Gold Plan (CA Only)
Employee Only $496.12 $214.00 $107.00
Employee and Spouse/Registered Domestic Partner $1,091.45 $626.78 $313.39
Employee and Child(ren) $992.23 $560.75 $280.38
Employee and Family $1,488.35 $874.32 $437.16
Kaiser Silver Plan (CA Only)
Employee Only $447.16 $165.04 $85.52
Employee and Spouse/Registered Domestic Partner $983.74 $519.07 $259.54
Employee and Child(ren) $894.31 $462.83 $231.42
Employee and Family $1,341.47 $727.44 $363.72
Aetna Dental
Employee Only $31.22 $7.58 $3.79
Employee and Spouse/Registered Domestic Partner $65.89 $20.68 $10.34
Employee and Child(ren) $69.03 $36.57 $18.29
Employee and Family $103.70 $53.64 $26.81
VSP Vision
Employee Only $5.04 $2.00 $1.00
Employee and Spouse/Registered Domestic Partner $8.63 $5.00 $2.50
Employee and Child(ren) $8.81 $5.00 $2.50
Employee and Family $14.21 $10.00 $5.00
Playworks 2018 Benefits Information Guide 23.COSTS & DIRECTORY
DIRECTORY & RESOURCES
Below, please find important contact information and resources for Playworks.
INFORMATION GROUP /
REGARDING POLICY # CONTACT INFORMATION
Enrollment & Eligibility
Human Resources Human Resources hr@playworks.org https://sites.google.com/a/playworks.org/hum
an-resources
Medical Coverage
Aetna
• Platinum
877.204.9186
• Gold 231836 www.aetna.com
• Silver
Kaiser
• Platinum 641882
800.464.4000
• Gold www.kp.org
• Silver
Dental Coverage
Aetna
• Dental PPO 231836 877.238.6200 www.aetna.com
Vision Coverage
VSP
• Vision PPO 30015056 800.877.7195 www.vsp.com
Life, AD&D and Disability
Met Life
• Life / AD&D KM 05715228 G
800.275.4638 www.metlife.com
• LTD and STD KM 05715228 G
FSA, COBRA, Transit &
Commuter
Discovery Benefits
866.451.3399 www.discoverybenefits.com
Employee Assistance Plan
MetLife
LifeWorks Counselors metlifeeap.lifeworks.com
• Relationship Problems 888.319.7819 User Name: metlifeassist
• Family Issues and Life Password: support
Changes
Grief Counseling Program
MetLife
LifeWorks Counselors metlifeeap.lifeworks.com
• Funeral Assistance Services 888.319.7819 User Name: metlifeassist
• Elder Care Services Password: support
• Confidential Assistance
401(k) Retirement Plan Adviser
Fidelity Member Services 800.343.3548 www.401k.com
Benefits Broker
Marsh & McLennan Insurance Employee Benefits 925.482.9300 www.MarshMMA.com
Agency LLC
1340 Treat Blvd., Ste. 250
Walnut Creek, CA 94597
24. Playworks 2018 Benefits Information GuideREQUIRED NOTICES PLAN GUIDELINES AND EVIDENCE OF COVERAGE The benefit summaries listed on the previous pages are brief summaries only. They do not fully describe the benefits coverage for your health and welfare plans. For details on the benefits coverage, please refer to the plan’s Evidence of Coverage. The Evidence of Coverage or Summary Plan Description is the binding document between the elected health plan and the member. A health plan physician must determine that the services and supplies are medically necessary to prevent, diagnose, or treat the members’ medical condition. These services and supplies must be provided, prescribed, authorized, or directed by the health plan’s network physician unless the member enrolls in the PPO plan where the member can use a non-network physician. The HMO member must receive the services and supplies at a health plan facility or skilled nursing facility inside the service area except where specifically noted to the contrary in the Evidence of Coverage. For details on the benefit and claims review and adjudication procedures for each plan, please refer to the plan’s Evidence of Coverage. If there are any discrepancies between benefits included in this summary and the Evidence of Coverage or Summary Plan Description, the Evidence of Coverage or Summary Plan Description will prevail. Playworks 2018 Benefits Information Guide 25.
REQUIRED NOTICES
MEDICARE PART D NOTICE
Important Notice about Your Prescription Drug Coverage and Medicare
Model Individual CREDITABLE Coverage Disclosure (for use on or after 04/01/2011)
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage and
about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a
Medicare prescription drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at
what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can
get help to make decisions about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare
Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug
plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2. Your employer has determined that the prescription drug coverage offered is expected to pay, on average, as much as standard Medicare
prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you
can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 to December 7. However, if you
lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special
Enrollment Period (SEP) to join a Medicare prescription drug plan.
What Happens to Your Current Coverage if You Decide to Join a Medicare Prescription Drug Plan?
Individuals who are eligible for Medicare should compare their current coverage, including which drugs are covered, with the coverage and cost
of the plans offering Medicare prescription drug coverage in their area.
If you are eligible for Medicare and do decide to enroll in a Medicare prescription drug plan and drop your employer’s group health plan
prescription drug coverage, be aware that you and your dependents may not be able to get this coverage back.
Please contact Human Resources for more information about what happens to your coverage if you enroll in a Medicare prescription
drug plan.
Your medical benefits brochure contains a description of your current prescription drug benefits.
When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with your employer and don’t join a Medicare prescription drug plan within
63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63
continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base
beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable
coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher
premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to
join.
For More Information about This Notice or Your Current Prescription Drug Coverage…
Contact your Human Resources Department for further information NOTE: You will receive this notice annually, before the next period you can
join a Medicare prescription drug plan, and if this coverage through your employer changes. You also may request a copy of this notice at any
time.
For More Information about Your Options Under Medicare Prescription Drug Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of
the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about
Medicare prescription drug coverage:
Visit www.medicare.gov
Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their
telephone number) for personalized help
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this
extra help, visit the Social Security Administration (SSA) online at www.socialsecurity.gov, or call SSA at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare prescription drug plans, you may be required to
provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore,
whether or not you are required to pay a higher premium (a penalty).
26. Playworks 2018 Benefits Information GuideREQUIRED NOTICES
LEGAL INFORMATION REGARDING YOUR PLANS
Required Notices Important Information on how Health Care Reform
Women’s Health & Cancer Rights Act Affects Your Plan
The Women’s Health and Cancer Rights Act (WHCRA) requires group health plans to make certain benefits
available to participants who have undergone or who are going to have a mastectomy. In particular, a plan Primary Care Provider Designations
must offer mastectomy patients benefits for:
For plans and issuers that require or allow for the designation of primary care providers by participants or
All stages of reconstruction of the breast on which the mastectomy was performed; beneficiaries:
Surgery and reconstruction of the other breast to produce a symmetrical appearance; Your HMO generally requires the designation of a primary care provider. You have the right to designate
Prostheses; and any primary care provider who participates in our network and who is available to accept you or your
Treatment of physical complications of the mastectomy, including lymphedema. family members. For information on how to select a primary care provider, and for a list of the
participating primary care providers, contact your Human Resources office
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical
and surgical benefits provided under this plan. For plans and issuers that require or allow for the designation of a primary care provider for a child:
Your plans comply with these requirements. For children, you may designate a pediatrician as the primary care provider
For plans and issuers that provide coverage for obstetric or gynecological care and require the designation
Health Insurance Portability & Accountability Act Non-discrimination by a participant or beneficiary of a primary care provider:
Requirements You do not need prior authorization from your insurance provider or from any other person (including a
Health Insurance Portability & Accountability Act (HIPAA) prohibits group health plans and health insurance primary care provider) in order to obtain access to obstetrical or gynecological care from a health care
issuers from discriminating against individuals in eligibility and continued eligibility for benefits and in professional in our network who specializes in obstetrics or gynecology. The health care professional,
individual premium or contribution rates based on health factors. however, may be required to comply with certain procedures, including obtaining prior authorization for
certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of
These health factors include: health status, medical condition (including both physical and mental illnesses), participating health care professionals who specialize in obstetrics or gynecology, contact your Human
claims experience, receipt of health care, medical history, genetic information, evidence of insurability Resources office.
(including conditions arising out of acts of domestic violence and participation in activities such as
motorcycling, snowmobiling, all-terrain vehicle riding, horseback riding, skiing, and other similar activities), Grandfathered Plans
and disability.
If your group health plan is grandfathered then the following will apply. As permitted by the Affordable Care
Special Enrollment Rights Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when
that law was enacted. Being a grandfathered health plan means that your plan may not include certain
If you are declining enrollment for yourself or your dependents (including your spouse) because of other consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for
health insurance or group health plan coverage, HIPAA Special Enrollment Rights require your plan to allow the provision of preventive health services without any cost sharing. However, grandfathered health plans
you and/or your dependents to enroll in your employer’s plans (except dental and vision plans elected must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination
separately from your medical plans) if you or your dependents lose eligibility for that other coverage (or if the of lifetime limits on benefits.
employer stopped contributing towards your or your dependents' other coverage). However, you must
request enrollment within 30 days (60 days if the lost coverage was Medicaid or Healthy Families) after your Questions regarding which protections apply and which protections do not apply to a grandfathered health
or your dependents' other coverage ends (or after the employer stops contributing toward the other plan and what might cause a plan to change from grandfathered health plan status can be directed to the
coverage). plan administrator.
In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, Prohibition on Excess waiting Periods
you may be able to enroll yourself and your dependents. However, you must request enrollment within 30
days after the marriage, birth, adoption, or placement for adoption. Group health plans may not apply a waiting period that exceeds 90 days. A waiting period is defined as the
period that must pass before coverage for an eligible employee or his or her dependent becomes effective
Other midyear election changes may be permitted under your plan (refer to “Change in Status” section). To under the Plan. State law may require shorter waiting periods for insured group health plans. California law
request special enrollment or obtain more information, contact your Human Resources Representative. requires fully-insured plans to comply with the more restrictive waiting period limitation of no more than 60-
“HIPAA Special Enrollment Opportunities” include: days.
COBRA (or state continuation coverage) exhaustion Preexisting Condition Exclusion
Loss of other coverage (1) Effective for Plan Years on or after January 1, 2014, Group health plans are prohibited from denying
Acquisition of a new spouse or dependent through marriage (1), adoption (1), placement for adoption (1) or coverage or excluding specific benefits from coverage due to an individual’s preexisting condition,
birth (1) regardless of the individual’s age. A PCE includes any health condition or illness that is present before the
Loss of state Children’s Health Insurance Program coverage (e.g., Healthy Families) coverage effective date, regardless of whether medical advice or treatment was actually received or
(60-day notice) (1) recommended
Employee or dependents become eligible for state Premium Assistance Subsidy Program (60-day notice)
“Change in Status” Permitted Midyear Election Changes Continuation Coverage Rights under COBRA
Due to the Internal Revenue Service (IRS) regulations, in order to be eligible to take your premium You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This
contribution using pre-tax dollars, your election must be irrevocable for the entire plan year. As a result, notice has important information about your right to COBRA continuation coverage, which is a temporary
your enrollment in the medical, dental, and vision plans or declination of coverage when you are first extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may
eligible, will remain in place until the next Open Enrollment period, unless you have an approved “change become available to you and your family, and what you need to do to protect your right to get it. When you
in status” as defined by the IRS. become eligible for COBRA, you may also become eligible for other coverage options that may cost less than
Examples of permitted “change in status” events include: COBRA continuation coverage.
Change in legal marital status (e.g., marriage (2), divorce or legal separation) The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget
Change in number of dependents (e.g., birth (2), adoption (2) or death) Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other
members of your family when group health coverage would otherwise end. For more information about your
Change in eligibility of a child rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan
Change in your/your spouse’s/your registered domestic partner’s employment status (e.g., reduction in Description or contact the Plan Administrator.
hours affecting eligibility or change in employment)
You may have other options available to you when you lose group health coverage. For example, you may
A substantial change in your/your spouse’s/your registered domestic partner’s benefits coverage be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage
A relocation that impacts network access through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket
Enrollment in state-based insurance Exchange
costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for
which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.
Medicare Part A or B enrollment
Qualified Medical Child Support Order or other judicial decree
(1) ”
Indicates that this event is also a qualified “Change in Status
A dependent’s eligibility ceases resulting in a loss of coverage (3) (2)
Indicates this event is also a HIPAA Special Enrollment Right
Loss of other coverage (2) (3)
Indicates that this event is also a COBRA Qualifying Event
Change in employment status where you have a reduction in hours to an average below 30 hours of
service per week, but continue to be eligible for benefits, and you intend to enroll in another plan that
provides Minimum Essential Coverage that is effective no later than the first day of the second month
following the date of revocation of your employer sponsored coverage
You enroll, or intend to enroll, in a Qualified Health Plan (QHP) through the State Marketplace (i.e.
Exchange) and it is effective no later than the day immediately following the revocation of your employer
sponsored coverage.
You must notify Human Resources within 30 days of the above change in status, with the exception of the
following which requires notice within 60 days:
Loss of eligibility or enrollment in Medicaid or state health insurance programs (e.g., Healthy Families)
Playworks 2018 Benefits Information Guide 27.You can also read
