2021 MEWA Admin Guide by AultCare

Administrative Manual

Table of Contents

1. Contact Information 2. Website Log-In 3. Enrollment Information 4. Explanation of Benefits and Appeals Process 5. Monthly Invoices 6. Enrollee Questionnaires and Forms 7. SBC Guidelines 8. Miscellaneous 9. Compliance

Contact Information Sales and Retention Department Company representatives* should contact the Sales and Retention Department to request new enrollment packets and any other issues not listed below. Phone: 330-363-6390 Fax: 330-454-7845

Service Center Company representatives and employees should contact the Service Center for questions regarding benefits that your plan covers or an outstanding claim. An AultCare Service Representative is available Monday through Friday 7:30 am to 5:00 pm. Phone: 330-363-6360 or 800-344-8858 Fax: 330-438-9804 Email: insuredservice@aultcare.com

Billing Department Company representatives may contact the Billing Department with questions in regards to monthly invoices. Phone: 330-363-6360 Fax: 330-363-5012

Member Services/Eligibility Department Company representatives may contact the Member Services/Eligibility Department with enrollment questions. Phone: 330-363-6360 Fax: 330-363-7746 Email: aultcareeligibility@aultcare.com

Visit our website at www.aultcare.com *Company representatives are individuals authorized to request information on behalf of the company

Website Log-In

Attachment #1: Employer Account Registration Guide

Attachment #2: File Retrieval Guide

Attachment #3: Blue Button Website Information

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AultCare Employer Account Registration Guide

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Background Welcome to our AultCare family. Whether you are a new member, or have been with us for many years, we are proud to help you and your employees with one of your most precious commodities, your health. We’ve created an area on www.aultcare.com designed just for you. You can use the online area to communicate with us, make changes to your groups, send and retrieve files, access your EOBs and more. Before you or your group members can use the AultCare website as a logged in member, you must register for a secure online account. This document is designed to walk you through each step to create your online members account. Once you’ve created an account, we encourage you to read the other “Website How to Guides” for employers. If you have questions, you can contact your group coordinator, or for technical assistance, email the AultCare Web Team at AultConnect@AultCare.com.

Sincerely,

Your AultCare Team

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Creating your Employer login on the AultCare website Open a web browser and go to www.AultCare.com Click on the Account Login link at the right of the screen.

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Click on the "Employer Login" button. Then click on the "Register for a new account" link.

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Select “Employers” as your “Membership Type” and click on the “SIGN UP NOW” button.

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Step # 1 You must agree with our “Terms of Service” before you can create an account with us. From this page: 1. Select “I Agree” to agree with the “Terms of service” outlined on this page. 2. By entering your name next to the “By” textbox, you are signing your signature.

Click on “CONTINUE” button to proceed.

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Step # 2 Enter the following information     

Your first name Your middle initial Your last name A phone number where we can reach you The title of your position at your company

Click on “CONTINUE” button to proceed.

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Step # 3 Fill in the Fields Below as Required 1. Enter the 9 digit Tax ID number of your company (without the dash) 2. Enter the name of your company 3. Enter the street address, City and State of your company Adding Group Numbers 1. 2. 3. 4.

Enter the Group Number of your company Click “Add” button The Group Number will then appear in a listbox underneath If you need to add more groups, repeat the steps in this section Optional Information

If you already know someone at AultCare (e.g Account Coordinator), you can help us expedite the verification process for your employer account by supplying the following ”optional” information:1. Enter Your Phone Number 2. Enter the name of the person you know at AultCare; (e.g. Group Account Coordinator) Click on “CONTINUE” button to proceed.

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Step # 4 - Enter the following information: 

Username for your account When you enter a username, the system will tell you if it is already taken or not. If the username is already taken, please choose and enter a different username.

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Password for your account The password that you choose should consist of: o 8 characters o At least one uppercase character and one lowercase character o At least one number

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Your email address Please enter correct email address. We will use this email to communicate with you.

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Three security questions with answers Please select your security questions carefully. We will ask you these questions if you forget your username and/or password.

Click on “CONTINUE” button to proceed.

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Step # 5 Fill this page in the following manner 1. Reason for requesting access Select your reason(s) for requestng access. You can select more than one reason. 2. SFTP IP Addresses If you will be using secure FTP transfer in addition to our website, please list the IP address(s) that will be used. 3. Authorization to represent your company Select “I Agree” to state that you are an authorized representative of the company you are applying this account for. Sign your name electronically by entering your name in “By” textbox. Optional Information on this page If you need to send us a message or have a question, enter it in the comments box. Click on “CONTINUE” button to proceed.

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This is the final page of your account registration process. You must agree to the Trading Partner Agreement specified on this page. You can print this agreement by clicking on “Print this agreement”. From this page: 1. Select “I Agree” to agree to the “Trading Partner Agreement” outlined on this page; 2. Indicate your approval by entering your name in “By:” textbox; Click on “FINISH” button to proceed.

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Upon successful completion of your account registration, you will see the following message:

Thank you for the submission of your registration request. You will be receiving an email shortly advising on the next steps to complete the process.

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Upon completion of the registration process, you should receive an email stating that the registration process has been completed. (Note: At this time, your account is not active yet) We will review the application and finish with the account setup process. When your account setup has been completed, you will receive an email informing you that your account has been set up and is ready for use. (Note: At this time, the process is complete and you will be able to login to our website)

If you have questions, you can contact your group coordinator, or for technical assistance, email the AultCare Web Team at AultConnect@AultCare.com.

Member ID Cards in the Employer Portal 1. Login to the Employer Portal, then click Eligibility.

2. Click Search to view a list of Active members.

3. Click the name of the person you want to view the card for.

4. Click “Member Card click here” to view a copy of the ID card.

Enrollment Information The following information is provided to explain the process of enrolling and terminating employees and/or dependents. In order to ensure timely enrollment of new eligible employee, please complete and return the membership report and group employee application.

Attachment #1: Membership Report All employee changes, additions and deletions are to be submitted on a Membership Report. Please be sure your company’s name and group number appear on each sheet. Refer to the Transaction Codes listed at the bottom of the form and include a Group Employee Application (see explanation below) when indicated.

Attachment #2: Group Employee Application Whenever an addition or change is made on the Membership Report, it is also necessary to have the employee complete a Group Employee Application. Be sure to have all new employees, and those employees requesting a change in their coverage, complete the entire form, unless otherwise instructed, to prevent delays. If an employee and/or dependent was covered by a prior health plan, attach a Creditable Coverage Letter provided by the former carrier. If this information is not provided, AultCare will not be able to credit the system for the amount of time they were insured. Any questions you have as you complete this form may be directed to the Service Center. Once completed, these forms may be mailed to: AultCare Eligibility Department PO Box 6910 Canton, OH 44706 Or it may be faxed directly to our eligibility Department at 330-363-7746. All changes must be received by the 10th of the month to be reflected on your next bill.

Attachment #3: MEWA Fact Sheet Attachment #4: HIPAA Disclosure Form/Notice of Privacy Practice/Member Guide Letter

The attached enclosures must be given to any potential AultCare enrollee in addition to the Group Employee Application so that the person understands portability and creditable coverage.

Attachment #5: Getting the Most from your Health Plan

Directions on How to Complete the Monthly Membership Report (MMR) The MMR (Monthly Membership Report) is a tool for the client to transmit enrollment information to AultCare. Listed below are instructions to assist the client when completing the form. Addition to Enrollment  #1 - Use transaction code #1 when adding a new enrollment.  Provide enrollment form.  If enrollment is due to the dependent losing their coverage with SCHIP (State Children’s Health Insurance Plan), please indicate this in the comments section of the MMR. Due to HR2, the dependent has a special enrollment period of 60 days.  

#1a - Use transaction code #1a to indicate a special election period or a measurement period qualifying event. Provide enrollment form.

Change to Enrollment  #2 – use when there is a change to enrollment from single coverage to family coverage.  Provide enrollment form.

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#3 – use when there is a change to enrollment from family coverage to single coverage. Provide enrollment form.

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#4 – use when there is a name or address change. If name change, provide new name in the comments section and provide enrollment form. If address change, provide new address in the comments section.

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#5 – use when adding a dependent to an existing plan. Specify dependents name in comments section. Provide enrollment form.

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#6 – use when deleting a dependent. Specify dependents name in comments section. Provide enrollment form with waiver section signed. Provide divorce decree, if applicable.

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#7 – use when the above change reasons do not apply (ex. change in location) Specify change in the comments section. Provide appropriate paperwork, if necessary.

P.O. Box 6910 / Canton, OH 44706 PHONE: 330-363-6360 / TOLL FREE: 1-800-344-8858 TTY LINE: 330-363-2393 / 1-866-633-4752 for the hearing impaired WEBSITE: www.aultcare.com

Cancellation of Coverage  #8 – use when an employee left employment or terminates.  Include date of termination in comments section.  Provide in the comments section whether termination was voluntary or involuntary.  Provide in comments section whether termination was due to gross misconduct.  

#9 – use when there is a cancellation of coverage due to a death. Specify date of death and member’s name in the comments section.

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#10 – use when there is a cancellation due to a layoff. Provide in comments section the date of the layoff and the last date worked. Provide in the comments section whether layoff was voluntary or involuntary.

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#11 – use when there is a cancellation because the member is waiving coverage. Provide enrollment form with waiver section signed. Specify in the comments section that member is waiving coverage.

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#12 – use when there is a cancellation because the member had a reduction in hours and is no longer meeting the minimum eligibility requirements.

Continuation of Coverage  #13 – use when member elected COBRA coverage.  Provide expiration date of COBRA coverage in the comments section.  Provide copy of COBRA election form and verification of first payment.   

#14 – use when member elected State Continuation Coverage. State Continuation Coverage is an extension of the plan for 12-months for companies under 20 employees. Please indicate State Continuation Coverage expiration date in the comments section.

Other  #15 – use when none of the above transaction codes apply. Please provide a detailed explanation. Revised 6/15, 4/15, 11/11

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P.O. Box 6910 / Canton, OH 44706 PHONE: 330-363-6360 / TOLL FREE: 1-800-344-8858 TTY LINE: 330-363-2393 / 1-866-633-4752 for the hearing impaired WEBSITE: www.aultcare.com

Cancellation/Continuation Notification Today’s Date: Employer: Group Numbers: Completed By: EFFECTIVE DATE OF TRANSACTION

LAST,

EMPLOYEE NAME FIRST,

COVERAGE TYPE TRANS. ID NUMBER M-Medical, D-Dental, CODE V-Vision

COMMENTS

Please indicate all cancellations on this report. Do not make changes on the monthly premium statement. Utilize transaction codes for each change. Include enrollment form where indicated and provide within 31 days of event. *Signed enrollment forms must include spouse’s signature when applicable. TRANSACTION CODES Cancellation of Coverage: A. Cancellation – Left Employment/Termination (Include in Comments section Termination Date & if Voluntary, Involuntary or due to Gross Misconduct) B. Cancellation – Deceased (Specify Date of Death in Comments section) C. Cancellation – Layoff (Include in Comments section the Date of Layoff & if Voluntary or Involuntary) D. Cancellation - Waiving (Specify in Comments if waiving coverage, include Enrollment Form with waiver section signed*.) E. Cancellation – Reduction in hours: no longer meets minimum eligibility requirements

Continuation of Coverage: F. COBRA Coverage Elected (Include Expiration Date, Copy of signed election form & proof of first payment) G. State Continuation of Coverage (For employers under 20 – please indicate expiration date of State Continuation of Coverage in the Comments section. Please include a signed Continuation of Coverage Election Form.) Other: H. Other (Include detailed explanation)

I understand AultCare is relying on my answers to the above questions to ensure overall compliance for my group health plan. I certify the answers are true to the best of my knowledge and belief. I also understand I am responsible for promptly notifying AultCare if any information changes. Please submit this form to AultCare by one of the following methods: Email: aultcareeligibility@aultcare.com | Fax: 330-363-7746 | Mail: AultCare Member Services PO Box 6910 Canton, OH 44706 7121/21

Please contact Customer Service with any questions: 330-363-6360

Guide for Completing the Enrollment Application/Change Form Please complete this form in its entirety.

EMPLOYER USE ONLY This section is to be completed by the employer representative. Leased Network Employer Group Numbers Designate if the employee is accessing an out-of-area List all AultCare group numbers that apply. (Medical, network. (Cigna, First Health Network, etc.) Dental, Vision) AultCare Effective Date Employee Location/Job Classification Provide the date the coverage is set to begin. Use this section to designate an employee classification, if needed. These designations should be set-up as rate codes during the implementation of your plan. (Example: hourly vs. salary; executive or management; physical plant location.)

OTHER COVERAGE INFORMATION This section is to be completed by the employee if any covered persons have other health insurance coverage.

EMPLOYEE COVERAGE ELECTION This section is to be completed by the employee.

All Employees Signature______________ Date __________ Employee must sign and date when electing coverage. Employees Waiving Coverage Reason for waiver of coverage: ______________ Employee and spouse must provide reason for waiving coverage. Signature______________ Date __________ Employee and spouse must sign if either are waiving coverage. Please submit this form to AultCare by one of the following methods: Email: aultcareeligibility@aultcare.com | Fax: 330-363-7746 | Mail: AultCare Member Services PO Box 6910 Canton, OH 44706 Employer to send completed form to AultCare by one of the following methods.

A) NEW POLICY APPLICATION  New Group  New Hire  Open Enrollment  Waiving Coverage Designate the reason for applying for coverage or if coverage is being waived. If waiving coverage, a signature is required on the back of this form. Qualifying Event — Explain: If applying for coverage for a qualifying event, please provide a detailed explanation. (For example: spouse lost coverage, marriage, birth, adoption.)

Hire Date If the original hire date is not available, please provide the month and year. Coverage Type(s) Requested: Check All that Apply Medical Dental Rx Vision STD Life Flex HSA HRA Be sure to check all benefit options being elected. Plan Requested: Plan Name Use this section to designate the employee’s plan election. (Example: PPO, HDHP or OPT 1, OPT 2, etc.)

ADDITIONAL COVERAGE FOR DEPENDENTS This section is to be completed by the employee. A(dd), C(hange), D(elete) Please provide the reason code for enrolling or disenrolling dependents. Social Security Number SSN are required for all dependents with coverage. 7120/21

Benefits Selected (M,D,V,R) List all that apply. Other Insurance Coverage? (Y/N) If yes, please complete the other coverage information on the back of this form.

MEDICARE INFORMATION This section is to be completed by the employee if any covered persons are enrolled in Medicare. OTHER INFORMATION This section is to be completed by the employee to designate any specified needs.

Enrollment Application/Change Form without Medical Questions AULTCARE USE ONLY Date Completed

EMPLOYER USE ONLY Employer Group Numbers Leased Network AultCare Yes No Effective Date

Employer Name Employee Location/ Job Classification

Completed By

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A) NEW POLICY APPLICATION  New Group  New Hire  Open Enrollment  Waiving Coverage

ADDITIONAL COVERAGE FOR DEPENDENTS

EMPLOYEE COVERAGE ELECTION

Qualifying Event — Explain: B) EMPLOYEE INFORMATION

Last Name

Gender Male Female Home Address (Number & Street) Preferred Phone Number

Date of Birth

Date of Qualifying Event (Qualified enrollment must be made within 31 days of event)

First Name

Middle Initial

Suffix

Social Security Number County Email Address

City State Primary Care Physician Name (HMO Only)

Zip Code

Marital Status  Married — Date of Marriage Single Widowed Divorced Separated Employment Currently on Hire Hours Worked Are you currently actively at work? Status Full Time Part-Time Retired COBRA Date Per Week Yes No If not, why? Coverage Type(s) Requested: Plan Requested: Check All that Apply Medical Dental Rx Vision STD Life Flex HSA HRA Plan Name A(dd), Relationship to C(hange), Enrollee D(elete)

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First Name

M.I.

Last Name (If different from employee)

Social Security Number

Benefits Gender Other Insurance Selected Date of Birth (M or F) Coverage? (Y/N) (M,D,V,R)

M - Medical D - Dental V - Vision R - Prescription

OTHER COVERAGE INFORMATION

Upon your effective date with this plan, will you or any of your family members have other health insurance?  YES  NO

MEDICARE INFORMATION

IMPORTANT INFORMATION

Do you or your spouse or any enrolled dependents have Medicare coverage?

If yes, what is the name of the other insurance company?

OTHER INFORMATION

If yes, what type(s) of other health insurance will you have? Check all that apply

 Medical

 Dental

 YES  NO

Medicare Enrollee Name

Medicare ID Number

Do you have Medicare Part D coverage?  YES  NO

If yes, what is the effective date of your coverage?

 Rx

 Vision

If yes, please provide information below.

Hospital Effective Date (Part A)

Medical Effective Date (Part B)

Do you, or any of your dependents, have any cultural or linguistic needs?  YES  NO If yes, what are they?

RELEASE OF INFORMATION/PLEASE READ CAREFULLY I am applying for group health coverage through AultCare Insurance Company and its related entities (“AultCare”). I acknowledge the coverage for which I am applying is subject to eligibility requirements and the terms of the policy. I acknowledge that I have read and understood all of the information contained within this document. Additionally, I acknowledge that all information that I have entered in this application, to the best of my knowledge, is complete, true, and accurate. I understand that any attempt to mislead or defraud AultCare is considered insurance fraud. INSURANCE FRAUD WARNING: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. I acknowledge that AultCare may use and disclose my protected health information, as well as, the protected health information of my family for payment, treatment, and operations. This information may be disclosed to other insurance companies, third party administrators, state and federal agencies, health care providers and other organizations and persons that perform professional, business, or insurance functions for AultCare, as permitted by state and federal law. The information may be used for, but not limited to, processing enrollment applications, risk classifications, detecting or preventing fraud, internal and external audits, claims administration, case management, quality improvement programs, public health reporting, law enforcement investigations, coordination of benefits, medical management programs, and subrogation.

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All Employees I have read all of the statements contained in this application and declare that by signing this application the information I have provided is true and complete to the best of my knowledge. Electronic Signature Disclaimer: Please be advised that AultCare will not deny the enforceability or effect of an electronic signature solely because it is in an electronic format. Any valid signature provided in this section shall have the same legal effect and enforceability as a manually executed signature. Signature

Date

Employees Waiving Coverage I have read all of the statements contained in this application and declare by signing that the information I have provided is true and complete to the best of my knowledge. I understand that I am eligible to apply for coverage through my employer. And I acknowledge that, subject to the terms and conditions of the policy, by waiving coverage at this time, I may not be able to enroll myself or my family again until the next annual enrollment period or a special enrollment period. I hereby decline coverage for (check all that apply):  Myself  Spouse  Child(ren) Reason for waiver of coverage: Signature

Spouse Signature

Date

Per the 2015 FTC TCPA, AultCare or a vendor of AultCare, may contact you for demographic, satisfaction, and/or medical care management information in accordance with its obligation under Federal Law.

Please submit this form to AultCare by one of the following methods: Email: aultcareeligibility@aultcare.com | Fax: 330-363-7746 | Mail: AultCare Member Services PO Box 6910 Canton, OH 44706 6241/20

MEWA Fact Sheet  Open enrollment is the month immediately prior to your renewal date.  Member coverage ends on the date of termination.  If you have an employee who becomes effective on the first day of the month, you will be invoiced for the entire month. If they become effective after the first of the month, you will not be charged until the following month.  If an employee terminates after the first of the month, you will be charged for the entire month.  COBRA vs. State Continuation o COBRA is for companies with 20 or more employees on at least half of the previous calendar year. AultCare to administer. o State Continuation is for companies with fewer than 20 employees. Must be involuntary termination other than gross misconduct. Employer to handle. (See attached model audit form.)  If we do not receive the completed annual MEWA attestation by the date indicated, your group may be placed on hold. Once placed on hold, claims will not be paid and prescription benefits will be suspended until the MEWA attestation is received.  Set-up your account on the AultCare website to retrieve your monthly invoices and to access other important information. Refer to the Administrative Guide for instructions.

REGIONAL

Administered by

Various state and federal laws have requirements based on employee counts. When counting employees, it’s important to conduct a related employer analysis.

EMPLOYEE COUNT ANALYSIS The information detailed below does not constitute legal advice and is intended only for informational purposes. Please reach out to your benefits counsel to discuss your individual circumstances.

RELATED EMPLOYER ANALYSIS requires counting all employees of all members of the employers in a controlled group of companies or affiliated service group to determine employee count. Below is a summary of those groups. • A controlled group may exist when two or more companies have any of the following:

- A Parent-Subsidiary Relationship: Exists when one or more chains of organizations are connected through ownership of a common parent company and 80% or more of the voting power or total value of each member of the group is owned by another member of the group, except for the common parent - A Brother-Sister Relationship: Exists when at least 50% of the voting power or total value of two or more organizations is owned by the same 5 or fewer persons taking into account only the ownership of each such organization that is identical for each other organization - A Combination Relationship: Exists when two or more organizations are members of a group that has common ownership which includes both parent-subsidiary relationships and brother-sister relationships, in which case all such organizations are considered the same controlled group of business • An affiliated service group may exist when two or more organizations have a service relationship and/or

ownership relationship with one another as satisfied by 1 of 3 tests (A-Org Test; B-Org Test; or Management Group Test)

More information about Controlled and Affiliated Service Groups can be found in the following IRS publication: https://www.irs.gov/pub/irs-tege/epchd704.pdf

CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA) ANALYSIS COBRA generally applies to all private sector group health plans as well as plans sponsored by state and local governments. To be subject to COBRA, employers need to have at least 20 employees on more than 50% of their typical business days in the previous calendar year. When counting employees for COBRA purposes, both full- and part-time employees are counted, taking into consideration the above Related Employer Analysis. Each part-time employee counts as a fraction of a full-time employee. The fraction should be equal to the number of hours worked divided by the number of hours required to be considered full-time. (For example, a company requires a full-time employee work 40 hours a week. A part-time employee who works 20 hours a week is considered ½ of a full-time employee.) If you have fewer than 20 employees, you may be subject to state continuation of coverage requirements under ORC 3923.38 depending on whether your group health plan is subject to state regulation. These plans typically include Insured, MEWA plans, and self-funded public employers. For more information, visit https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/ publications/an-employers-guide-to-group-health-continuation-coverage-under-cobra.pdf 7060/20

Complete this form to update Group Size and Eligibility changes. Changes will become effective on your renewal. Form is to be completed no later than 15 days days prior to renewal date.

Canton Regional Chamber Health Fund Renewal Attestation GENERAL INFORMATION Company Name: Current Group Number:

Current Plan Design(s):

Are you a Public Employer:  Yes  No If yes, please check one of the options below:  The Broker has not been retained as a consultant by the Public Employer for the purchase of insurance for the Public Employer  The Broker has been retained as a consultant by the Public Employer for the purchase of insurance for the Public Employer and is not authorized to receive commissions or other forms of compensations without the prior written consent of the Public Employer GROUP SIZE INFORMATION 1. Is your company a part of an affiliated service group or controlled group?  YES  NO (Refer to the Employee Count Analysis Fact Sheet) If yes, please list the other Related Employer names b. If yes, please consider that fact when answering the remaining questions in this section. 2. Provide the following current employee counts: Full-time:

Part-time:

Average number of seasonal and temporary employees for current year:

Other (Briefly describe): Total number of employees: 3. To determine the appropriate continuation of coverage (COBRA v State Continuation), provide the following counts for 50% of the typical business days in the previous calendar year: Full-time:

Part-time (Each is counted as a fraction of a full-time employee):

(Refer to the Employee Count Analysis Fact Sheet)

Total number of employees: ELIGIBILITY INFORMATION Waiting Period – New hires on or after renewal date will be eligible to participate in plan on: (Eligible employees are those working 30 hours or more per week)  Keep existing waiting period  Change in the waiting period If a change, complete below:  1st of the month following date of hire  30 days-coverage effective on 31st day  90 days-coverage effective on 91st day

 1st of the month following 30 days  45 days-coverage effective on 46th day  Date of hire

 1st of the month following 60 days  Contract start date

ACKNOWLEDGMENTS AND SIGNATURES I hereby certify that the information provided herein, relative to this application and agreement form, is true and complete to the best of my knowledge. I understand that all terms of the group insurance coverage are governed by the terms of the group insurance policy(ies). I understand that it is the employer’s responsibility to notify all covered employees of any change or termination in coverage. I understand that Workers’ Compensation coverage is not a policy benefit under any of the plans in the application. I also understand that the Group Health Insurance Policy is not a substitute for Workers’ Compensation and does not satisfy any legal requirement for such coverage. Any person who with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. NOTE: FALSE INFORMATION MAY RESULT IN THE FULL OR PARTIAL DENIAL OF A CLAIM AND/OR THE IMMEDIATE CANCELLATION OF COVERAGE FOR THE GROUP. By: Date: (Signature of Authorized Company Representative) (Title) Witness: Date: 2021 – CRCCHFATT – 9/20

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Ohio’s Statutory Requirements Regarding

Continuation of Employee Health Care Coverage Ohio’s law provides that an employee has a right to continue coverage under his or her employer’s group health plan upon involuntary termination of employment if certain requirements are met. All employer groups should be knowledgeable about Ohio’s continuation insurance laws; employers with fewer than 20 employees must be particularly aware of the requirements. For those employers, Ohio’s continuation coverage is the only continuation coverage available to their employees.

An employee is eligible for continuation of coverage if he or she satisfies all of the following requirements: •

Employee must have been continuously covered under the employer’s group health plan during the entire three months preceding his or her termination.

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Employee must have been involuntarily terminated for reasons other than gross misconduct.

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Employee is not eligible for or enrolled in Medicare or other group health coverage or COBRA.

If an employee satisfies these requirements, then the employer must offer that employee the right to continue coverage under its group health plan (even after the employee loses eligibility as a member of that group). The employer must inform the employee of his or her contribution amount in advance. Some important notes: •

Coverage is only available for a maximum of twelve months.

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Coverage is not required to include benefits in addition to the hospital, surgical or major medical coverage, and prescription drug coverage if covered under the group policy. However, it may include dental, vision, or other benefits under the health plan.

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Payment is due from the employee to the employer in advance of each month of continuation coverage.

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Continuation coverage ceases if the employee fails to make timely premium payments. There is no grace period.

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Coverage ceases if the employee becomes eligible for or is covered under Medicare or any other group health plan.

This information is only intended to highlight the major requirements for the right to receive continuation of coverage and is not intended to offer legal guidance or advice regarding how an employer can comply with Ohio’s laws. There are many other significant requirements relating to continuation insurance not covered in this notice. Employers are advised to consult with their tax professionals and attorneys to ensure compliance with these state laws. Employers may also call the Ohio Department of Insurance at 614.644.2658 or log on to www.insurance.ohio.gov for additional information.

OHIO STATE CONTINUATION GUIDELINES

OHIO STATE CONTINUATION GUIDELINES Eligibility Requirements Qualifying Event (Must Meet All) Termination 1) Covered by of group health plan Employment at least three months prior to termination;

Eligible Beneficiary Employee Spouse Dependent Child(ren)

Maximum Coverage Time Notice Requirements 12 months 1) Employer must notify Employee of right of continuation at time Employee is notiified of termination

2) Involuntary termination other than gross misconduct

Reservist called or ordered to active duty

3) Not eligible for or enrolled in Medicare or other group health coverage 1) Employee is a reservist called or ordered to active duty; and 2) Policy in effect covers eligible person at time of active duty.

Election Employee must request continuation coverage and pay the first contribution to the Employer by the earliest of the following dates:

Coverage Ceases When 1) Premium payments are not make on a timely basis. NOTE: Payment can be made by parties other than the Employee.

2) Employer must notify 1) 31 days after date Employee's Insurer of Employee's coverage terminates continuation of coverage.

2) Group policy is terminated by the Employer.

2) 10 days after date Employee's coverage terminates, if Employer has notified Employee of right to continuation prior to that date

3) Period of 12 months expires after date Employee's coverage would have terminated because of termination of employment.

3) 10 days after date Employer 4) Employee becomes eligible for notifies Employee of right to or covered by Medicare or any continuation if notice is given after group health plan. Employee's coverage terminates Employee Spouse Dependent Child(ren)

18 months after date coverage would otherwise terminate with an option to extend to 36 months.

At the time reservist is called to duty, Employer notifies Employee about continuation.

Eligible person files a written election of continuation with the Employer and pays the first required contribution no later than 31 days after the date on which the coverage would otherwise terminate.

1)Premium payments are not made on a timely basis. NOTE: Payment may be made by parties other than the enrollee. 2) Group policy is terminated by the Employer.

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Notice of HIPAA Special Enrollment Rights We would like to take this opportunity to advise you of an important provision in your health care plan. To participate, you must complete an enrollment form. Dependent upon which specific plan you wish to enroll in, you may have to pay part of the premium through payroll deduction. Additionally, HIPAA requires that we notify you of the “Special Enrollment Provision.”

Special Enrollment Provision Loss of Other Coverage. If you decline enrollment for yourself or for another eligible dependent (including your spouse) while other health insurance or group health plan coverage is in effect, you may be able to enroll yourself and your dependents in this plan, if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependent’s other coverage). However, you must request enrollment within 30 days after you or your dependents’ other coverage ends or after the employer stops contributing toward the other coverage. In addition, if you have a new dependent because of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your new dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. To request special enrollment or to obtain more information about the plan’s special enrollment provisions, contact your Human Resources representative or the AultCare Service Center at 330-363-6360 or 1-800-344-8858.

Procedures for Requesting Certificate of Health Plan Coverage HIPAA requires that plan sponsors and/or insurers provide a Certificate of Health Plan Coverage (HIPAA Certificate) to each individual who requests one, as long as it is requested while the individual is covered under the AultCare Health Plan or within 24 months of the individual’s AultCare Health Plan ending. The request also can be made on someone else’s behalf for an individual. For example, an individual who previously was covered under the AultCare Health Plan may authorize a new plan in which the individual enrolls to request a certificate of the individual’s health plan coverage from the AultCare Health Plan. An individual is entitled to receive a certificate upon request even if the AultCare Health Plan has previously issued a certificate to that individual. Requests for certificates should be directed to AultCare Corporation, Attn: Member Services, P.O. Box 6910, Canton, Ohio 44706 or by calling the AultCare Service Center at 330-363-6360 or 1-800-344-8858. Telephone requests are accepted only if the certificate is to be mailed to the address the plan has on file for the individual to whom the request relates. Other requests must be made in writing. All requests must include:  The name of the individual for whom the Certificate is requested  AultCare Group Number and Identification Number  The last date the individual was covered under the plan  The name of the person who enrolled the individual in the plan  A telephone number to reach the individual, for whom the Certificate is requested 2016-HIPAA & LCC

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P.O. Box 6910 / Canton, OH 44706 PHONE: 330-363-6360 / TOLL FREE: 1-800-344-8858 TTY LINE: 330-363-2393 / 1-866-633-4752 for the hearing impaired WEBSITE: www.aultcare.com

Required written requests must also include:   

The name of the person making the request and evidence of the person’s authority to request and receive the certificate on behalf of the individual The address to which the certificate should be mailed The requester’s signature

After receiving a request that meets these requirements, the plan will act in a reasonable and prompt fashion to provide the Certificate. NOTE: A pre-existing condition exclusion does not apply to enrollees of any AultCare plans that have renewed effective January 1, 2014 and after. The Certificate of Health Plan Coverage can be used as proof of loss of coverage.

2016-HIPAA & LCC

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P.O. Box 6910 / Canton, OH 44706 PHONE: 330-363-6360 / TOLL FREE: 1-800-344-8858 TTY LINE: 330-363-2393 / 1-866-633-4752 for the hearing impaired WEBSITE: www.aultcare.com

NOTICE OF PRIVACY PRACTICES AULTCARE INSURANCE COMPANY THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. AultCare Insurance Company (also d/b/a AultCare HMO, d/b/a PrimeTime Health Plan, and Aultra), which is part of an Organized Health Care Arrangement with AultCare Corporation and Aultra Administrative Group (collectively referred to as “AultCare,” “We,” or “Our”) is a Group Health Plan Covered Entity under HIPAA. AultCare is committed to safeguarding the Privacy and Security of Protected Health Information of its enrollees and their eligible dependants (referred to as “You”) whether it is oral, paper or in electronic form (“PHI/ePHI”). This Notice of Privacy Practices (“NPP”) describes our HIPAA-compliant policies and procedures for the Use and Disclosure of your PHI/ePHI. It also describes how you can access your PHI/ePHI and your legal rights. This NPP is available on our website www.aultcare.com. If you do not have a computer or internet access, or if you prefer a paper copy of this Notice, please call our Service Center at 330-363-6361 or 1-800-344-8858. Please read this Notice. Feel free to share it with your family or personal representative. Not every use or disclosure of PHI, with or without a signed Authorization, may be listed in this Notice. Uses or disclosures not specified in this Notice generally will require an Authorization. Terms Used in this Notice Business Associates. We contract with outside persons or entities called business associates, who may access, use, or disclose PHI/ePHI to perform covered services for us, such as auditing, accounting, accreditation, actuarial services, and legal services. Business associates must protect the privacy and security of your PHI/ePHI to the same extent we do. If a business associate delegates responsibilities for performing services to a subcontractor or agent, that subcontractor or agent also is considered to be a business associate, which must comply with HIPAA. Covered Entities. Covered entities include health care providers (e.g. hospitals, doctors, nurses, nursing homes, home health agencies, durable medical equipment suppliers, and other health care professionals and suppliers), group health plans, and health care clearinghouses. AultCare is a group health plan covered entity. Disclose. Disclose means our releasing, transferring, providing access to, or divulging your PHI/ePHI to a third party, including covered entities and their business associates: (1) for treatment, payment, and health care operations; or (2) when you permit us by your signed authorization; or (3) as permitted or required by law. Health Plan. Health plan means an individual or group health plan that provides, or pays the cost of, medical care and includes a health insurance issuer, HMO, Part A or B of Medicare, Medicaid, voluntary prescription drug benefit program, issuer of Medicare supplemental policy, issuer or a long-term care policy, employee welfare benefit plan, plan for uniformed services, veterans health care program, CHAMPUS, Indian health service program, federal employee health benefit program, Medicare+Choice program, Medicare Advantage plan, approved state child health plan, high risk pool, and any other individual or group health plans or combination that provides or pays for the cost of medical care. AultCare is a group health plan.

Health Care Operations. We will use PHI/ePHI for health care operations that include quality assurance, performance improvement, utilization review, accreditation, licensing, legal compliance, provider and supplier credentialing, peer review, business management, auditing, enrollment, underwriting, reinsurance, and other functions related to your health plan and its status as a group health plan, as well as offering and providing preventive, wellness, case management, and related services. We may disclose your PHI/ePHI to another health care facility, health care professional, or health plan for purposes of quality assurance, case management and related services if that facility, professional, or plan also has a relationship with you. Minimum Necessary. We will limit the use or disclosure of your PHI/ePHI to the minimum needed to accomplish the intended purpose of the use, disclosure, or request. Payment. Payment means the activities undertaken a group health plan to obtain premiums or to determine or fulfill its responsibility for coverage and the provisions of benefits under your plan and includes eligibility or coverage determination, coordination of benefits, adjudication and subrogation of health benefit claims, billing, claims management, health care data processing, reinsurance (including stop-loss and excess), determination of medical necessity, utilization review (including pre-certification and retrospective review), and related activities. Protected Health Information (PHI/ePHI). PHI/ePHI means individually identifiable medical and health information regarding your medical condition, treatment of your medical condition, and payment of your medical condition, and includes oral, written, and electronically generated and stored information. PHI/ePHI excludes de-identified information or health information regarding a person who has been deceased for more than 50 years. Treatment. Treatment means the provision, coordination, and management of health care and related services by one or more health care providers, including referrals and consultations between providers or suppliers. Use. Use means our accessing, sharing, employing, applying, utilizing, examining, or analyzing your PHI/ePHI within the AultCare organization for payment and health care operation purposes. Your PHI/ePHI accessible only to members of AultCare’s workforce who have been trained in HIPAA Privacy and have signed a confidentiality agreement that limits their access and use of PHI/ePHI, according to the minimum necessary standard, to perform the authorized purpose. Use and Disclosure of PHI for Treatment, Payment, and Health Care Operations No Authorization Needed. We will create, receive, or access your PHI/ePHI, which we may use or disclose to other covered entities for treatment, payment, and health care operations, without the need for you to sign an authorization. 

Disclosures for Treatment. We will disclose your PHI/ePHI necessary for treatment. For example, a doctor or health facility involved in your care may request your PHI/ePHI that we hold to make decisions about your care.

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Uses and Disclosures for Payment. We will use or disclose your PHI needed for payment. For example, we will use information about your medical procedures and treatment to process and pay claims, to determine whether services are medically necessary, and to pre-authorize or certify services covered by your health plan. We may disclose PHI/ePHI to other governmental or commercial health plans that may be obligated under coordination of benefit rules to process and pay your claims.

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Uses and Disclosures for Health Care Operations. We will use and disclose your PHI/ePHI as necessary or permitted by law for our health care operations. For example, we may use or disclose PHI/ePHI for underwriting purposes; however, we will not use or disclose your genetic information for underwriting purposes.

No Authorization Needed for Business Associates. We may disclose PHI/ePHI to business associates with whom we contract to perform certain covered services, It is not necessary for you to sign an authorization for us to share PHI/ePHI with our business associates. Other Uses and Disclosures of PHI/ePHI Authorization. Except for treatment, payment, or health care operations, or as stated below, we will not use or disclose your PHI/ePHI for any other purpose without your signed HIPAA-compliant authorization, unless required by law. We will not condition your treatment or coverage on your signing an authorization. We will not disclose psychotherapy notes without a signed authorization unless required by law. We will not disclose your PHI/ePHI to your employer without your signed authorization. We will not release medical records if we are subpoenaed, unless you sign an authorization, or the lawyers enter into a qualified protective order, or if we receive a valid court or administrative order. You may cancel your authorization at any time by notifying us in writing. Once we receive your written cancellation, we no longer will disclose your PHI/ePHI. We are not responsible for any use or disclosure of PHI/ePHI according to your authorization before we receive your written cancellation. Communications With You. We may communicate with you about your claims, premiums, or other things connected with your health plan. You may request us to communicate with you by alternative means or at alternatives locations. For example, you may request that messages not to be left on voice mail or that explanation of benefits (EOBs) be sent to post office box or address other than your home. You may send your request to: Privacy Coordinator, P.O. Box 6029, Canton, Ohio 44706. We will honor reasonable requests. Communications with Family or Others Involved In Your Care. With your approval, we may disclose your PHI/ePHI to designated family, friends, guardians, persons authorized by a durable power of attorney for health care, personal representative, or others involved in your care or payment for your care to assist that person’s caring for you or paying your medical bills. If you are unavailable, incapacitated, or facing an emergency medical situation, and we determine that a limited disclosure may be in your best interest, we may share limited PHI/ePHI with these individuals without your approval. We may disclose limited PHI/ePHI to a public or private entity authorized to assist in disaster relief efforts, so it may locate a family member or other persons who may be involved in caring for you. Minors and Emancipated Minors. We will disclose PHI/ePHI of a minor (a person less than 18 years old) to the minor’s parent(s) or guardian. We will not disclose PHI/ePHI to the parent(s) or guardian of an emancipated minor. A minor is considered emancipated if he/she: (1) does not live with his/her parent(s); (2) is not covered by parental health insurance; (3) is financially independent of parent(s); (4) is married; (5) has children; or (6) is in the military. Deceased Enrollees and their Dependents. If you die, we will disclose your PHI/ePHI to the probate court’s appointed executor or administrator of your estate. We may disclose PHI/ePHI to your spouse, family, personal representative, or others who were involved in your care or management of your affairs, unless doing so would be inconsistent with your expressed wishes made known to us.

Other Health-Related Products or Services. We may periodically use your PHI/ePHI to determine whether you may be interested in, or benefit from, treatment alternatives, wellness, preventive, disease management, or healthrelated programs, products or services that may be available to you as an enrollee or eligible beneficiary under your health plan. For example, we may use your PHI/ePHI to identify whether you have a particular illness, and contact you to advise you that a disease management program is available to help manage your illness. If you do not want to be contacted or receive information about these services and programs, you may opt out by contacting the Service Center. Your opting out will not affect any coverage or services we provide to you. We will not use your information to communicate with you about products or services that are not health-related without your authorization. We will not sell or disclose your PHI/ePHI to third-parties for marketing without your authorization, which will indicate whether we receive remuneration for selling PHI. Fundraising. We may contact you about charitable fundraising. If you do not want to be contacted or receive fundraising materials, you may opt out by contacting our Service Center. Your opting out will not affect any coverage or services we provide to you. Research. In limited circumstances, we may use and disclose your PHI/ePHI for research. For example, a research organization wishing to compare outcomes of patients by payer source would need to review a series of records we hold. In all cases where your specific authorization has not been obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board or privacy board that oversees the research. Use and Disclosure of Health Information Permitted or Required by Law We may use or disclose PHI/ePHI, without your authorization, as permitted or required by law, including, but not limited to, the following: Plan Sponsor. We may disclose PHI/ePHI to the plan sponsor of your health benefit plan on condition that the plan sponsor certifies that it will maintain PHI/ePHI provided a confidential manner and will not use it for employmentrelated decisions, other improper employee benefit determinations, or in any other manner not permitted by law. Workers’ Compensation. Ohio law permits us to disclose PHI/ePHI to workers’ compensation agencies and for related purposes when an employee files a workers’ compensation claim or seeks benefits for work-related injuries or illnesses. Public Health Agencies. Ohio law requires us to disclose PHI/ePHI to public health agencies for reporting births and deaths, to help control disease, injury or disability and for reporting cases of suspected abuse, neglect, or domestic violence. FDA and OSHA. Certain Federal laws from the FDA and OSHA require us to disclose PHI/ePHI for reporting adverse events, product problems, and biological product deviations, so safety precautions, recalls, and notifications can be conducted. Regulatory and Licensing Agencies. We will disclose PHI/ePHI to certain Ohio and Federal governmental regulatory and licensing agencies (including the Ohio Department of Insurance) and health oversight agencies for purposes of their reviewing health care system, civil rights, privacy laws, and compliance with other governmental programs. National and Homeland Security. We may disclose information concerning enrollees and their eligible dependants to authorized federal officials for intelligence and other National and Homeland Security purposes.

Protective Services for the President and Others. We may disclose PHI/ePHI to authorized federal officials, so they may protect the President, other authorized persons and foreign heads of state and officials, or to conduct special investigations. Red Cross and Armed Forces. We may disclose PHI/ePHI to the Red Cross or Armed Forces to assist them in notifying family members of your location, general condition, or death. Coroners, Medical Examiners, and Funeral Directors. We may disclose PHI/ePHI to coroners, medical examiners, or funeral directors for them to perform legally authorized responsibilities. Law Enforcement. We may disclose PHI to law enforcement officials when it: (1) is limited to identification purposes; (2) applies to victims of crime; (3) involves a suspicion that injury or death has occurred because of criminal conduct; (4) is needed for a criminal investigation; (5) is needed to prevent or lessen the threat to the health or safety of a person or to the public; (6) is in response to a valid court order; (7) is used to identify or locate a suspect, fugitive or missing person; (8) is used to report a crime on our premises; or (9) is otherwise required by law. Reporting of Wounds. We may disclose PHI/ePHI to law enforcement officials as required by law to report gunshot wounds, stabbing, burns, injuries and crimes. Emergency or Disaster. If the President declares an emergency or disaster, and the Secretary of HHS declares a public health emergency, the Secretary may waive our obligation to comply with any or all of the following Privacy requirements to: (1) obtain your agreement to speak to family members or friends involved in your care; (2) your right to request privacy restrictions; or (3) your right to request confidential communications. Waiver only applies during an emergency period up to 72 hours. Prevent Threat of Serious Harm. We will disclose PHI/ePHI if a reasonable belief exists that it may prevent or lessen a serious and imminent threat to the health or safety to you, another person, or the public, and disclosure is made to a person(s) reasonably able to prevent or lessen the threat, including the target or intended victim of the threat. Proof of Immunization. We may disclose PHI to schools for the limited purpose of showing proof of immunization of a student or prospective student, and the parent, guardian, or person acting in loco parentis does not object. Organ and Tissue Donation. If you are an organ or tissue donor, we may disclose medical information to the organizations that handle: (1) organ procurement; (2) organ, eye, or tissue transplantation; or (3) an organ donation bank, as applicable, to facilitate organ or tissue donation and transplantation. Correction Institution or Custody. If you are an inmate of a jail, prison, correctional institution, or under the custody of law enforcement officials, we may use or disclose medical information about you for purposes of: (1) the institution’s providing you with health care; (2) protecting your health and safety and the health and safety of others; and (3) protecting the safety and security of the correctional institution or custodial facility. Institutional Review Board. We may release PHI/ePHI for certain research purposes where the research is approved by a formal institutional review board with established rules to ensure privacy.

Your Rights Restrictions on Use and Disclosure of Your PHI. You have the right to request restrictions on our use and disclosures of your PHI/ePHI for treatment, payment, or health care operations by notifying us in writing of your request. A restriction request form can be obtained by calling the AultCare Service Center or by visiting our website at www.aultcare.com. We are not required to agree to your request for restriction, unless disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, or the PHI/ePHI pertains solely to a health care item or service for which you or your personal representative has paid out-of-pocket the covered entity in full. In other instances, we will attempt to accommodate reasonable requests, if appropriate. We reserve the right to terminate a restriction at any time if we believe termination is appropriate. We will notify you if we terminate the restriction. You also have the right to terminate any by calling or sending the termination notice to the Privacy Coordinator. Access to Your PHI. You have the right to copy and/or inspect your PHI/ePHI maintained in a designated record set. There are exceptions. You may not have the right to inspect or copy psychotherapy notes or information compiled for civil, criminal or administrative proceedings. Your right may not extend to information covered by other laws or information obtained from someone other than another covered entity. We may deny you access if, in our judgment, seeing the information could endanger the life or safety of you or another. All requests for access must be made in writing and signed by you or your personal representative. If the subject of the request for access is ePHI maintained in one or more designated record sets electronically, and if you request an electronic copy, we will provide you with access to your ePHI in the electronic form and format requested if it is readily producible in such form or format or, if not, in a mutually agreed-to readable electronic form and format. If your request for access directs us to transmit a copy of the ePHI to another person whom you designate, we will provide a copy of the requested ePHI to that designated person. We may charge you for postage if you request a mailed paper copy and will charge for preparing a summary of the requested information if you request such summary. You may obtain an access request form by calling the AultCare Service Center or by visiting our website at www.aultcare.com. Amendments to Your PHI. You have the right to request in writing that PHI/ePHI we maintain about you in a designated record set be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. All amendment requests, in order to be considered by us, must be in writing, signed by you or your personal representative, and must state the reasons for the amendment/correction request. If an amendment or correction you request is made by us, we may also notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary. You may obtain an amendment request form by calling the AultCare Service Center or by visiting our website at www.aultcare.com. Accounting for Disclosures of Your PHI. You have the right to receive an accounting of certain disclosures we made of your PHI after April 14, 2003. There are certain exceptions and limitations, including, but not limited to disclosures made: (1) for treatment, payment, and health care operations; (2) to you or personal representative of your own PHI; and (3) according to your signed authorization. Requests must be made in writing and signed by you or your personal representative. Accounting request forms are available by calling the AultCare Service Center or by visiting our website at www.aultcare.com. The first accounting in any 12-month period is free. You may be charged a fee for each subsequent accounting you request within the same 12- month period. Breach Notification. You have the right to notification if a breach of your PHI/ePHI occurs. We will promptly notify you by first-class mail, at your last known address, or by email (if you prefer) if we discover a breach of unsecured PHI/ePHI, which includes the unauthorized acquisition, access, use, or disclosure of your PHI/ePHI, unless we determine that a low probability exists that the compromise of your PHI would cause you financial, reputational, or other harm. We will include in the breach notification a brief description of what happened, a description of the types of unsecured PHI involved, steps you should take to protect yourself from potential harm, a brief description of what we are doing to investigate the breach and mitigate any potential harm, as well as contact information for you to ask questions and learn additional information.

Patient Concern and Complaint Resolution We are committed to protecting your PHI/ePHI. Despite our best efforts, questions, concerns, or problems may occur. If you have a concern, or if you believe that your privacy rights have been violated or breached, we encourage you to contact us immediately. You may ask a question, express a concern, or file a complaint by writing to the Privacy Coordinator, P.O. Box 6029, Canton, Ohio 44706. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C. in writing within 180 days of a violation of your rights. Under no circumstances, will we “retaliate” against you for expressing a concern or filing a complaint regarding your privacy rights. Changes to this Notification of Privacy Practices We reserve the right to change this Notice of Privacy Practices at any time, which we may make effective for PHI/ePHI we already used or disclosed, and/or for any PHI/ePHI we may create, receive, use, or disclose in the future. We will make material amendments based on changes in the HIPAA laws. The revised notice will be posted on our website www.aultcare.com. Copies of revised notices will be mailed to all enrollees covered by the plan, and copies may be obtained by mailing a request to: Privacy Coordinator, P.O. Box 6029, Canton, Ohio 44706. If you have questions or need further assistance regarding this Notice, you may contact the Service Center at 330363-6360 or 1-800-344-8858. If you are hearing impaired and have access to a TTY phone, you may reach us at our TTY line at 330-363-2393 or 1-866-633-4752. Our call center hours of business are from 7:30 a.m. to 5:00 p.m., Monday-Friday.

EFFECTIVE DATE This Notice of Privacy Practices became effective on April 14, 2003.

Understanding Your Benefits

Dear Member, It is important to us that you understand your benefits, as well as our operating procedures prior to your enrollment. This would include, but is not limited to, the following:       

Covered Benefits Non-Covered Benefits Access to doctors, health care providers, and facilities (Provider Network) Key medical management (utilization management) procedures Potential network, service, or benefit restrictions Pharmaceutical management procedures Policies and practices regarding collection, use, and disclosure of Protected Health Information (PHI), including: o Routine notification of privacy practices o Use of authorizations o Access to medical records o Protection of oral, written, and electronic information across the organization o Information for employers

To ensure this information is easily accessible to our potential members, we provide the information in our Member Guide, which is located on our website: www.aultcare.com. The Member Guide is located on the ‘Member’ page of the website. To request a printed copy of the Member Guide, please contact our Customer Service Department at 330-363-6360 or 1-800-344-8858. Customer service representatives are available weekdays from 7:30am – 5:00pm. (For hearingimpaired assistance, please call 330-363-2393 or 1-866-4752).

GETTING THE MOST FROM YOUR HEALTHCARE PLAN AultCare is dedicated to providing you and and your family with convenient access to healthcare. In order to provide access to quality care, it is important to keep AultCare updated with any major life events. In addition, AultCare may reach out to you if more information is required regarding you and your family to accurately manage your health plan.

MAJOR LIFE EVENTS Notifying AultCare of any major life events ensures continued healthcare coverage. If any of the below life events have recently occurred, please notify your Human Resources Coordinator as soon as possible. » Marriage » Divorce or legal separation » Spouse now working » Spouse loss of health coverage » New baby » Adoption » Child between ages 19 – 25 requires coverage

ADDITIONAL INFORMATION If AultCare requires additional information, you may receive a form in the mail. Please complete the form and return it to AultCare as soon as possible. Examples of additional information:

Other Coverage – If your spouse and/or child(ren) have other health coverage, AultCare will ask you to complete an Other Coverage form each year to confirm.

Divorce/Not Married – AultCare may request a copy of your divorce decree or court order if you are divorced or a single parent covering children on your plan. The required court document provides information on which parent’s healthcare plan has been ordered to pay first. If you do not have a court document, you will be asked to complete an Affidavit for Financial Support annually.

Injury – AultCare will need to know if an injury is related to an accident that may be connected to a Workers’ Compensation claim, automobile or other accident. You will receive an Accident Questionnaire to confirm how the injury occurred.

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Explanation of Benefits and Appeals

Explanation of Benefits: AultCare is now posting Explanation of Benefits (EOB) forms electronically. You can access, view or print an electronic EOB from the AultCare website anytime you want. Please refer to the following instructions. Encourage your employees to obtain access to their claim information on the website or to call the service center to answer specific questions about their claims.

Appeals: The attached documents outline AultCare’s appeal procedures and timelines. AultCare Request for Review by the Ohio Department of Insurance (Use this form if you disagree with our decision to deny your request for External Review) AultCare Treating Physician Certification for Experimental/Investigational ABD (You may have your provider complete this form if your request for benefit determination has been denied as Experimental or Investigational) AultCare Treating Physician Certification for Internal Appeal and/or External Review (You may have your provider complete this form if your request for benefit determination has been denied as Experimental or Investigational or not Medically Necessary) External Review Procedures Summary (An explanation of the new External Review procedure for all Insured and Public Employer Plans effective 01/01/2012) External Review Request Form (Use this form to request an External Review after you have exhausted your internal appeal process with us, unless your request is expedited) Internal Appeal Request Form (Use this form to request an internal appeal. You may also submit your appeal in writing to us)

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Online EOB (Explanation of Benefit) for Claim Guide

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Background

Welcome to our AultCare family. Whether you are a new member, or have been with us for many years, we are proud to help you and your employees with one of your most precious commodities, your health. Our websites give you the ability to view your EOB (Explanation of Benefit) claims online. EOBs contain detailed information relating to claims, including diagnosis and costs involved. The remainder of this document contains information on availability of EOBs and how to find them. Before you can use the AultCare website as a logged in member, you must register for a secure online account. This document is designed to walk you through each step to create your online members account. There are additional “How to Guides” to help members, employers, providers, vendors and brokers located in the AultSupport area of our website. If you have questions, you can email the AultCare Web Team at AultConnect@AultCare.com.

Sincerely,

Your AultCare Team

Access your EOBs on www.aultcare.com

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How do I know if an EOB is available for a claim? Availability of EOBs per claim depends on the date of the claim. An online EOB will be available no earlier than 1 week after we receive a claim. o An EOB will also not be available if it incurred prior to August, 2011. If your claim is through an Aultra group, an online EOB for that claim will be available no earlier than 1 week after we receive claim. o The EOB is also not available if it incurred prior to 2008.

Step 1) Log into our website at www.aultcare.com

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Step 2) Select the "Employer Login" button.

Step 3) Log in with your username and password.

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Step 3) Click on the “Claims and EOBs” link near the top of the page

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Step 4) Enter your search criteria and click the “Search” button

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Step 5) Locate a claim and look for the “EOB” link:

If you have questions, you can contact your group coordinator, or for technical assistance, email the AultCare Web Team at AultConnect@AultCare.com

UNDERSTANDING YOUR EXPLANATION OF BENEFITS (EOB) WHAT IS AN EOB? An EOB is a statement from your health insurance plan detailing the costs towards a medical procedure or service you received. An EOB is not a bill. The purpose of an EOB is to clearly state the cost of care received, costs covered by the insurance plan, and member cost share.

HOW DO I RECEIVE MY EOBS? Members are automatically enrolled to receive their EOBs via their secured, online member account. To access your EOBs: • Visit www.aultcare.com and log into your account. • Select My Claims. • Use the filters to find a specific claim or scroll to the bottom of the page to view your claims. Select a claim number to review the EOB. If you would like to receive paper EOBs via mail, please contact AultCare Customer Service.

ITEMS OF INTEREST When reviewing your EOB, these areas are clearly denoted. On the reverse side of this flyer, there is an example of an EOB. • Claim payment details » Provider name » Claim number • Date of service and name of procedure/service • Cost of procedure/service • Any applicable discounts and provider adjustments • Payment amount paid by AultCare based on your plan’s deductible, copayment and insurance • Amount the member is responsible to pay CONTACT US 330-363-6360 | 1-800-344-8858 www.aultcare.com 6312/20

EXAMPLE: EXPLANATION OF BENEFITS (EOB)

Member address information

Group information Claim payment detail

EXTERNAL REVIEW PROCEDURES SUMMARY

Understanding the External Review Process Under Ohio law, AultCare is required to provide a process that allows a person covered under a health benefit plan or a person applying for health benefit plan coverage to request an independent external review of an adverse benefit determination. An adverse benefit determination is a decision by AultCare not to provide benefits because we believe services are not medically necessary, or not covered, excluded, or limited under the plan, or we believe the covered person is not eligible to receive the benefit. An adverse benefit determination can also be a decision to deny health benefit plan coverage or to rescind coverage. Opportunity for External Review An external review may be conducted by an Independent Review Organization (IRO) or by the Ohio Department of Insurance. A covered person is entitled to an external review by an IRO in the following instances: •

The adverse benefit determination involves a medical judgment or is based on any medical information

•

The adverse benefit determination indicates the requested service is experimental or investigational, and the treating physician certifies at least one of the following: o Standard health care services have not been effective in improving the condition of the covered person o Standard health care services are not medically appropriate for the covered person o No available standard health care service covered by AultCare is more beneficial than the requested health care service

There are two types of IRO reviews, standard and expedited. A standard review is normally completed within 30 days. An expedited review for urgent medical situations is normally completed within 72 hours and can be requested if any of the following applies: •

The covered person's treating physician certifies that the adverse benefit determination involves a medical condition that could seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function if treatment is delayed until after the time frame of an expedited internal appeal or a standard external review

•

The adverse benefit determination concerns an admission, availability of care, continued stay, or health care service for which the covered person received emergency services, but has not yet been discharged from a facility

AC External Review Procedures Summary Rev.2/2012

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•

EXTERNAL REVIEW PROCEDURES SUMMARY

An expedited internal appeal is in process for an adverse benefit determination of experimental or investigational treatment and the covered person's treating physician certifies in writing that the recommended health care service or treatment would be significantly less effective if not promptly initiated

A covered person is entitled to an external review by the Ohio Department of Insurance in either of the following instances: •

The adverse benefit determination is based on a contractual issue that does not involve a medical judgment or any medical information

•

The adverse benefit determination indicates that emergency medical services did not meet the definition of emergency AND the health plan issuer's decision has already been upheld through an external review by an IRO

Request for External Review • The covered person must request an external review within 180 days of the date of the notice of final adverse benefit determination issued by AultCare. •

All requests must be in writing, except for a request for an expedited external review.

•

Expedited external reviews may be requested electronically or orally; however written confirmation of the request must be submitted to AultCare no later than five (5) days after the initial request.

•

If the request is complete AultCare will initiate the external review and notify the covered person in writing that the request is complete and eligible for external review. o The notice will include the name and contact information for the assigned IRO or the Ohio Department of Insurance (as applicable) for the purpose of submitting additional information o The notice will inform the covered person that, within 10 business days after receipt of the notice, they may submit additional information in writing to the IRO or the Ohio Department of Insurance (as applicable) for consideration in the review

•

AultCare will also forward all documents and information used to make the adverse benefit determination to the assigned IRO or the Ohio Department of Insurance (as applicable).

•

If the request is not complete AultCare will inform the covered person in writing and specify what information is needed to make the request complete.

•

If AultCare determines that the adverse benefit determination is not eligible for external review, we must notify the covered person in writing and provide the covered person with

AC External Review Procedures Summary Rev.2/2012

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EXTERNAL REVIEW PROCEDURES SUMMARY

the reason for the denial and inform the covered person that the denial may be appealed to the Ohio Department of Insurance. •

The Ohio Department of Insurance may determine the request is eligible for external review regardless of the decision by AultCare and require that the request be referred for external review. The Department's decision will be made in accordance with the terms of the health benefit plan and all applicable provisions of the law.

IRO Assignment • The Ohio Department of Insurance maintains a secure web based system that is used to manage and monitor the external review process. • When AultCare initiates an external review by an IRO in this system, the Ohio Department of Insurance system randomly assigns the review to an Ohio accredited IRO that is qualified to conduct the review based on the type of health care service. •

AultCare and the IRO are automatically notified of the assignment.

IRO Review and Decision • The IRO must forward, upon receipt, any additional information it receives from the covered person to AultCare. At any time AultCare may reconsider its adverse benefit determination and provide coverage for the health care service. Reconsideration will not delay or terminate the external review. If AultCare reverses the adverse benefit determination, they must notify the covered person, the assigned IRO and the Ohio Department of Insurance within one day of the decision. Upon receipt of the notice of reversal by AultCare, the IRO will terminate the review. •

In addition to all documents and information considered by AultCare in making the adverse benefit determination, the IRO must consider things such as; the covered person's medical records, the attending health care professional's recommendation, consulting reports from appropriate health care professionals, the terms of coverage under the health benefit plan and the most appropriate practice guidelines.

• The IRO will provide a written notice of its decision within 30 days of receipt by AultCare of a request for a standard review or within 72 hours of receipt by AultCare of a request for an expedited review. This notice will be sent to the covered person, AultCare and the Ohio Department of Insurance and must include the following information. o A general description of the reason for the request for external review o The date the independent review organization was assigned by the Ohio Department of Insurance to conduct the external review o The dates over which the external review was conducted o The date on which the independent review organization's decision was made o The rationale for its decision

AC External Review Procedures Summary Rev.2/2012

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EXTERNAL REVIEW PROCEDURES SUMMARY

o References to the evidence or documentation, including any evidence-based standards, that was used or considered in reaching its decision Binding Nature of External Review Decision •

An external review decision is binding on AultCare except to the extent that we have other remedies available under state law. The decision is also binding on the covered person except to the extent the covered person has other remedies available under applicable state or federal law

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A covered person may not file a subsequent request for an external review involving the same adverse benefit determination that was previously reviewed unless new medical or scientific evidence is submitted to AultCare

If You Have Questions About Your Rights or Need Assistance You may contact:

Ohio Department of Insurance ATTN: Consumer Affairs 50 West Town Street, Suite 300, Columbus, OH 43215 800-686-1526 / 614-644-2673 614-644-3744 (fax) 614-644-3745 (TDD) Contact ODI Consumer Affairs: https://secured.insurance.ohio.gov/ConsumServ/ConServComments.asp File a Consumer Complaint: http:ljinsurance.ohio.gov/Consumer/OCS/Pages/ConsCompl.aspx

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AC External Review Procedures Summary Rev.2/2012

EXTERNAL REVIEW REQUEST FORM

Name of person filing request for external review: Relationship to covered person:

□ Covered Person/Applicant

□Authorized Representative (please complete the Appointment ofAuthorized

Representative section)

How would you like us to contact you?

□ Phone

□ Fax

□ Email

□ Mail

Contact information of authorized representative (if applicable} Mailing Address: Daytime Phone:

Evening Phone:

Email Address:

Fax:

Covered Person/Applicant Information Name:

ID Number:

Mailing Address: Daytime Phone:

Evening Phone:

Email Address:

Fax:

Treating Physician/Health Care Provider Information Name: Mailing Address:

Phone Number:

Email Address:

Fax Number:

Contact Person:

Phone Number:

External Review Specifications 1. If your situation is urgent, are you requesting an expedited review?*

□YES

□ NO

2. Is your requested health care service considered an experimental or investigational treatment?** □ NO □YES *If you answer yes, your physician must certify that your condition could, in the absence of immediate medical treatment, result in the following: -Seriously jeopardize your life or health or your ability to regain maximum function, or -Subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim AC External Review Request Form Rev.2/2012

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EXTERNAL REVIEW REQUEST FORM **If you answer yes, your physician must certify that he or she is requesting authorization for a drug, device, procedure or therapy denied for coverage due to the determination that the treatment is experimental and/or investigational and the your medical condition meets certain requirements:

-Standard health care services have not been effective in improving your condition -Standard health care services are not medically appropriate for you -There is no available standard health care service covered by the health plan issuer that is more beneficial than the requested health care service Briefly describe why you disagree with this decision (you may attach additional information, such as a physician's letter, bills, medical records, or other documents to support your claim):

Appointment of Authorized Representative (complete when someone else is representing you in this appeal) You may represent yourself, or you may ask another person, including your treating health care provider, to act as your authorized representative. You may revoke this authorization at any time. I hereby authorize __________________ to pursue my external review on my behalf.

Date

Signature of Covered Person (or legal representative**) Signature and Release of Medical Records

To appeal the denial of coverage, you must sign and date this Appeal Request Form and consent to the release of medical records. __ _ _

_ ___________ hereby request an external review. I attest that the information

provided on this form is true and accurate to the best of my knowledge. I authorize my treating physician, health care provider and/or health plan issuer to release all relevant medical or treatment records to the independent review organization and/or the Ohio Department of Insurance. I understand that the independent review organization and the Ohio Department of Insurance will use this information to make a determination on my external review and that the information will be kept confidential and not be released to anyone else. This release is valid for one year. I understand that I or my authorized representative is entitled to receive a copy of this authorization.

Date

Signature of Covered Person (or legal representative**)

AC External Review Request Form Rev.2/2012

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EXTERNAL REVIEW REQUEST FORM

*Parent, Guardian, Conservator or Other - please specify SEND THIS FORM AND A COPY OF YOUR NOTICE OF FINAL ADVERSE BENEFIT DETERMINATION TO ONE OF THE FOLLOWING ADDRESSES: Fax Number: 330-363-3066

Email Address: appeals@aultcare.com

Mailing Address: Attention: Grievance and Appeal Coordinator P.O. Box 6029 Canton, Ohio 44706 Be certain to keep copies of this form, your Notice of Final Adverse Benefit Determination and all documents and correspondence related to this claim.

AC External Review Request Form Rev.2/2012

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INTERNAL APPEAL REQUEST FORM Name of person filing appeal: Relationship to covered person:

□ Covered Person/Applicant □Authorized Representative (please complete the Appointment ofAuthorized

Representative section)

How would you like us to contact you?

□ Phone

□ Fax

□ Email

□ Mail

Contact information of authorized representative (if applicable) Mailing Address: Daytime Phone:

Evening Phone:

Email Address:

Fax:

Covered Person/Applicant Information ID Number:

Name: Mailing Address: Daytime Phone:

Evening Phone:

Email Address:

Fax:

Treating Physician/Health Care Provider Information Name: Mailing Address:

Phone Number:

Email Address:

Fax Number:

Contact Person:

Phone Number:

Internal Appeal Specifications 1. Are you requesting an expedited appeal because your health, life or ability to regain maximum function may be in □YES □ NO serious jeopardy while you wait up to 30 days for a decision on your appeal? 2. Are you requesting an expedited appeal because your physician certifies that your pain can not be controlled while □YES* □ NO you wait up to 30 days for a decision on your appeal? 3. Are you requesting a Concurrent Expedited Internal Appeal and Expedited External Review and your physician certifies that it is necessary? (Note: Request for External Review form is not required.) DYES* ONO *If you answer YES to question 2 or 3 above, your physician must certify that your condition could, in the absence of immediate medical treatment, result in any of the following: AC Internal Appeal Request Form Rev.2/2012

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INTERNAL APPEAL REQUEST FORM -Seriously jeopardize your life or health or your ability to regain maximum function, or -Subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. You may also have your physician certify if you answer YES to question 1. Briefly describe why you disagree with this decision (you may attach additional information, such as a physician's letter, bills, medical records, or other documents to support your claim):

Signature of Covered Person (or legal representative**)

Date

Signature and Release of Medical Records To appeal the denial of coverage, you must sign and date this Appeal Request Form and consent to the release of medical records. _________________ hereby request an appeal. I attest that the information provided on this form is true and accurate to the best of my knowledge. I authorize my treating physician, health care provider, and/or health plan issuer to release all relevant medical or treatment records to an independent review organization, the Ohio Department of Insurance, and/or my health plan issuer. I understand that the independent review organization, the Ohio Department of Insurance, and/or my health plan issuer will use this information to make a determination on my appeal and that the information will be kept confidential and not be released to anyone else. This release is valid for one year. I understand that I or my authorized representative is entitled to receive a copy of this authorization.

Signature of Covered Person (or legal representative**)

Date

**Parent, Guardian, Conservator or Other - please specify SEND THIS FORM AND A COPY OF YOUR NOTICE OF ADVERSE BENEFIT DETERMINATION TO ONE OF THE FOLLOWING ADDRESSES: AC Internal Appeal Request Form Rev.2/2012

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INTERNAL APPEAL REQUEST FORM Fax Number: 330-363-3066

Email Address: appeals@aultcare.com

Mailing Address: Attention: Grievance and Appeal Coordinator P.O. Box 6029 Canton, Ohio 44706 Be certain to keep copies of this form, your Notice of Adverse Benefit Determination and all documents and correspondence related to this claim.

AC Internal Appeal Request Form Rev.2/2012

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Monthly Invoices An example of the monthly invoice that each company receives is provided on the following page. The invoice you receive may differ in column headings and amounts. The top portion of the invoice indicates the Run Date of the invoice and the Due Date of the payment. AultCare strives to have all bills run by the 15th and mailed by the 25th of each month. Payment is then due by the date indicated. If you have signed up to receive your bill electronically, you will be notified by e-mail that the invoices are available and you will access your invoice throughout our website at www.aultcare.com. Any adjustments made to membership, such as termination, will be indicated in a section before the Grand Total. Eligibility changes that were received by the 10th of the month will be reflected on that month’s bill. General policy is to credit up to three months for terminations, so it is important to be up-to-date with eligibility changes. It is your responsibility to review this monthly billing for accuracy. Please note when mailing in your payment that no adjustments are to be written on the invoices and the amount sent should equal the Grand Total. Please remit premium payment to: Canton Regional Chamber Health Fund Insurance Premium Enclosed PO Box 6910 Canton, OH 44706  Upon Initial Set-Up: Automatically enrolled in Electronic Invoicing, unless otherwise specified.  Monthly Premium Funding Form

INVOICE TOTAL: 0.00

LIFE/ VISION

0.00

0.00 0.00 0.00 0.00 0.00

0.00

0.00 0.00 0.00 0.00 0.00

BROKER FEES

4191.79

1476.65 476.34 881.23 881.23 476.34

TOTAL FEES

Total Enrollee Count Total Adjustment Count

Total Counts:

$4,191.79

$0.00

0.00

0.00 0.00 0.00 0.00 0.00

RIDERS/ REINS

EMPLOYEE EMP/DEPENDENTS EMP/FAMILY

0.00

0.00 0.00 0.00 0.00 0.00

HRA/HSA/ FLEX

$4,191.79

0.00

4191.79

0.00 0.00 0.00 0.00 0.00

DENTAL FEES

05/2018

PERIOD:

Coverage Counts:

GRAND TOTAL:

0.00 0.00 0.00 0.00 0.00

1476.65 476.34 881.23 881.23 476.34

MEDICAL NETWORK ADMIN FEES

INVOICE:

PO BOX 6910 l CANTON OH 44799-6117 Phone: 330.363.6360 l Toll Free: 1.800.344.8858 l TTY Line: 330.363.2393 1.866.633.4752

EMP/FAMILY EMPLOYEE EMP/DEPENDENTS EMP/DEPENDENTS EMPLOYEE

BALANCE FORWARD:

COVERAGE TYPE

NUMBER:

NAME:

ENROLLEE NAME

GROUP

Monthly Premium Funding COMPANY NAME:___________________________________________________________ GROUP NUMBER: ___________________ MONTHLY INVOICE

(Pay as billed, enrollment adjustments will be made to subsequent invoices)

FUNDING ARRANGEMENT Select and complete one option ACH Transfer to AultCare:

Yes

Mail Check:

Yes

Canton Regional Chamber Health Fund Account Number: 01030329006 Routing Code: 044115090

Make check payable to Canton Regional Chamber Health Fund AultCare Draft from your account: Yes No Bank Name: __________________________

If yes, provide the following:

Bank Contact & Phone Number: _______________________

Account Number: _____________________ Routing Code: _______________________ Note: Automatic withdrawal on the 1st of every month

Completed by (printed name):

_________________________

Signature: ____________________________________________________________________ Date: Forward to AultCare Billing Department

Revised 6/19/2018

Enrollee Questionnaires

This section provides an explanation of various questionnaires that enrollees may receive if there is a question regarding how to pay a claim. Encourage employees to respond to any forms received in order to have their claims paid quickly and correctly. Attachment #1: Other Coverage Information Form (2-page form) Unless otherwise instructed by a self-funded company, AultCare will send out a yearly Other Coverage Information Form to be updated with the next claims received for any member of the family following one year on the plan. Upon receipt of the completed form, the system is noted with the updated information and any pended claims are processed. Attachment #2: Accident Questionnaire The Accident Questionnaire is mailed in the cases of accidents mainly to determine if a third party might be responsible for an accident. Claims are pended until we receive a signed response to the questionnaire. Cases involving a third party are referred to our Subrogation Department to pursue reimbursement for the Plan. Attachment #3: Designation of Authorized Representative Form The Designation of Authorized Representative Form is used to confirm permission to discuss with or disclose to a person’s protected health information (PHI).

Other Coverage Information Form Group#: Enrollee Name: Member ID #:

  

Actively Working Retired: Date of Retirement___/____/____ Disabled-Working Disabled-Not Working

Have you, your spouse, or any dependents covered under this AultCare plan had any other Medical, Dental, Vision, RX, or Medicare coverage in the past 24 months? No: The rest of the form does not need to be completed, please sign & date second page & return to AultCare. Yes: Please complete entire form, sign, date, and return to AultCare.

PART 1 ENROLLEE INFORMATION Do you have health insurance in which you are the enrollee/policyholder other than this AultCare plan?  No Previous carrier termination date___/____/____  Yes complete below. Is OTHER coverage:  Active plan  Retiree plan  COBRA  Individual Plan  Medicare Insurance Name:____________________________________ Group#___________ Effective Date: ___/____/____ Current Employer Name: _____________________________________________________________________ Who is covered under OTHER plan?______________________________________________________________ Check coverage(s):  MEDICAL  DENTAL  VISION  PRESCRIPTION  SUPPLEMENTAL

PART 2 SPOUSE INFORMATION-COMPLETE IF MARRIED Spouse’s name ____________________________Date of Birth ____/____/____ Date of Marriage ____/____/____ Is spouse employed?  No Yes Employer_______________________________________________________ Does spouse have other coverage?  No Part time  Benefits not offered Unemployed Self employed Cost Waiting period Eligible for coverage ____/____/_____  Prior coverage terminated:date ___/____/_____ Yes Is OTHER coverage:  Active plan  Retiree plan  COBRA  Individual Plan  Medicare Policyholder’s Name_________________________________ ID#_____________________ Group # _________ Insurance Name _______________________________ Effective Date: ____/____/____ Who is covered under spouse’s plan? ____________________________________________________________ Check coverage(s):  MEDICAL  DENTAL  VISION  PRESCRIPTION  SUPPLEMENTAL

PART 3 CHILDREN INFORMATION-if additional space is needed, complete on the back of form. Children’s first and last names Relationship Natural child of enrollee & spouse Natural child of enrollee 4 a. Natural child of spouse Part 4 Other_______________ 4 Natural child of enrollee & spouse Natural child of enrollee 4 b. Natural child of spouse Part 4 Other_______________ 4 Natural child of enrollee & spouse Natural child of enrollee c. 4

Part Part Part Part Part

Natural child of spouse Part 4 4 Natural child of enrollee & spouse

Other_______________

Part

Natural child of enrollee

Part

Other_______________

Part

Natural child of spouse 4

Part 4

For any children age 18 or older who have insurance coverage other than through a natural/step parent, please complete part 4A. **

Group#: Enrollee Name: Member ID #: PART 4 DIVORCED, LEGALLY SEPARATED, SINGLE PARENT OR OTHER ***Please complete all information in this section for each child covered under your plan who have a different biological parent other than the enrollee & spouse listed on the first page. If not previously provided, court documentation and/or divorce decrees must be submitted to AultCare in order to accurately update your records*** Child ’s name_____________________________________________________________________________ Is their address the same as the enrollee? Yes No provide address ___________________________________ If 17 or older, please provide date of graduation from high school ___________________________________ Name of other biological/adoptive parent ______________________________Parent’s Date of Birth ____/____/____ Other Parent’s address __________________________________________________________________________ Does child(ren) have insurance coverage other than this AultCare plan?  Yes No Same as spouse’s coverage? Yes No complete below Policyholder’s Name________________________________ Relationship to child________________________ Insurance Name _______________________________ Effective Date: ____/____/____ Term date: ____/____/____ Check coverage(s):  MEDICAL  DENTAL VISION PRESCRIPTION  SUPPLEMENTAL PART 4A CHILDREN WITH INSURANCE COVERAGE OTHER THAN A PARENT’S PLAN Child ’s name_____________________________________________________________________________ Is insurance coverage available through adult child’s employer?  Yes  No Policyholder’s Name________________________________ Relationship to child________________________ Insurance Name _______________________________ Effective Date: ____/____/____ Term date: ____/____/____ Check coverage(s):  MEDICAL  DENTAL VISION PRESCRIPTION  SUPPLEMENTAL PART 5 MEDICARE INFORMATION-PLEASE COMPLETE FOR ALL MEDICARE RECIPIENTS Name________________________________ Name________________________________ Part A Effective Date ____/____/____ Part A Effective Date ____/____/____ Part B Effective Date ____/____/____ Part B Effective Date ____/____/____ Part D Effective Date ____/____/____ Part D Effective Date ____/____/____ Reason for Medicare coverage: Reason for Medicare coverage:  Age 65 or older  Disabled  Age 65 or older  Disabled  End Stage Renal Disease (ESRD)  End Stage Renal Disease (ESRD) Date dialysis treatment began ____/____/____ Date dialysis treatment began ____/____/____ Dialysis started in a: Facility Self/Home dialysis Dialysis started in a: Facility Self/Home dialysis Date of kidney transplant ____/____/____ Date of kidney transplant ____/____/____ Insurance Fraud Warning: “Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files any claim containing false or deceptive statements is guilty of insurance fraud.” Enrollee’s signature_____________________________________________

Date__________________

Enrollee’s phone number_________________________ Email____________________________________ AULTCARE ATTN: COB PO BOX 6910 CANTON OH 44706 FAX 330-363-7746 Note: If any changes occur during the year, please notify the Service Center at 330-363-6360 or 1-800-344-8858.

AultCare/Aultra Notice Tag Lines for the State of Ohio

English This Notice has Important Information. This notice has important information about your application or coverage through AultCare /Aultra. Look for key dates in this notice. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call Local: 330.363.6360 Outside Stark County: 1.800.344.8858 TTY Local: 330.363.2393 Outside Stark County: 1.866.633.4752 Spanish Español Este Aviso contiene información importante. Este aviso contiene información importante acerca de su solicitud o cobertura a través AultCare/Aultra. Preste atención a las fechas clave que contiene este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted tiene derecho a recibir esta información y ayuda en su idioma sin costo alguno. Llame al Local : 330.363.6360 Fuera del condado de Stark : 1.800.344.8858 TTY Local : 330.363.2393 Fuera del condado de Stark : 1.866.633.4752 Chinese 中文本通知有重要的訊息。本通知有關於您透過AultCare/Aultra保险公司提交的申請或保險的重要訊息。請留意本通知內的重要日期。您可能需要在截止日期之前採取行動，以保留您的健康保險或者費用補貼。您有權利免費以您的母語得到本訊息和幫助。請撥電話本地： 330.363.6360 斯塔克縣外： 1.800.344.8858 TTY線本地： 330.363.2393斯塔克縣外： 1.866.633.4752。 German Deutsche Diese Benachrichtigung enthält wichtige Informationen. Diese Benachrichtigung enthält wichtige Informationen bezüglich Ihres Antrags auf Krankenversicherungsschutz durch AultCare/Aultra. Suchen Sie nach wichtigen Terminen in dieser Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unter Local: 330.363.6360 Außerhalb von Stark County : 1.800.344.8858 TTY –Linie Local: 330.363.2393 Außerhalb von Stark County : 1.866.633.4752. Arabic ‫ال عرب ية‬

AultCare/Aultra ‫�شركةالتأمين‬K ‫بخصوصطلبكللحصولعلىالتغطية من‬ ‫�عارمعلومات م همة‬K ‫مة يحوي هذا ا‬. ‫يحوي هذا��عارمعلومات ها‬ ‫حق فيالحصورعلىالمعلو مات‬ ‫ف لكال‬ . ‫فعالتكالي‬ ‫مساعدة في د‬ ‫لصحيةاو لل‬ ‫يتك ا‬ ‫اء فيتواريخنةمعيللحفاظعلىتغط‬ ‫�� اجر‬ ‫شعارقد تحتاج‬ . �K ‫بحث عنالتواريخال هامة في هذا‬ ‫ا‬ ‫ خارجمقاطعة ستارك‬3932.363.033 :‫لمحلي‬TTY ‫ا‬ ‫لخط‬8588.443.008.1: ‫ خارجمقاطعة ستارك‬0636.363.033‫تصلبـ‬ ‫ ا‬.‫دونتكلفة‬ ‫بلغتك من أي‬ ‫والمساعدة‬ 2574.336.668.1:

Pennsylvania Dutch Deitsch Die Bekanntmaching gebt wichdichi Auskunft. Die Bekanntmaching gebt wichdichi Auskunft baut dei Application oder Coverage mit AultCare/Aultra. Geb Acht fer wichdiche Daadem in die Bekanntmachung. Es iss meeglich, ass du ebbes duh muscht, an beschtimmde Deadlines, so ass du dei Health Coverage bhalde kannscht, odder bezaahle helfe kannscht. Du hoscht es Recht fer die Information un Hilf in deinre eegne Schprooch griege, un die Hilf koschtet nix Local: 330.363.6360 Außerhalb von Stark County : 1.800.344.8858 TTY –Linie Local: 330.363.2393 Außerhalb von Stark County : 1.866.633.4752. Russian русский Настоящее уведомление содержит важную информацию. Это уведомление содержит важную информацию о вашем заявлении или страховом покрытии через Страховая компания AultCare/Aultra. Посмотрите на ключевые даты в настоящем уведомлении. Вам, возможно, потребуется принять меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по телефону Местный: 330.363.6360 Вне Старка County : 1.800.344.8858 TTY линия Местный: 330.363.2393 Вне Старка County : 1.866.633.4752. French Français Cet avis a d'importantes informations. Cet avis a d'importantes informations sur votre demande ou la couverture par l'intermédiaire de Compagnie d'Assurance AultCare/Aultra. Rechercher les dates clés dans le présent avis. Vous devrez peut-être prendre des mesures par certains délais pour maintenir votre couverture de santé ou d'aide avec les coûts. Vous avez le droit d'obtenir cette information et de l’aide dans votre langue à aucun coût. Appelez Locale: 330.363.6360 En dehors du comté de Stark : 1.800.344.8858 ligne ATS Local : 330.363.2393 En dehors du comté de Stark : 1.866.633.4752

Designation of Authorized Representative Form You have the right to appoint a representative, including an attorney, to act on your behalf. This form is used to confirm permission to discuss with or disclose a person’s Protected Health Information (“PHI”) held by the affiliated entities AultCare Corporation, Aultra Administrative Group (AAG), and AultCare Insurance Company (AIC) which also does business as AultCare HMO, to a particular individual who acts as the person’s personal representative. We are not always required to grant such access, but each request will be carefully reviewed and approved if warranted. Use of this information is strictly limited to that purpose. Name: ID Number:

Date of Birth: Group Number:

I hereby authorize the following person to act as my personal representative as indicated below. (Must fill out) Name of Representative:

Relationship:

Password that the personal representative must provide to access “PHI” about me: Password: ______________________________________ OR

No Password needed

(Check Box)

I understand that I have the right to limit the information that is released under this authorization. For example, I may limit my personal representative’s access to information about a particular issue. *Any such limitations must be described below in writing. I understand that by leaving this section blank, I am imposing no limitations on disclosure*. However, if my authorization is for use/disclosure of substance abuse information, I understand that the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements. Therefore I release the affiliated entities AultCare Corporation, AultCare Insurance Company, and Aultra Administrative Group from all liability arising from this disclosure of my health information. Note: State Law mandates that Authorizations are limited to 12 months. This form will expire upon 12 months from the date of signature unless an earlier date is noted here. __________________________________________________________ *Any limitations described here: ______________________________________________________________ I understand that this authorization is voluntary and that I may revoke this authorization at any time by providing written notice of such revocation to the Health Plan, except to the extent that action has been taken in reliance on this authorization. I have had full opportunity to read and consider the content of this form. I understand that this authorization is consistent with my request. I understand that, by signing this form, I am confirming my authorization that the Health Plan may use and/or disclose my PHI to the person named as personal representative for the purpose as described above. Your Signature:

Date:

Form must be signed by member. If form is signed by Power of Attorney or Legal Representative, a copy of documentation of position must be in AultCare’s receipt or attached to form. Please designate position held.

Please return the completed form to: ATTN: Privacy Coordinator, PO Box 6029, Canton, OH 44706.

(S)ummary of (B)enefits and (C)overage

Attachment #1: Employer’s Guide to SBC’s Attachment #2: Sample SBC Attachment #3: Glossary of Health Coverage and Medical Terms

EMPLOYER GUIDE SUMMARY OF BENEFITS AND COVERAGE GLOSSARY OF HEALTH COVERAGE AND MEDICAL TERMS

Summary of Benefits and Coverage On Feb. 14, 2012, the Departments of Treasury, Internal Revenue Service, Labor, Health and Human Services, and Employee Benefits Security Administration released a final rule that implemented disclosure requirements under section 2715 of the Public Health Service Act. This health insurance market reform under the Patient Protection and Affordable Care Act requires group health plans and health insurance issuers in the group market to provide a summary of benefits and coverage and uniform glossary to members of their health plans. Final Regulations were again issued in June 2015. A revised SBC template and uniform glossary is expected to be finalized in early 2016 and take effect in January 2017.

What’s an SBC and a Uniform Glossary?

Table of Contents • What’s an SBC and a Uniform Glossary? • What is Culturally and Linguistically Appropriate Manner? • How do I meet the Electronic Disclosure requirements to distribute the SBC to my employees? • What happens if I fail to comply? • Who will provide me with the materials I need for distribution to my employees? • When will I receive my SBC? • Who should receive the SBC? • When do I need to distribute the materials? • FAQs

The Summary of Benefits and Coverage or “SBC” and Glossary of Health Coverage and Medical Terms or “Uniform Glossary” are designed to help consumers better understand their health coverage and allow for easy comparison of other coverage options when shopping, applying, enrolling and re-enrolling into a health plan. The SBC is a resource for your employees that will summarize your health plan options including: • Deductible

Insurance Company 1: Plan Option 1 Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 01/01/2013 – 12/31/2013 Coverage for: Individual + Spouse | Plan Type: PPO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.[insert] or by calling 1-800-[insert]. Important Questions

Answers

What is the overall deductible?

You must pay all the costs up to the deductible amount before this plan begins to pay for $500 person / covered services you use. Check your policy or plan document to see when the deductible $1,000 family starts over (usually, but not always, January 1st). See the chart starting on page 2 for how Doesn’t apply to preventive care much you pay for covered services after you meet the deductible.

Why this Matters:

Are there other deductibles for specific services?

Yes. $300 for prescription drug coverage. There are no other specific deductibles.

Is there an out–of– pocket limit on my expenses?

Yes. For participating providers $2,500 person / $5,000 The out-of-pocket limit is the most you could pay during a coverage period (usually one family year) for your share of the cost of covered services. This limit helps you plan for health For non-participating providers care expenses. $4,000 person / $8,000 family

What is not included in the out–of–pocket limit?

Premiums, balance-billed charges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Is there an overall annual limit on what the plan pays?

No.

The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

Yes. See www.[insert].com or call 1-800-[insert] for a list of participating providers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to see a specialist?

No. You don’t need a referral to You can see the specialist you choose without permission from this plan. see a specialist.

Are there services this plan doesn’t cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 4. See your policy or plan document for additional information about excluded services. OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Corrected on May 11, 2012

• In- and out-of-network provider coverage • Coverage of common medical events • Excluded services

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

Questions: Call 1-800-[insert] or visit us at www.[insert]. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.[insert] or call 1-800-[insert] to request a copy.

• Out-of-pocket and annual limits

1 of 8

• Common covered services • Rights to continue coverage • Member grievance and appeal rights • Coverage examples for having a baby and managing type 2 diabetes The “Uniform Glossary” lists commonly used terms in insurance coverage. You can access the glossary by logging on to www.aultcare.com.

What is Culturally and Linguistically Appropriate Manner?

Who will provide me with the materials I need for distribution to my employees?

This requirement provides employees and dependents the option to request their SBC in a non-English language if they reside in a county that meets or exceeds a 10 percent threshold of non-English speaking residents. The SBC that we provide will contain directions for non-English speaking individuals to receive further information in their non-English language.

As your health issuer or third-party administrator, we are committed to providing you with the tools that you need to meet this regulatory requirement.

How do I meet the Electronic Disclosure requirements to distribute the SBC to my employees? Under the Department of Labor Electronic Disclosure requirement, if your employees are able to effectively access documents provided in electronic format at their worksite (i.e. e-mail) and this access is a part of their duties as an employee, you can send the SBC to them electronically. You can also allow the employees to elect to receive their SBC electronically. Eligible employees (not currently enrolled) can receive the SBC electronically as long as a paper version option is available upon request. You can accomplish this by email, e-card, posting on your intranet or sending a postcard.

What happens if I fail to comply? POTENTIAL FINES AND PENALTIES • Up to $1,000 per day for each instance of willing non-compliance • A fine of $100 per day per affected individual until compliant

• We will provide you with an SBC master copy for distribution (electronically or paper copy) for your employees, dependents and eligible employees for health insurance coverage. This will include an SBC for each benefit package you offer and a new SBC when coverage changes. • Continuously monitor changes to regulation that may impact you.

When will I receive my SBC? We will deliver your SBC to you at the following times: • Upon my application for coverage or within 7 days • Within 7 days upon my request • If terms of my plan are not yet final, upon the first day of coverage • Upon changes to my plan • If automatically re-enrolled, a new SBC will be provided at that re-enrollment

Who should receive the SBC? If you have an employee and all of the dependents reside at one address, only one SBC is required to be distributed. However, if an employee has dependents who have an alternate address, you are required to distribute an SBC to those alternate addresses. You are also required to distribute an SBC to all of your employees who are eligible for health insurance coverage, even if they are not currently enrolled in your health plan.

When do I need to distribute the materials? OPEN ENROLLMENT You need to provide the SBC with open enrollment materials. If you do not hold an open enrollment period, provide the SBC no later than the first date your employees are eligible to enroll for coverage. ONLINE ENROLLMENT If you offer online enrollment, you are permitted to provide the SBC at the time of online enrollment or online renewal of coverage electronically but must provide the option to receive a paper copy.

Frequently Asked Questions 1. Does this regulation impact small and large groups? Yes. Whether you are a small or large employer group, the SBC requirements apply to your health plan.

2. Does this apply to both fully insured and self-insured plans? Yes, this impacts both fully insured and selfinsured plans.

3. Am I exempt because I am in a “grandfathered” plan? No, the SBC requirement applies to both “grandfathered” and “non-grandfathered” plans.

AUTOMATIC RENEWAL If you have an automatic renewal, the SBC must be provided 30 days prior to the first day of the new plan year. This SBC will reflect the plan that the employee and dependents are currently enrolled.

4. Do I need an SBC for stand-alone dental or vision benefits?

UPON REQUEST If you have an employee or dependent who requests an SBC or Uniform Glossary, you must fulfill the request within seven business days. If the request is online, then you can deliver it electronically but you must provide the option to receive a paper copy.

5. Can I combine the SBC and Uniform Glossary with other documents?

SBC CHANGES If the SBC changes from what was distributed at enrollment, you must provide an updated SBC prior to the first day of coverage. SPECIAL ENROLLMENT For Special Enrollment, you must provide an SBC within 90 days after they enrolled in your plan.

No, the SBC regulations do not apply to standalone excepted benefits. Excepted benefits are generally benefits that require the individual to pay an additional premium.

Yes, as long as the SBC is displayed at the beginning.

6. Do COBRA enrollees receive SBCs? Yes, COBRA enrollees have the same rights as other enrollees to receive SBCs.

7. Do I have to provide the SBC and Uniform Glossary in color?

No, you are

permitted to provide in color or grayscale.

MIDYEAR BENEFIT CHANGES If you make a midyear change to your plan that changes the content of your SBC, you must provide a 60-day advance notice to employees. This can be complete via a new SBC or a separate notice (summary of material modification).

2600 Sixth Street SW • Canton, Ohio 44710 • 330-363-6360 • 1-800-344-8858 • www.aultcare.com INSURANCE

COMPANY

5066/19

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Service

Canton Regional Chamber Health Fund 500B

Coverage Period: Beginning on or after 01/01/2018

Coverage for: Individual/Family| Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of his plan (called the premium)will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call AultCare at 330-363-6360 or go to www.aultcare.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.aultcas.com/aultcare/login.aspx or call 330-363-6360 or 1-800-344-8858 to request a copy. Important Questions Answers Why This Matters: For Network Providers Generally, you must pay all of the costs from providers up to the deductible amount before this What is the overall $500 individual / $1,000 family; plan begins to pay. If you have other family members on the plan, each family member must deductible? For Out-of-network Providers meet their own individual deductible until the total amount of deductible expenses paid by all $1,500 individual / $3,000 family family members meets the overall family deductible. Are there services covered before you meet your deductible?

Yes. Network preventive care services are covered before you meet your deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

No.

You don’t have to meet deductibles for specific services.

For Network Providers The out-of-pocket limit is the most you could pay in a year for covered services. If you have other What is the out-ofpocket $4,500 individual / $9,000 family; family members in this plan, they have to meet their own out-of-pocket limits until the overall limit for this plan? For Out-of-network Providers family out-of-pocket limit is met. $13,500 individual / $27,000 family; For Prescription Drugs $2,850 Individual / $5,700 family What is not included in the out-of-pocket limit?

Premiums, balance- billing charges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

OBM Control Numbers 1545-2229, 1210-0147, and 0938-1146; Released on April6, 2016

Non-GF/ Non-Integrated MOOP/ Embedded Ded & OOP

1 of 7

Will you pay less if you use a network provider?

Do you need a referral to see a specialist?

Yes. See www.aultcare.com or call 330-363-6360 or 1-800-344-8858 for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

You can see the specialist you choose without a referral.

2 of 7

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event If you visit a health care provider’s office or clinic

Services You May Need Primary care visit to treat an injury or illness Specialist visit Preventive care/screening/ immunization

What You Will Pay Out-of-Network Provider Network Provider (You will pay the most) (You will pay the least) $25 copayment/visit

40% coinsurance

$25 copayment/visit

40% coinsurance

No charge

50% coinsurance

Diagnostic test (x-ray, blood 20% coinsurance 40% coinsurance work) Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance Generic Preferred (Tier 1) Retail: $10 copayment/prescription or 20% coinsurance If you need drugs to whichever is greater for 1-34 day supply; Retail or Mail treat your illness or order: $27 copayment / prescription or 20% coinsurance condition whichever is greater for 35-60 day supply More information about prescription drug Generic Non Preferred (Tier 2) Retail: $20 copayment/prescription or 30% coinsurance coverage is available at whichever is greater for 1-34 day supply; Retail or Mail www.aultcare.com order: $45 copayment/prescription or 30% coinsurance whichever is greater Brand Preferred (Tier 3) Retail: $30 copayment/prescription or 30% coinsurance whichever is greater; Mail order: $55 copayment/prescription or 25% coinsurance whichever is greater, up to maximum of $125 Retail: $45 copayment/prescription or 50% coinsurance Brand Non-Preferred (Tier 4) whichever is greater; Mail order: $85 copayment/prescription or 45% coinsurance whichever is greater, up to maximum of $250 Most Non-Preferred (Tier 5) 75% coinsurance Specialty/Limited Distribution $125 copayment/prescription or 20% coinsurance whichever is greater. Limited to a 30-day supply per fill. Preferred If you have a test

Specialty/Limited Distribution Non-Preferred

Limitations, Exceptions, & Other Important Information Deductible does not apply to office visits to a network provider. Deductible does not apply to office visits to a network provider. You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. None Deductible does not apply. A 34-day supply is available at the retail pharmacy for generic and brand name prescription drugs. You may obtain up to a 60-day supply of generic prescription drugs at the retail pharmacy for the mail order amount. A 90-day supply is available through the mail order program. If a prescription drug is purchased without using your card, this Plan will pay up to the allowed amount. Once the prescription drug out-of-pocket limit is reached, the copayment is $0.

$250 copayment/prescription or 40% coinsurance whichever is greater. Limited to a 30-day supply per fill. 3 of 7

Common Medical Event If you have outpatient surgery If you need immediate medical attention

If you have a hospital stay If you need mental health, behavioral health, or substance abuse services

If you are pregnant

What You Will Pay

Services You May Need

Limitations, Exceptions, & Other Important Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) 20% coinsurance 40% coinsurance None

Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees

20% coinsurance

40% coinsurance

None

Emergency room care

$150 copayment/visit

Deductible does not apply to this benefit.

Emergency medical transportation Urgent care

20% coinsurance

Network deductible will apply.

$50 copayment/visit

Facility fee (e.g., hospital room) 20% coinsurance

40% coinsurance

Deductible does not apply to this benefit. Preauthorization is recommended.

Physician/surgeon fees Outpatient services

20% coinsurance 20% coinsurance

40% coinsurance 40% coinsurance

None None

Inpatient services

20% coinsurance

40% coinsurance

Preauthorization is recommended.

Office visits

20% coinsurance

40% coinsurance

Childbirth/delivery professional services Childbirth/delivery facility services Home health care

20% coinsurance

40% coinsurance

Depending on the type of services, a copayment, coinsurance or deductible may apply. None

20% coinsurance

40% coinsurance

Preauthorization is recommended.

20% coinsurance

40% coinsurance

Rehabilitation services

20% coinsurance

40% coinsurance

Preauthorization is recommended. Coverage is limited to 60 visits per calendar year. Must be illness/injury related.

20% coinsurance

40% coinsurance

Skilled nursing care

20% coinsurance

40% coinsurance

Durable medical equipment

20% coinsurance

40% coinsurance

Preauthorization is recommended for a single item with a purchase price over $1,000.

Hospice services

20% coinsurance

40% coinsurance

Preauthorization is recommended.

Autism Spectrum Disorder If you need help recovering or have other special health needs

Coverage is limited to Autism Spectrum Disorder. Services are limited to the following: Speech/ Language/ Occupational Therapy – 20 visits per calendar year for each service; and Clinical Therapeutic Intervention at 20 hours per week; and Mental/Behavioral Health Outpatient Services. Preauthorization is recommended. Coverage is limited to 50 days per illness.

4 of 7

Common Medical Event

What You Will Pay

Services You May Need

Limitations, Exceptions, & Other Important Information

Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) Children’s eye exam

No charge

50% coinsurance

Children’s glasses Children’s dental check-up

Not covered Not covered

If your child needs dental or eye care

Coverage is provided for vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors.

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)  Cosmetic Surgery  Abortion (except in cases of rape, incest, or  Non-Emergency care when traveling outside the U.S.  Dental Care(adult) when the life of the mother is endangered)  Routine Eye Care(Adult)  Hearing Aids  Acupuncture  Routine Foot Care  Long Term Care  Bariatric Surgery  Weight Loss Programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)  Chiropractic Care  Private Duty Nursing  Infertility Treatment

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: for group health coverage subject to ERISA, contact Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA(3272) or www.dol.gov/ebsa/healthreform; for non-federal governmental group health plans, contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: for group health coverage subject to ERISA, contact Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA(3272) or www.dol.gov/ebsa/healthreform or call the Ohio Department of Insurance 1-800-686-1526; for non-federal governmental group health plans and church plans that are group health plans, contact AultCare at 1-800-344-8858 or call the Ohio Department of Insurance 1-800-686-1526. Does this plan provide Minimum Essential Coverage? Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the 5 of 7

requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: [Spanish (Español): Para obtener asistencia en Español, llame al 330-363-6360 / 1-800-344-8858 [Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 300-363-6360 / 1-800-344-8858 [Chinese (中文): 如果需要中文的帮助，请拨打这个号码 330-363-6360 / 1-800-344-8858 [Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 330-363-6360 / 1-800-344-8858 ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

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About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby

Managing Joe’s type 2 Diabetes

Mia’s Simple Fracture

(9 months of in-network pre-natal care and a hospital delivery)

(a year of routine in-network care of a wellcontrolled condition)

(in-network emergency room visit and follow up care)

 The plan’s overall deductible  Specialist copayment  Hospital (facility)coinsurance  Other coinsurance

$500 $25 20% 20%

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost

$12,800

 The plan’s overall deductible  Specialist copayment  Hospital (facility)coinsurance  Other coinsurance This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost

In this example, Peg would pay:

In this example, Joe would pay:

Cost Sharing

Deductibles Copayments Coinsurance

What isn’t covered Limits or exclusions The total Peg would pay is

$500 $40 $2,030 $260 $2,830

$500 $25 20% 20%

Deductibles Copayments Coinsurance

What isn’t covered Limits or exclusions The total Joe would pay is

$7,400

 The plan’s overall deductible  Specialist copayment  Hospital (facility)coinsurance  Other coinsurance

$500 $25 20% 20%

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost

$1,900

In this example, Mia would pay:

$500 $440 $1,500 $60 $2,500

Deductibles Copayments Coinsurance

Cost Sharing

What isn’t covered Limits or exclusions The total Mia would pay is

The plan would be responsible for the other costs of these EXAMPLE covered services.

$500 $50 $200 $0 $750

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Glossary of Health Coverage and Medical Terms •

• •

This glossary defines many commonly used terms, but isn’t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan or health insurance policy. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any case, the policy or plan governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document.) Underlined text indicates a term defined in this Glossary. See page 6 for an example showing how deductibles, coinsurance and out-of-pocket limits work together in a real life situation.

Allowed Amount

This is the maximum payment the plan will pay for a covered health care service. May also be called "eligible expense", "payment allowance", or "negotiated rate".

Appeal

A request that your health insurer or plan review a decision that denies a benefit or payment (either in whole or in part).

Balance Billing

When a provider bills you for the balance remaining on the bill that your plan doesn’t cover. This amount is the difference between the actual billed amount and the allowed amount. For example, if the provider’s charge is $200 and the allowed amount is $110, the provider may bill you for the remaining $90. This happens most often when you see an out-of-network provider (non-preferred provider). A network provider (preferred provider) may not bill you for covered services.

Claim

A request for a benefit (including reimbursement of a health care expense) made by you or your health care provider to your health insurer or plan for items or services you think are covered.

Coinsurance

Your share of the costs of a covered health care service, calculated as a percentage (for example, 20%) of the Jane pays Her plan pays allowed amount for the 20% 80% service. You generally pay coinsurance plus (See page 6 for a detailed example.) any deductibles you owe. (For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.) Glossary of Health Coverage and Medical Terms

Complications of Pregnancy

Conditions due to pregnancy, labor, and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a nonemergency caesarean section generally aren’t complications of pregnancy.

Copayment

A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.

Cost Sharing

Your share of costs for services that a plan covers that you must pay out of your own pocket (sometimes called “out-of-pocket costs”). Some examples of cost sharing are copayments, deductibles, and coinsurance. Family cost sharing is the share of cost for deductibles and outof-pocket costs you and your spouse and/or child(ren) must pay out of your own pocket. Other costs, including your premiums, penalties you may have to pay, or the cost of care a plan doesn’t cover usually aren’t considered cost sharing.

Cost-sharing Reductions

Discounts that reduce the amount you pay for certain services covered by an individual plan you buy through the Marketplace. You may get a discount if your income is below a certain level, and you choose a Silver level health plan or if you're a member of a federallyrecognized tribe, which includes being a shareholder in an Alaska Native Claims Settlement Act corporation.

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146

Page 1 of 6

Deductible

An amount you could owe during a coverage period (usually one year) for covered health care services before your plan begins to pay. An overall Jane pays Her plan pays deductible applies to all or 100% 0% almost all covered items (See page 6 for a detailed and services. A plan with example.) an overall deductible may also have separate deductibles that apply to specific services or groups of services. A plan may also have only separate deductibles. (For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible.)

Diagnostic Test

Tests to figure out what your health problem is. For example, an x-ray can be a diagnostic test to see if you have a broken bone.

Durable Medical Equipment (DME)

Equipment and supplies ordered by a health care provider for everyday or extended use. DME may include: oxygen equipment, wheelchairs, and crutches.

Emergency Medical Condition

An illness, injury, symptom (including severe pain), or condition severe enough to risk serious danger to your health if you didn’t get medical attention right away. If you didn’t get immediate medical attention you could reasonably expect one of the following: 1) Your health would be put in serious danger; or 2) You would have serious problems with your bodily functions; or 3) You would have serious damage to any part or organ of your body.

Emergency Medical Transportation

Ambulance services for an emergency medical condition. Types of emergency medical transportation may include transportation by air, land, or sea. Your plan may not cover all types of emergency medical transportation, or may pay less for certain types.

Emergency Room Care / Emergency Services

Services to check for an emergency medical condition and treat you to keep an emergency medical condition from getting worse. These services may be provided in a licensed hospital’s emergency room or other place that provides care for emergency medical conditions. Glossary of Health Coverage and Medical Terms

Excluded Services

Health care services that your plan doesn’t pay for or cover.

Formulary

A list of drugs your plan covers. A formulary may include how much your share of the cost is for each drug. Your plan may put drugs in different cost sharing levels or tiers. For example, a formulary may include generic drug and brand name drug tiers and different cost sharing amounts will apply to each tier.

Grievance

A complaint that you communicate to your health insurer or plan.

Habilitation Services

Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Health Insurance

A contract that requires a health insurer to pay some or all of your health care costs in exchange for a premium. A health insurance contract may also be called a “policy” or “plan”.

Home Health Care

Health care services and supplies you get in your home under your doctor’s orders. Services may be provided by nurses, therapists, social workers, or other licensed health care providers. Home health care usually doesn’t include help with non-medical tasks, such as cooking, cleaning, or driving.

Hospice Services

Services to provide comfort and support for persons in the last stages of a terminal illness and their families.

Hospitalization

Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. Some plans may consider an overnight stay for observation as outpatient care instead of inpatient care.

Hospital Outpatient Care

Care in a hospital that usually doesn’t require an overnight stay. Page 2 of 6

Individual Responsibility Requirement

Sometimes called the “individual mandate”, the duty you may have to be enrolled in health coverage that provides minimum essential coverage. If you don’t have minimum essential coverage, you may have to pay a penalty when you file your federal income tax return unless you qualify for a health coverage exemption.

In-network Coinsurance

Your share (for example, 20%) of the allowed amount for covered healthcare services. Your share is usually lower for in-network covered services.

In-network Copayment

A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network copayments usually are less than out-of-network copayments.

Marketplace

A marketplace for health insurance where individuals, families and small businesses can learn about their plan options; compare plans based on costs, benefits and other important features; apply for and receive financial help with premiums and cost sharing based on income; and choose a plan and enroll in coverage. Also known as an “Exchange”. The Marketplace is run by the state in some states and by the federal government in others. In some states, the Marketplace also helps eligible consumers enroll in other programs, including Medicaid and the Children’s Health Insurance Program (CHIP). Available online, by phone, and in-person.

Maximum Out-of-pocket Limit

Yearly amount the federal government sets as the most each individual or family can be required to pay in cost sharing during the plan year for covered, in-network services. Applies to most types of health plans and insurance. This amount may be higher than the out-ofpocket limits stated for your plan.

Medically Necessary

Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms, including habilitation, and that meet accepted standards of medicine.

Glossary of Health Coverage and Medical Terms

Minimum Essential Coverage

Health coverage that will meet the individual responsibility requirement. Minimum essential coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage.

Minimum Value Standard

A basic standard to measure the percent of permitted costs the plan covers. If you’re offered an employer plan that pays for at least 60% of the total allowed costs of benefits, the plan offers minimum value and you may not qualify for premium tax credits and cost sharing reductions to buy a plan from the Marketplace.

Network

The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.

Network Provider (Preferred Provider)

A provider who has a contract with your health insurer or plan who has agreed to provide services to members of a plan. You will pay less if you see a provider in the network. Also called “preferred provider” or “participating provider.”

Orthotics and Prosthetics

Leg, arm, back and neck braces, artificial legs, arms, and eyes, and external breast prostheses after a mastectomy. These services include: adjustment, repairs, and replacements required because of breakage, wear, loss, or a change in the patient’s physical condition.

Out-of-network Coinsurance

Your share (for example, 40%) of the allowed amount for covered health care services to providers who don’t contract with your health insurance or plan. Out-ofnetwork coinsurance usually costs you more than innetwork coinsurance.

Out-of-network Copayment

A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.

Page 3 of 6

Out-of-network Provider (Non-Preferred Provider)

A provider who doesn’t have a contract with your plan to provide services. If your plan covers out-of-network services, you’ll usually pay more to see an out-of-network provider than a preferred provider. Your policy will explain what those costs may be. May also be called “non-preferred” or “non-particiapting” instead of “outof-network provider”.

Out-of-pocket Limit

The most you could pay during a coverage period (usually one year) for your share of the costs of covered services. After you Jane pays Her plan pays meet this limit the 100% 0% plan will usually pay (See page 6 for a detailed example.) 100% of the allowed amount. This limit helps you plan for health care costs. This limit never includes your premium, balance-billed charges or health care your plan doesn’t cover. Some plans don’t count all of your copayments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit.

Physician Services

Health care services a licensed medical physician, including an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic Medicine), provides or coordinates.

Plan

Health coverage issued to you directly (individual plan) or through an employer, union or other group sponsor (employer group plan) that provides coverage for certain health care costs. Also called "health insurance plan", "policy", "health insurance policy" or "health insurance".

Preauthorization

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment (DME) is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.

Glossary of Health Coverage and Medical Terms

Premium

The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly, or yearly.

Premium Tax Credits

Financial help that lowers your taxes to help you and your family pay for private health insurance. You can get this help if you get health insurance through the Marketplace and your income is below a certain level. Advance payments of the tax credit can be used right away to lower your monthly premium costs.

Prescription Drug Coverage

Coverage under a plan that helps pay for prescription drugs. If the plan’s formulary uses “tiers” (levels), prescription drugs are grouped together by type or cost. The amount you'll pay in cost sharing will be different for each "tier" of covered prescription drugs.

Prescription Drugs

Drugs and medications that by law require a prescription.

Preventive Care (Preventive Service)

Routine health care, including screenings, check-ups, and patient counseling, to prevent or discover illness, disease, or other health problems.

Primary Care Physician

A physician, including an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic Medicine), who provides or coordinates a range of health care services for you.

Primary Care Provider

A physician, including an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist, or physician assistant, as allowed under state law and the terms of the plan, who provides, coordinates, or helps you access a range of health care services.

Provider

An individual or facility that provides health care services. Some examples of a provider include a doctor, nurse, chiropractor, physician assistant, hospital, surgical center, skilled nursing facility, and rehabilitation center. The plan may require the provider to be licensed, certified, or accredited as required by state law.

Page 4 of 6

Reconstructive Surgery

Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries, or medical conditions.

Referral

A written order from your primary care provider for you to see a specialist or get certain health care services. In many health maintenance organizations (HMOs), you need to get a referral before you can get health care services from anyone except your primary care provider. If you don’t get a referral first, the plan may not pay for the services.

UCR (Usual, Customary and Reasonable)

The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.

Urgent Care

Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

Rehabilitation Services

Health care services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Screening

A type of preventive care that includes tests or exams to detect the presence of something, usually performed when you have no symptoms, signs, or prevailing medical history of a disease or condition.

Skilled Nursing Care

Services performed or supervised by licensed nurses in your home or in a nursing home. Skilled nursing care is not the same as “skilled care services”, which are services performed by therapists or technicians (rather than licensed nurses) in your home or in a nursing home.

Specialist

A provider focusing on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.

Specialty Drug

A type of prescription drug that, in general, requires special handling or ongoing monitoring and assessment by a health care professional, or is relatively difficult to dispense. Generally, specialty drugs are the most expensive drugs on a formulary.

Glossary of Health Coverage and Medical Terms

Page 5 of 6

How You and Your Insurer Share Costs - Example Jane’s Plan Deductible: $1,500

Coinsurance: 20%

Out-of-Pocket Limit: $5,000 December 31st End of Coverage Period

January 1st Beginning of Coverage Period

more costs

Jane pays

100%

Her plan pays

Jane hasn’t reached her $1,500 deductible yet Her plan doesn’t pay any of the costs. Office visit costs: $125 Jane pays: $125 Her plan pays: $0

Glossary of Health Coverage and Medical Terms

more costs

Jane pays

20%

Her plan pays

80%

Jane reaches her $1,500 deductible, coinsurance begins Jane has seen a doctor several times and paid $1,500 in total, reaching her deductible. So her plan pays some of the costs for her next visit. Office visit costs: $125 Jane pays: 20% of $125 = $25 Her plan pays: 80% of $125 = $100

Jane pays

Her plan pays

100%

Jane reaches her $5,000 out-of-pocket limit Jane has seen the doctor often and paid $5,000 in total. Her plan pays the full cost of her covered health care services for the rest of the year. Office visit costs: $125 Jane pays: $0 Her plan pays: $125

Page 6 of 6

The Canton Regional Chamber of Commerce and AultCare

have partnered together to offer a healthcare plan for the small business community through a Multiple Employer Welfare Arrangement (MEWA).

The MEWA was developed to provide additional options and to help control the costs of healthcare benefits. Medically underwritten MEWA rates may provide a less expensive option than a smaller community rated plan obtained under the Affordable Care Act (ACA). This plan is available for small group employers with less than 50 employees.

Product Overview

Eligible Employers

• Small group coverage

• Under 50 eligible employees

• Self-funded plan with fixed monthly payments

• 75% minimum participation requirement

• Groups are not subject to ACA community rating

• 50% minimum employer contribution for single coverage

• Benefits administered by AultCare • AultCare Provider Network

www.aultcare.com/mewa

• Member in good standing with the Canton Regional Chamber of Commerce

Benefit Plan Options • 14 plan options » Traditional co-pay plans » Consumer Driven Health Plans/Health Savings Account (HSA) Compatible • Ancillary Product Offerings » Dental Coverage » Vision Coverage

For Chamber Membership information call 330-456-7253. For healthcare or health fund information, contact your independent Broker or your AultCare Representative. All AultCare health plan quote proposals include commission, unless otherwise specified. 6069/20

GRIEVANCES AND APPEALS

GRIEVANCE PROCESS If you are unsatisfied with Aultra or your network providers, you are advised to contact Aultra as soon as possible to begin the grievance process. You can contact Aultra Customer Service about your concern and you will be forwarded to someone who can assist you in the necessary steps to help reach a resolution. You may also mail your grievance to: Grievance and Appeal Coordinator, PO Box 6029, Canton, OH 44706.

APPEALS PROCESS If you disagree with a determination about a specific benefit, you have the right to appeal Aultra’s decision and request a review of the determination through the appeals process. The appeal process can be initiated by you and/or your provider or your authorized representative. Your appeal must be submitted within 180 calendar days of the adverse determination and should contain a statement describing the reasons why you feel your claim/services should not have been denied, written comments, documents, records or other information relating to the claim/service. A full and fair review will be conducted, taking into consideration all of the information received with the appeal. Clinical appeals, or appeals relating to decisions based on medical necessity, are conducted by health professionals. Appeals can be mailed to: Grievance and Appeal Coordinator, PO Box 6029, Canton, OH 44706. You may contact Aultra Customer Service or refer to your plan documents for more information on how to file an appeal. You can also contact Customer Service if you would like a copy of the appeal process specific to your group plan.

AultCare will send you a notification in writing regarding the determination of your appeal based upon the type of appeal. Time frames are as follows: • Pre-service appeals will be answered within 15 calendar days of receipt • Post-service appeals will be answered within 30 days of receipt • Urgent/concurrent care appeals will be answered as soon as possible, but not greater than 72 hours of receipt Certain Self-Funded and Insured Employer Groups have contracted with an external vendor to complete their medical management decisions, including prior authorizations for services and benefits and medical management appeals. Please refer to your plan document for the Grievance and Appeals process or contact Aultra Customer Service if you have any questions.

11 12 1 10 2 9 3 8 4 7 6 5

AN D

VE TI

MON

BE PREPARED Get the right care. Whether that’s finding the right doctor, specialist, therapist or something else altogether. Just use the Find a Provider button at www.aultcare.com or contact the AultCare Customer Service department. Local: 330-363-6360  Toll-Free: 1-800-344-8858  Email: aultcare@aultcare.com

Find care near you whenever you need it. You get in-network coverage at hospitals, ambulatory care facilities and providers throughout a five-county area in Stark, Wayne, Holmes, Tuscarawas and Carroll Counties. With location options in more places, AultCare gives you more. Who usually provides care

Emergency Room

Retail Health Clinic

Doctors trained in emergency medicine

Physician assistants or nurse practitioners

Walk-in Doctor’s Office

Family practice doctors

Urgent Care Center

Doctors who treat conditions that should be looked at right away

* Teladoc

Board-certified doctors

Average wait time and cost For non-emergencies:

4 hours $1,145

When to go • Symptoms feel life-threatening or disabling • Chest pain or severe shortness of breath • Major injury or broken bones • Sudden or unexplained loss of consciousness

30 minutes $92

• Allergic reactions (minor) • Bumps, cuts, scrapes, rashes • Burning with urination • Burns (minor) • Cold, cough and sore throat • Sinus pain and fever (minor) • Eye or ear pain or irritation • Shots

30 minutes $102

Same as retail health clinic plus ... • Asthma (mild) • Back pain • Nausea or diarrhea • Headache (minor)

30 minutes $133

Same as walk-in doctor’s office plus ... • Animal bites • Sprains and strains • Stitches • X-rays

10 minutes $55

• Cold & flu symptoms • Allergies • Sinus problems • Respiratory infection • Skin problems • And more!

Do you have health related questions or concerns? By calling 330-363-7620 or 1-866-422-9603, an operator will take your information and an experienced registered nurse will return your call. Money-saving tip Visit hospitals and doctors that are in your plan. If you don’t, you’ll often pay much more out-of-pocket for your care.

* Not all plans include the Teladoc® service. Please contact your AultCare representative to see if Teladoc® is included in your healthcare plan.

6354/20

AULTLINE 24/7 AultCare provides telephonic health services 24 hours a day, 7 days a week. If you have health-related questions or concerns, contact AultLine at 330-363-7620 or 1-866-422-9603 to speak with a trained medical professional

YOUR TRUSTED SOURCE OF INFORMATION AND SUPPORT AultLine is a trusted source of information and support for a wide range of health concerns and topics. You can find answers to questions regarding family health, medication, illness, injury first aid, and much more. Calls are confidential and free of charge. If you have an emergency, call 911 or go to the emergency room. AultLine is unable to assist with questions regarding benefits or claims. If you have questions, please contact AultCare during normal business hours for assistance.

HEALTH–RELATED QUESTIONS OR CONCERNS? Do you have health–related questions or concerns? When you contact AultLine, an operator will take your information, and an experienced, registered nurse will return your call. Contact AultLine if you have questions or concerns regarding: » First aid instructions » General health information » Determination of what level of care is most appropriate for your condition » Answers for your medication questions » Suggestions for self-care

you you

matter

PROGRAMS AND SERVICES Through our partnerships, coordination, products, network, and customer service, AultCare offers members a wide variety of programs and services. These programs and services provide a diverse spectrum of value to members towards their health and wellness.

CARE COORDINATION AultCare’s Care Coordination program encompasses all of the clinical areas of AultCare including: » Utilization Management » Population Health Management CARE » COORDINATION Case Management

» Disease Management » Pharmacy » Wellness

As an AultCare member, you may receive the following services: » » » »

Assistance with chronic illnesses Help with transitioning care Access to healthcare professionals Educational mailings

» Tele-monitoring programs for heart failure and diabetes » Assistance with navigating the healthcare system

24-HOUR NURSE HOTLINE When it comes to your health, AultCare members can talk with an experienced, registered nurse and get advice or answers to their health-related questions day or night. Please call 330-363-7620 or 1-866-422-9603 for additional assistance.

ONLINE HEALTH LIBRARY If you are preparing for surgery, living with a chronic condition, or want to take a more active role in your health, our online health library can empower you to take care of your health. The online health library can help you prepare for surgery and manage your health conditions. The online health library delivers reliable information, created in collaboration with only board-certified physicians, and makes it easy to understand. To view the online health library, visit www.aultcare.com and select Members. The health library can be found under the Care Coordination heading on the right side of the webpage.

MEDICAL COST ESTIMATOR In an effort to empower members to take control of their healthcare dollars, members have access to a Medical Cost Estimator. This program was designed to provide an estimate as to what members can expect to pay for a wide variety of in-network services and procedures, while taking into consideration their deductible/out-of-pocket expenses.

Advantages of the Medical Cost Estimator » Compares costs of most common procedures between physicians, hospitals, and facility charges » Provides members with a greater transparency » By utilizing this tool, members have the opportunity to save money

ONLINE RESOURCES Throughout AultCare’s website, you are able to manage your account information including: reviewing your claims and Summary of Benefits, ordering ID cards, and accessing a wide variety of forms. AultCare’s website is also a great resource for many other health-related topics.

Health & Wellness

AultCare Blue Button

» Provider directory » Health programs and services » Health information and tips

» Organize and store medical information » Download text file » Share data with members of your care team

Prescription Information » » » »

Prescription history Money saving drug alternatives Detailed drug information National pharmacy search

Online Resources » Account statements » Benefits » Claims

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Member Frequently Asked Questions What is Teladoc? Teladoc provides 24/7 access to U.S. boardcertified doctors by phone or video for many non-emergency illnesses, including flu, allergies, sinus infections, and more. Who are the Teladoc doctors? Teladoc doctors are licensed internists, family doctors, and pediatricians. They average 20 years of experience and are licensed to practice in your state. Does Teladoc replace my doctor? No. Teladoc doesn’t replace your primary care doctor. Teladoc should be used for non-emergency illnesses when it is not convenient to get to the doctor or it is outside of regular office hours. How do I talk to a Teladoc doctor? video. You can connect with a doctor via phone or video. How do I set up my Teladoc account? Visit the website listed below and click “Member Login.” You can also download the mobile app or call the number below.

Teladoc.com

How do I request a visit? Log in to your account online or via the app and click “Request a Consult.” You can also request a visit by calling the number below. Is there a time limit when talking with a doctor? There is no time limit for visits. Am I charged more for talking longer? There is no extra charge for longer doctor visits. Can Teladoc doctors write a prescription? Yes, Teladoc doctors can prescribe medication when medically necessary. Visit teladoc.com/prescription-policy.com for details. If the Teladoc doctor recommends that I see my primary care doctor or a specialist, will I be charged? Yes. Just like any other doctor appointment, you must pay for the consulting doctor's time. Can my primary care doctor get a record of my Teladoc visit? With your consent, we’ll send an electronic copy of your Teladoc visit to your primary care doctor.

Talk to a doctor anytime 1-800-TELADOC (835-2362)

Download the app

© 2019 Teladoc Health, Inc. All rights reserved. Teladoc and the Teladoc logo are registered trademarks of Teladoc Health, Inc. and may not be used without written permission. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services. 10E_104B_05032018

HOW TO REGISTER FOR YOUR NEW ONLINE ACCOUNT With the launch of AultCare's new online account platform, all members will be required to register for a new account, regardless if they previously had an online account. Follow these steps to register for your new account.

Step #1 Visit www.aultcare.com. Select Account Login.

Step #2 Select a log in button based on if you are a member, employer, provider, broker, vendor, or non-member.

Step #3 Select Not Yet Registered?

Continued on reverse side.

Step #4 Complete the member registration information. Members can use the same email, username, and password previously used. Accept the Terms & Conditions and select Register.

Step #5 Check your email for your account verification link. Click the link to verify your account.

Step #6 Sign into the portal using your updated username and password. Select Log In.

Step #7 Complete the required fields, such as your member ID, to finish linking your account. Select Link. Your account is now registered. Use your new account to find information regarding your health plan.

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YOUR ONLINE ACCOUNT AultCare’s online portal features an updated look and easy to access resources to enhance your experience and provide the tools you need to take an active role in your healthcare. Follow these steps to login to your account: 1

Select Account Login on the homepage of www.aultcare.com.

Based on your account type (member, employer, provider, broker, vendor, or non-member), select the corresponding login button.

If you are an existing AultCare member, you will need to register for a new account regardless if you had an account on our old platform. You can use the same username when you register, but you may need to update your password.

All new AultCare members will need to register for an online account.

Features available on your online account: My Costs – Accumulator information for easyto-read calculations of deductibles and out-ofpocket costs. My Policy – Information regarding your policy and plan benefits. My Claims – Information regarding claims, including claim status, payments, and owed payments. Use this feature to also find Explanation of Benefit information for each claim. My ID Card – Access to your member ID card. Through this feature, member ID cards can be downloaded, printed, or sent via postal mail.

Medical Cost Estimator – Review an estimate of expenses for in-network services and procedures. Provider Search – Use our online directory to find an in-network provider. A compilation of other resources are available on the platform but vary dependent on your plan. • Pharmacy Benefit Manager* • HealthEquity* • Other Coverage Information • Explanation of Benefits FAQ *If applicable

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IBM MEDICAL COST CALCULATOR In collaboration with IBM, the AultCare Medical Cost Estimator has been remodeled for members to access accurate, personalized cost estimates for a wide variety of in-network healthcare services.

Benefits of the Cost Calculator » Search for a medical treatment, service, or condition. » Review your out-of-pocket estimates. » Compare quality, cost, and location for providers.

Improvements to the Cost Calculator » Access to more procedures. » Easy-to-read graphs for out-of-pocket estimates. » Disease and Condition feature provides an estimated range of costs to treat a condition for an entire year.

STEP 1 » Visit www.aultcare.com and log into your secured online account. » On the dashboard, select the blue Medical Cost Estimator button. » Agree to the Terms of Use for the Medical Cost Estimator.

STEP 2 » On the drop-down menu, select the member who will be receiving the medical

treatment or service.

STEP 3 » This screen denotes a benefit summary for the member (deductible and out-of-pocket). » Search for a cost estimate by selecting the appropriate button (treatment, physician, or medical facility). Type in the text box the corresponding name of the treatment, physician, or medical facility. » You may also click on a category in the “Browse by” section.

STEP 4 » The information displayed is an estimated out-of-pocket calculation, along with a

brief description of the procedure/treatment. » A list of providers and facilities may also be shown for a cost comparison.

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A guide

to our services.

AultCare Health Plans

Helpful Tips

Things to have ready when you call us: > Your AultCare ID Card, which has your

group information and member ID number > Your Explanation Of Benefits (EOB) form if you are calling about a

claim (You can access your EOBs by going to www.aultcare.com and logging into your account.)

AultCare Service Center Contact Information > 330-363-6360 (local) > 1-800-344-8858 (toll-free) > TTY Line for the Hearing Impaired:

330-363-2393 (local) or 1-866-633-4752 (toll-free)

> Monday - Friday 7:30 am - 5:00 pm EST

Special Communication Needs AultCare offers numerous services to meet the cultural and linguistic needs of our members. These services include access to translators of various foreign languages and a TTY line for the hearing impaired. 24-Hour Nurse Hotline Contact Information > 330-363-7620 > 1-866-422-9603 (toll-free)

AultCare Mailing Address: AultCare P.O. Box 6910 Canton, OH 44706

www.aultcare.com

2 About AultCare 4 Your Physician is Your Partner in Health & Wellness 6 Care Coordination - Disease Management Program - Case Management Program - Population Health Management Program - Utilization Management Program - Pharmacy Program 11 What’s Not Covered Filing a Claim 13 Grievance & Appeals 15 Enrollee Rights & Responsibilities 17 19 Privacy Practices 21 Frequently Asked Questions 23 Glossary

About

AultCare. For 35 years, AultCare has provided quality healthcare plans at an affordable cost to the community it serves. Through the use of innovative plan designs, superior customer service, and a high-quality network, AultCare strives to satisfy enrollees and clients and remain committed to providing affordable healthcare plan options. Not only do we help control healthcare costs, we are a health and wellness company full of valuable resources to prevent health concerns arising in the first place. Sometimes health issues are inevitable. We have programs and staff in place to help manage those issues, too. Healthcare is complex and confusing, but it doesn’t need to be. Through use of our personalized customer service, our members can rely on AultCare for guidance navigating the healthcare system. AultCare is proud to support its members and serve as a trusted resource in the community.

Where You Matter We believe your healthcare plan should be focused on your needs, in ways that matter to you. From the network you choose to how you receive communication from us, our plans and services are designed with you in mind so that you can take an active role in your health. When you are covered by AultCare, you are part of our local family!

Advocate We help our members live healthier lives by giving them the tools and support that will help them take control of their health. If you are diagnosed with a health condition, our experienced Care Coordination team can identify your healthcare needs and provide you with programs and services you need.

When you call us, we pick up the phone. You won’t get stuck in an automated answering system. When you have questions, we are here to help you. We make it easy for you to get information day or night. Meet with us in-person, call us to speak with a knowledgeable customer service representative, or visit our website at www.aultcare.com anytime you need answers.

24-Hour Free Nurse Line We offer our members a way to get credible health information and support 24 hours a day, 7 days a week. AultCare members can talk with an experienced registered nurse and get answers to their health-related questions and concerns by calling 330-363-7620 or toll-free 1-866-422-9603. Calls are confidential.

Accurate Accuracy is at the heart of what we do. Our processes are tested and streamlined, so you can trust that what you receive from us is dependable and accurate. We value your trust and are committed to giving you consistent, excellent service. Recognition The National Committee for Quality Assurance (NCQA) has awarded our Commercial PPO, Commercial HMO, Medicare HMO, and Marketplace PPO products with NCQA Health Plan Accreditation.

Answers Prefer to use the internet? The AultCare website, www.aultcare.com, is your health and wellness hub and where you can manage your account. On the website, you can: • Create an online account to manage your personal claim information, view your EOBs, download forms, and more • Look for providers • Find current health-related information • Tell us what matters to you by taking satisfaction surveys

A Guide to Our Services

Your Physician is Your Partner in Health & Wellness You should visit your primary care physician for regular checkups to maintain your best level of health and wellness.

Choosing a Doctor When you join AultCare, you can see any doctor in the network. If you need specialty care, your Primary Care Physician (PCP) can identify network doctors who treat your condition. You can also go to our website to search for a doctor in our network. Begin your search by visiting www.aultcare.com. You can identify and select network physicians according to the characteristics important to you, including: • Office location • Language spoken • Gender • Specialty • Hospital affiliations • Acceptance of new patients • Board certifications Customer service representatives are also available to help. They can help find a doctor who can meet your special or cultural needs.

Your physician may have more than one office. Alternate offices and locations of your physician may be considered outside the network. Please refer to the online Provider Directory at www.aultcare.com or contact the AultCare Service Center at 330-363-6360 or 1-800-344-8858 to confirm if an office is in-network. Refer to your plan documents for your physical and wellness benefits and for specific information about access to providers. If you need mental health and/or substance abuse services and do not have a mental health provider, please contact your primary physician. If your need is an emergency, go to the nearest emergency facility for evaluation. There are behavioral health providers available to you within your network.

In Case of Emergency If you have a medical problem that must be treated right away and it is outside your physician’s normal office hours, call his/her office and the physician on call will assist you. If you have an emergency, call 911 or go to the nearest emergency care facility. You do not have to contact AultCare to obtain emergency services. If you are out-of-town and need emergency care, please go to the nearest emergency care facility. If you become ill and you are out-of-town, and it is not an urgent or emergency situation, try to call your physician first. If that is not possible, seek treatment at the nearest medical care facility or physician’s office. Notify the AultCare Service Center the next business day if you are admitted to an out-of-town hospital. Schedule an appointment with your physician for all follow-up care and services.

Some examples of emergency situations are: • High fever • Convulsions • Difficulty breathing • Uncontrolled vomiting and/or diarrhea • Broken bones • Possible miscarriage or pregnancy with vaginal bleeding • Poisoning • Severe bleeding • Severe burns • Severe pain in the stomach or chest • Shock • Unconsciousness

Remember, if you need emergency services: 1. Go to the nearest emergency care facility. Be sure to present your AultCare ID card. 2. If you are admitted to the hospital, please make sure AultCare is notified on the next business day. 3. Remember to contact your PCP as soon as possible after your visit. 4. Schedule an appointment with your PCP for all follow-up care and services.

A Guide to Our Services

Care Coordination AultCare offers many health and wellness services to its members. These services are streamlined into a program known as Care Coordination. With Care Coordination, AultCare members have access to a team of local physicians, nurses, dietitians, pharmacists, and other clinical and non-clinical staff to help resolve any potential and ongoing health and wellness issues. This system allows AultCare to provide its members with a comprehensive approach to healthcare. Members may be affected by one or more programs provided by Care Coordination. The programs work collectively to cover all aspects of a member’s health and wellness.

Disease Management Program Provides members with education on prevention, ensuring members with chronic health issues have all the tools and services necessary to improve their health.

The Disease Management program offers an integrated and comprehensive approach to manage conditions, reduce complications, improve quality of life, and decrease costs. Disease Management nurses reach out to members with diagnoses such as Diabetes, Congestive Heart Failure (CHF), and Chronic Obstructive Pulmonary Disease (COPD) through telemonitoring programs. Outreach is also provided to members with mental health concerns through the Disease Management program. Members will receive targeted materials to introduce available opportunities and AultCare Care Coordination resources. Nurses will also contact members for preventive care reminders and available educational programs. Common reminders AultCare nurses provide are preventive screenings, adherence follow-up, medication follow-up, and information on how to improve overall outcomes.

24-Hour Nurse Hotline

AultCare offers a health and information line to assist members with health-related questions day or night. By calling 330-363-7620, or toll-free 1-866-422-9603, you will be directed to an experienced registered nurse who is available 24 hours a day to answer your health-related questions and provide confidential information. They will be able to: • Provide first aid instructions and general health information • Determine what level of care is most appropriate for your condition • Answer your medication questions • Offer suggestions for self-care

Utilization Management (UM) Helps control healthcare costs through management of the use of healthcare resources Pre-Certification

Pre-Certification, also known as pre-authorization or pre-approval, is the process of notifying your health plan prior to an elective hospital stay or elective surgery procedure. This process helps to determine that all medical care possibilities have been explored and are within acceptable time limits. The pre-certification process has two parts: 1. Notification - AultCare receives a request for services from your provider

Case Management Program Promotes quality, cost-effective outcomes through assessment, planning, coordination, education, and referral

The Case Management program is made up of nurses and social workers who help members receive the care, information and community services they need. The program promotes quality, cost-effective outcomes through assessment, planning, coordination, education, and referral. AultCare case managers may contact members if they have recently had a long hospital stay, have a new cancer diagnosis, have a complex medical issue, or require specialized care from an out-of-network provider.

Population Health Management (PHM) Serves as the link between the member, the primary care physician, and the health plan to help the member navigate the healthcare system and receive integrated care

The Population Health Management program focuses on providing patient-centered, accessible, comprehensive, and coordinated care. Population Health Management nurses connect with members over the phone or face-to-face for as long as needed. Education is offered to those dealing with chronic and acute conditions along with additional information and resources to ensure members’ needs are met. The Population Health Management team of nurses is the link between members, providers, and the health plan.

2. Determination of coverage/verification of eligibility - we review your plan document and clinical information as it relates to the request for services Getting pre-certification for a procedure does not mean the service will be covered and paid at the highest level of benefit, or at all. All claims are subject to review upon receipt of the actual claim or documentation and are subject to updates in eligibility upon receipt of the actual claim. Refer to your plan documents, access our website at www.aultcare.com or contact the AultCare Service Center to determine if your particular plan has additional pre-certification requirements or to obtain a list of items requiring pre-certification. Reference Based Pricing vs. Usual Customary Reasonable Allowances

All benefits are subject to Reference Based Pricing (RBP) or Usual Customary and Reasonable Allowances (UCR). Amounts exceeding RBP or UCR for services rendered by a network provider are not patient responsibility. Amounts exceeding the RBP or UCR for services rendered by a non-network provider or for services rendered under a traditional plan in the absence of a provider network, are the financial responsibility of the patient. If you have questions regarding this information, please contact the AultCare Service Center. Please refer to your Certificate or Plan Document and Summary Plan Description for details on your coverage.

Utilization Management Evaluation of New and Existing Technology

AultCare investigates all requests for coverage of new technology using a medical technology assessment company as a guideline. If additional information is needed, AultCare utilizes sources including, but not limited to Medicare and Medicaid policies and Food and Drug Administration releases of any current medical peer review literature. This information is reviewed and evaluated by AultCare’s medical director and other physician advisors in order to determine if a new technology is appropriate for coverage under your AultCare plan. Members may request that a certain new technology be investigated for coverage by contacting the UM department. How to Submit a Request for Pre-Certification

Requests should be submitted by phone, fax or in writing to: AultCare Care Coordination P.O. Box 6910 Canton, Ohio 44706 Phone: 330-363-6360 or 1-800-344-8858 Fax: 330-454-9635 Responses are made according to the following time lines:

• Emergency Care: does not require preauthorization • Urgent Care: not later than 72 hours of receipt of the request • Non-urgent, pre-service: within 15 calendar days of receipt of the request • Post-service: within 30 calendar days of receipt of the request • Requests to extend treatment of urgent care: within 24 hours of the request • Reduction or terminations of previously approved course treatment: adequate notice is given to allow an appeal to be completed

Denials are documented in the form of a letter to you and the requesting provider. The letter includes: • The specific reason for denial • Reference to the benefit provision, guideline, protocol or other similar criteria on which the denial decision is based • Decision of additional information needed to analyze the request •

Notification that you can obtain a copy of the actual benefit provision, guideline, protocol or criteria on which the denial was based (this is upon request and at no extra cost)

• Description of your appeal rights and appeal process, including your right to have an authorized representative act on your behalf • A description of the expedited appeal process if the denial is urgent pre-service or urgent concurrent review If the denial is based on medical necessity, a reviewer is available to discuss the decision with the physician or provider.* AultCare provides you with access to staff to discuss the UM process and any issue relating to the UM process. Professional staff members are available from 8 a.m. to 5 p.m. Monday - Friday by contacting the AultCare Service Center at 330-363-6360 or toll free at 1-800-344-8858. The TTY number for the hearing impaired is 330-363-2393 or toll-free at 1-866-633-4752. If you call after business hours, please leave a message and we will respond to your call the next business day. *Emergency care does not require pre-certification.

Pharmacy Program This information only applies if AultCare is your pharmacy benefit administrator

AultCare’s pharmacy program provides you with a variety of safe, effective and affordable prescription choices to meet your medication needs. Find out what medications are covered under your plan by accessing your plan’s formulary at www.aultcare.com or by contacting AultCare Customer Service. The formulary is a list of medications your plan covers based on evaluations of efficacy, safety, and cost-effectiveness. If your pharmacy benefits are covered under a co-pay structure, you will save money by asking your doctor if your prescription can be filled with a generic equivalent or by choosing drugs in the lowest-cost tiers of your plan design. Talk to your doctor about which prescriptions will work best for you. Generic medications, with the lowest co-payments, are affordable alternatives that have met multiple quality and safety standards set by the FDA. For certain prescription drugs, AultCare has additional requirements for coverage. These requirements ensure the drug prescribed is clinically appropriate for the plan member and also helps us manage drug plan costs. A team of physicians and pharmacists developed these requirements for our plan to help us provide quality coverage to our members. For a current listing of medications that require prior authorization, please visit the website at www.aultcare.com or call customer service at 330-363-6360 or 1-800-344-8858.

Mail Order

Some AultCare plans include the option to have your prescriptions filled by mail-order. A mail-order option offers you an alternative to the retail pharmacy for long-term medications. With mail-order service, you have the convenience of home delivery and the ability to refill orders online, by phone, fax, or mail. To have your prescription filled by mail-order, simply ask your physician for a new prescription. Check your plan documents to see how many days supply your plan will cover. Mail your prescription to your mail-order vendor/ pharmacy, or have your physician fax it. Please refer to your individual schedule of benefits to determine your actual copayment. Most plans allow up to a 60 or 90-day supply by mail-order. To obtain information regarding the mail-order services, please call AultCare at 330-363-6360 or visit the Pharmacy Services page on our website at www.aultcare.com. Prior Authorization/Step Therapy

Certain medications require prior authorization or step therapy, meaning your physician must consult with AultCare before prescribing a medication for you for the first time. For a current listing of medications requiring prior authorization, visit the Pharmacy Services page at www.aultcare.com.

Medication Safety

The medications you take are an important part of your health. AultCare has compiled guidelines you can use to help your doctor and pharmacist provide you with quality healthcare. They are as follows: • Keep an updated list of all the medications you take (including prescription, over-the counter, herbal remedies and supplements). • Make sure all of your doctors know all of the medications you are taking. •

Read prescription labels carefully and always follow the directions exactly. If you have questions about a prescription, such as side effects or interactions with other medications or food, ask your doctor or pharmacist. If a medication you’ve taken before looks different, notify your pharmacist immediately.

• When you get a new prescription ask your doctor if it replaces any of your current medications. • Keep medications in their original container, unless you use a pill organizer. • Discard all expired medications properly. •

Whenever possible, use only one pharmacy. This will ensure you do not take conflicting medications. If you use both retail and mail order pharmacies, make sure each pharmacy is aware of all your medications and allergies.

A Guide to Our Services

What’s

Not Covered Members should refer to their plan documents to determine which healthcare services are covered and to what extent. The following is a partial list of services that are usually NOT covered. However your plan documents may contain exceptions to this list based on state mandates or the plan design purchased.

• All medical and hospital services not

specifically covered in, or which are limited or excluded in your plan documents, including costs of services before coverage begins and after coverage ends

• Care, services or supplies which are not deemed medically necessary

• Radial keratotomy, lasik, or related procedures • Cosmetic surgery, except as specifically stated in the benefit descriptions • Respite, custodial, and residential care except as specifically stated in the benefit descriptions

• Treatment, services or procedures that are experimental, or investigative • Non-rehabilitative chiropractic services • Dental care, except as specifically stated in the benefit descriptions • Eyeglasses, contact lenses, hearing aids and their fittings, and hearing tests except as specifically stated in the benefit descriptions

• Sterilization reversal and some infertility processes and related services • Implantable drugs and certain injectable infertility drugs • Physical, mental or substance abuse examinations done for or ordered by third parties • Immunizations for travel or work

As a part of our AultCare family, your opinions are important to us. What our members tell us helps us to evaluate our services and processes, and make improvements when needed.

• New Enrollee Survey • Member Satisfaction

• Over-the-counter medications and supplies • Marital counseling

Ways you can complete a survey:

• Services for the treatment of sexual dysfunction or inadequacies including therapy, supplies or counseling

The surveys can be taken two ways: online or printed and a paper copy returned by mail. To take the survey online, log into your AultCare online member account. Register for a new account if you do not have one. Once logged in, the survey link will appear at the bottom of your screen.

Most plans exclude all forms of gastric restrictive procedures for the purpose of weight loss/control. Check your specific plan or contact the AultCare customer service to determine if these procedures are covered under your specific plan. You must consult your specific plan document. Contact AultCare customer service if you have additional questions.

If you do not have internet access, but would still like to participate, contact the AultCare customer service to request a paper copy. As always, your answers are confidential, anonymous, and in no way will affect your coverage.

We Want Your Feedback

A Guide to Our Services

Filing a Claim

Physician Claims You do not need to send in claim forms when you use network providers. As long as you use network providers, your physician will submit claims to AultCare for you. If your doctor is not a network provider, call AultCare Utilization Management at 330-363-6360 or 1-800-344-8858. In some cases, we may continue to pay for covered services at the network provider rate for a limited period of time to let you complete a course of treatment. We also will help you find an in-network provider or you may reference our provider directory at http://www.aultcare.com/findaprovider. If you have an approved referral to a non-network provider, those services may be covered at the same level as network providers. Charges that exceed Usual, Customary and Reasonable (UCR) rates are not covered by your plan and are therefore your responsibility to pay. Refer to your plan’s schedule of benefits for details. If your non-network provider does not send in your claim, you should: 1. 2. 3.

Fill out the Application for Benefits form Include a copy of the bill from your non-network provider Mail the forms to AultCare at the address below:

AultCare P.O. Box 6910 Canton, Ohio 44706

Application for Benefits You can get a copy of the Application for Benefits form on AultCare’s website at www.aultcare.com or by calling customer service at 330-363-6360 or 1-800-344-8858. A separate Application for Benefits form is needed for each bill. Be sure to complete all sections of the form that apply to your situation and sign it.

Hospital Claims When you receive services at a hospital, show your AultCare ID card. The hospital will send the claim information to AultCare. Other Coverage Every year, AultCare will request an update about other coverage that you and your dependents may have. The information about other coverage is necessary so we know whether to pay as primary or secondary on claims for your family members. You may not be able to collect benefits from both plans.

Application for Benefits You will need to show your ID card when you go to a provider for services. Your provider will use the information on the card to verify coverage. If your coverage changes, you might receive a new ID card. Use the most current card as reflected by the effective date on the card. Keep Your Records Up to Date We need current information about you and your dependents to accurately pay claims. Outdated or incorrect information can cause mistakes, delays in payment or denial of coverage. Updating Your Records Tell your employer (groups) or AultCare (individuals) within 31 calendar days if there are changes in your: • Name • Address • Phone number • Marital status •

Family status, including information about your dependents, new dependents, changes in family status or who is to be covered by the health plan

Remember: Notify your employer of changes, additions, or to end coverage as soon as possible.

Grievances and Appeals How to let AultCare know if you are dissatisfied or disagree with a decision about your benefit coverage.

Use this information to let AultCare know if you are dissatisfied or disagree with a decision about your benefit coverage. If you are dissatisfied with AultCare or your network providers, please contact us as soon as possible. Your concerns will be forwarded to the Grievance Department who will conduct a thorough investigation and provide a written response to you within 30 days. This is known as the Grievance Process. You may contact AultCare customer service to voice your concern or you may also put your grievance in writing to the attention of: AultCare Grievance and Appeal Department P.O. Box 6029 Canton, Ohio 44706 If you disagree with a determination about a specific benefit, you have the right to appeal AultCare’s decision. This is known as the Appeals Process. The appeal process can be initiated by you, your provider, or your authorized representative. Your appeal must be submitted within 180 calendar days of the adverse determination and should contain a statement describing the reasons why you feel your claim/services should not have been denied, in addition to written comments, documents, records, or other information relating to the claim/service. A full and fair review will be conducted, taking into consideration all of the information received with the appeal. Clinical appeals, or appeals relating to decisions based on medical necessity, are conducted by health professionals who are: • The same or similar specialty as the servicing physician or requesting provider • Board-certified, if applicable 15

Appeals will not be reviewed by the individual who made the original decision nor will they be a subordinate of that person. Appeal decisions are based only on appropriateness of care and the existence of coverage. AultCare does not speciﬁcally reward practitioners of care or other individuals for issuing denials of coverage or service care. AultCare will provide a written notification detailing the outcome of your appeal. The timeframe for the appeal response is dependent on the type of appeal filed. Timeframes and descriptions of appeal types are as follows: Pre-Service Appeal: An appeal filed prior to receiving the requested service. Notification of a decision will be issued within 10 days of our receipt of your appeal. Post-Service Appeal: An appeal filed after services have been received. Notification of a decision will be issued within 30 days of our receipt of your appeal. Urgent Appeal: An appeal, if not answered expeditiously, could seriously jeopardize your health. You will be notified of our decision as soon as possible, but no later than 72 hours of our receipt of your appeal.

Appeals can be mailed to: AultCare Grievance and Appeal Department P.O. Box 6029 Canton, Ohio 44706 AultCare communicates your appeal rights in many ways to ensure each member understands their rights. Your plan documents, your Explanation of Benefits, and a benefit denial letter describe your appeal rights as an AultCare member. Every member is granted the same first level of appeal rights or internal review. If you initiate a first-level appeal and we uphold our original decision, your resolution letter will outline your additional appeal rights, which may include external review rights. Your rights vary depending on state and federal laws. For more information on your appeal rights, you can review your plan document, Explanation of Benefits, benefit denial letter, appeal resolution letter or contact AultCare customer service for a copy of your appeal procedure at 330-363-6360 or toll-free 1-800-344-8858.

A Guide to Our Services

Enrollee Rights & Responsibilities Quality healthcare benefits are responsibilities shared with your doctors and your plan. We want you to know your rights and responsibilities. Please read your plan documents for a full description. If you have a question, concern, or a recommendation for how AultCare could improve its policies for promoting enrollee responsibilities and rights, contact us through our website at www.aultcare.com or call customer service at 330-363-6360 or toll-free at 1-800-344-8858.

You have a responsibility to: •

Take your AultCare ID card when you go to the doctor, hospital, drug store, or healthcare provider. It contains important information. Having your card may help save time and prevent mistakes.

•

Tell the doctor or nurse about your condition. Tell your doctor what medications you are taking. Answer any questions the doctor or nurse may ask you truthfully. This information may help your doctor form treatment goals and alternatives. Understand your health problems and participate in developing mutually agreed-upon goals.

•

Ask questions if you do not understand something about your medical condition and the treatment alternatives (including medications) the doctor is recommending.

•

Follow your doctor’s medical advice and instructions. Take medications as directed. Let the doctor know if you have a bad reaction. Let your doctor know if your symptoms do not get better, or if they get worse. Schedule recommended follow-up appointments.

• Live a healthy lifestyle. • Check your Schedule of Benefits. • Let your employer (groups) or AultCare (individuals) know if there are changes with you and your dependents. • Obtain all required pre-approvals (pre-certifications) and second opinions. • Ask your employer or call AultCare if you have questions about your coverage or responsibilities.

You have a right to: • Receive information about the organization, its services, its practitioners and providers, and member rights and responsibilities. • Receive information about your coverage and services (see your plan documents). •

A list of doctors, hospitals, and other AultCare network providers. Visit our website at www.aultcare.com or call AultCare customer service.

• Be treated with dignity and respect. •

A frank discussion with your doctor about your medical condition, including appropriate and medically necessary treatment options, regardless of cost or benefit coverage and to participate in making decisions about your healthcare. Your doctors are independent. They are not restricted or prohibited from discussing treatment options with you, including those not covered.

•

Privacy of your healthcare and claims information. Your Protected Health Information will be used to pay claims, as permitted by HIPAA and as described in your Notice of Privacy Practices. Protected Health Information will not be disclosed to others without your authorization, except as permitted by HIPAA and state law.

•

Ask questions, raise concerns, make complaints, and appeal denials, as explained in your certificate or benefits booklet.

• Make recommendations about AultCare’s Member Rights and Responsibilities Policy. • Request accommodation if you have limited knowledge of the English language.

Privacy Practices Notice of Privacy Practices AultCare, on behalf of AultCare Insurance Company, maintains a Notice of Privacy Practices that provides information on the use and disclosure of Protected Health Information (PHI). This notice is available on our website www.aultcare.com. If you would like a copy of AultCare’s Notice of Privacy Practices, please contact customer service at 330-363-6360 or toll-free at 1-800-344-8858. AultCare prides itself on ensuring our members’ PHI is maintained with appropriate privacy and confidentiality. All employees are held to internal standards of protecting written, oral, and electronic PHI. Use and Disclosure of PHI to plan sponsors is handled with security and certification the plan sponsor agrees to AultCare’s policies on PHI.

Uses and Disclosures Unless permitted by state or federal law, we will not use or disclose your protected health information for any purpose without your express written authorization. You have the right to revoke that authorization and we will take every effort to honor those requests. We are permitted or required by law to make certain uses and disclosures of your protected health information without your authorization. For a detailed list of the uses and disclosures that do not require your authorization, please review the Notice of Privacy Practices. Examples of such uses and disclosures include: • Treatment • Payment • Healthcare operations

AultCare maintains a Notice of Privacy Practices that provides important information on the Use and Disclosure of PHI and your rights regarding your PHI. Highlights from the notice are outlined on the right.

Access to Your Protected Health Information

Accounting for Disclosures of Your Protected Health Information

You have the right to copy and/or inspect much of the protected health information that we retain on your behalf. All requests for access must be made in writing and signed by you or your representative.

You have the right to receive an accounting of certain disclosures made by us of your protected health information after April 14, 2003. Requests should be made in writing and signed by you or your representative.

Restrictions on Use and Disclosure of Your Protected Health Information

You have the right to request restrictions on certain uses and disclosures of your protected health information for treatment, payment, or healthcare operations by notifying us of your request for a restriction in writing. Amendments to Your Protected Health Information

You have the right to request in writing an amendment or correction to the protected health information we maintain about you. We are not obligated to make all requested amendments, but we will give each request careful consideration. All amendment requests should be in writing, signed by you or your representative, and must state the reasons for the amendment/correction request.

Please review the Notice of Privacy Practices for more detailed information on our Use and Disclosure of Protected Health Information. The Notice of Privacy Practices and the necessary request forms are available on our website at www.aultcare.com/aultcare-privacy. If you would like a copy of the notice or the request forms, please contact customer service at 330-363-6360 or toll-free at 1-800-344-8858.

Frequently Asked Questions Q.

Do I need a Primary Care Physician (PCP)?

We recommend you have a PCP to help guide you in your healthcare needs.

How can I find a doctor? How do I find a doctor in my network?

You may search for network doctors in various ways: • Visit the AultCare website at www.aultcare.com. Click on the ‘Find A Provider’ button at the top of the page. Select the ID card that matches the ID card you have to search the correct network directory. • Call AultCare customer service. When making an appointment with your doctor, be sure to confirm the doctor or provider is still a network provider.

What if my PCP cannot provide the care I need?

Your doctor may refer you to a specialist. If the recommended specialist is in your network, no additional actions are necessary.

What if my doctor refers me to an non-network doctor?

My PCP or network doctor has sent a request for my treatment with a non-network doctor. How will I know if my treatment was approved?

You will receive a letter from AultCare Utilization Management. The letter will tell you if your treatment has been approved at the network level of benefits, or if it has been denied (for PPO plans, services can be partially approved, which means the services have been approved at the non-network level of benefits).

If you receive care from a non-network provider, you may have to pay a different deductible and/or co-insurance. You will be responsible for paying any difference between what the provider charges for the service and what the plan allows.

The letter approving my care at the network level of benefits mentioned UCR. What does this mean?

This means that the non-network treatment requested by your network doctor has been approved at the network level of benefits, and payable based on Usual, Customary, and Reasonable (UCR) schedule of charges.

If the specialist is not in the network, your network doctor will need to provide detailed information to AultCare Utilization Management and request an approval before you seek treatment.

Q. A.

What does UCR mean?

UCR is a schedule of average fees most providers in the area charge for a given procedure. It affects insurance reimbursement and out-ofpocket charges you might have to pay. If your provider charges more than the UCR, you will be responsible for paying the difference between what the provider has charged and the UCR amount that will be used to pay your benefits. Will I owe the amounts over UCR?

Yes. The amounts over UCR are not covered by your plan. You are responsible for those amounts. We suggest discussing payment options with your provider.

I received a letter that the recommended treatment was not approved. What does this mean?

Although the treatment may be recommended by your doctor, it may not be covered under your plan. If your referral is not approved, there is not reduced coverage for the treatment under your plan. Always refer to your plan document for specific limitations that apply. Refer to page 15 for your appeal rights.

What if I need help understanding my approval/denial letter content?

Contact Utilization Management at 330-363-6360 or 1-800-344-8858. Refer to your plan document for specific limitations that apply. Refer to page 15 for your appeal rights.

What if I need after-hours care in or out of the area?

If you need care after hours, contact your physician’s office. If you feel your needs are urgent or your situation is an emergency, proceed to the nearest emergency room, urgent care center, or call 911. How do I view my medical benefits online?

Go to www.aultcare.com - Log into your account - Click on “Eligibility” - Select “Member” from the drop-down box - Select “Active” from the Status drop-down box - Click “Search” - Select plan to see benefits OR Call customer service at 330-363-6360 or toll free at 1-800-344-8858 (TTY Line: 330-363-2393 or 1-866-633-4752)

Glossary This glossary defines many commonly used terms, but it is not a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan or health insurance policy. Some of these terms may not have the same meaning when used in your policy or plan, and in any case, the policy or plan governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document.)

Allowed Amount- This is the maximum

payment the plan will pay for a covered healthcare service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”

Appeal- A request for your health insurer

or plan to review a decision that denies a benefit or payment (either in whole or in part).

Balance Billing- When a provider bills you

for the balance remaining on the bill your plan does not cover. This amount is the difference between the actual billed amount and the allowed amount. For example, if the provider’s charge is $200 and the allowed amount is $110, the provider may bill for the remaining $90. This happens most often when you see an out-of-network provider (non-preferred provider). A network provider (preferred provider) may not bill you for covered services.

Claim- A request for a benefit (including

reimbursement of a healthcare expense) made by you or your healthcare provider to your health insurer or plan for items or services you think are covered.

Coinsurance- Your share of the costs of

a covered healthcare service, calculated as a percentage (for example, 20%) of the allowed amount for the service. You generally pay coinsurance plus any deductibles you owe. (For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.)

Complications of Pregnancy-

Conditions due to pregnancy, labor, and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency cesarean section generally are not complications of pregnancy. Copayment- A fixed amount

(for example, $15) you pay for a covered healthcare service, usually when you receive the service. The amount can vary by the type of covered healthcare service.

Cost-Sharing- Your share of costs for services a plan covers that you must pay out of your own pocket (sometimes called “out-of-pocket costs”).

Some examples of cost-sharing are copayments, deductibles, and coinsurance. Family cost-sharing is the share of cost for deductibles and out-of-pocket costs you and your spouse and/or child(ren) must pay out of your own pocket. Other costs, including your premiums, penalties you may have to pay, or the cost of care a plan does not cover usually are not considered cost-sharing. Cost-Sharing Reductions- Discounts that reduce the amount you pay for certain services covered by an individual plan you buy through the Marketplace. You may get a discount if your income is below a certain level, and you choose a Silver level health plan or if you are a member of a federally-recognized tribe, which includes being a shareholder in an Alaska Native Claims Settlement Act corporation. Deductible- An amount you could owe during a coverage period (usually one year) for covered healthcare services before your plan begins to pay. An overall deductible applies to all or almost all covered items and services. A plan with an overall deductible may also have separate deductibles that apply to specific services or groups of services. A plan may also have only separate deductibles. (For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered healthcare services subject to the deductible.) Diagnostic Test- Tests to figure out a health problem. For example, an x-ray can be a diagnostic test to see if you have a broken bone.

Durable Medical Equipment (DME)-

Equipment and supplies ordered by a healthcare provider for everyday or extended use. DME may include: oxygen equipment, wheelchairs, and crutches. Emergency Medical Condition-

An illness, injury, symptom (including severe pain), or condition severe enough to risk serious danger to your health if you did not receive medical attention right away. If you did not receive immediate medical attention you could reasonably expect one of the following: 1) Your health would be put in serious danger; 2) You would have serious problems with your bodily functions; 3) You would have serious damage to any part or organ of your body. Emergency Medical Transportation-

medical condition and treat you to keep an emergency medical condition from getting worse. These services may be provided in a licensed hospital’s emergency room or other place that provides care for emergency medical conditions.

Excluded Services- Healthcare services that

your plan does not pay for or cover.

Formulary- A list of drugs your plan covers.

A formulary may include how much your share of the cost is for each drug. Your plan may put drugs in different cost-sharing levels or tiers.

For example, a formulary may include generic drug and brand name drug tiers and different cost-sharing amounts will apply to each tier. Grievance- A complaint communicated to

your health insurer or plan.

Habilitation Services-

Healthcare services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Health Insurance- A contract that requires a health insurer to pay some or all of your healthcare costs in exchange for a premium. A health insurance contract may also be called a “policy” or “plan.” Home Healthcare- Healthcare services

and supplies you receive in your home under your doctor’s orders. Services may be provided by nurses, therapists, social workers, or other licensed healthcare providers. Home healthcare usually does not include help with non-medical tasks, such as cooking, cleaning, or driving.

Hospice Services- Services to provide

comfort and support for persons in the last stages of a terminal illness and their families.

Hospitalization- Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. Some plans may consider an overnight stay for observation as outpatient care instead of inpatient care. Hospital Outpatient Care- Care in a

hospital that usually does not require an overnight stay.

Individual Responsibility Requirement- Sometimes called the

“individual mandate,” the duty you may have to be enrolled in health coverage that provides minimum essential coverage. If you do not have minimum essential coverage, you may have to pay a penalty when you file your federal income tax return unless you qualify for a health coverage exemption. In-Network Coinsurance- Your share (for example, 20%) of the allowed amount for covered healthcare services. Your share is usually lower for in-network covered services. In-Network Copayment- A fixed

amount (for example, $15) you pay for covered healthcare services to providers who contract with your health insurance or plan. In-network copayments usually are less than out-of-network copayments.

Marketplace- A marketplace for health insurance where individuals, families and small businesses can learn about their plan options; compare plans based on costs, benefits and other important features; apply for and receive financial help with premiums and cost-sharing based on income; and choose a plan and enroll in coverage.

Also known as an “Exchange.” The Marketplace is run by the state in some states and by the federal government in others. In some states, the Marketplace also helps eligible consumers enroll in other programs, including Medicaid and the Children’s Health Insurance Program (CHIP). Available online, by phone, and in-person. Maximum Out-of-Pocket Limit-

suppliers your health insurer or plan has contracted with to provide healthcare services.

Network Provider (Preferred Provider)-

Yearly amount the federal government sets as the most each individual or family can be required to pay in cost-sharing during the plan year for covered, in-network services. Applies to most types of health plans and insurance. This amount may be higher than the out-of-pocket limits stated for your plan.

Orthotics and Prosthetics- Leg, arm, back and neck braces, artificial legs, arms, and eyes, and external breast prostheses after a mastectomy. These services include: adjustment, repairs, and replacements required because of breakage, wear, loss, or a change in the patient’s physical condition.

Medically Necessary- Healthcare services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms, including habilitation, and that meet accepted standards of medicine.

Out-of-Network Coinsurance- Your share (for example, 40%) of the allowed amount for covered healthcare services to providers who do not contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.

Minimum Essential Coverage- Health coverage that will meet the individual responsibility requirement. Minimum essential coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage.

Out-of-Network Copayment- A fixed

Minimum Value Standard-

contract with your plan to provide services. If your plan covers out-of-network services, you will usually pay more to see an out-of-network provider than a preferred provider. Your policy will explain what those costs may be. May also be called “non-preferred” or “non-participating” instead of “out-of-network provider.”

A basic standard to measure the percent of permitted costs the plan covers. If you’re offered an employer plan that pays for at least 60% of the total allowed costs of benefits, the plan offers minimum value and you may not qualify for premium tax credits and cost-sharing reductions to buy a plan from the Marketplace.

Network- The facilities, providers and

amount (for example, $30) you pay for covered healthcare services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.

Out-of-Network Provider (Non-Preferred Provider)- A provider who does not have a

Out-of-Pocket Limit- The most

you could pay during a coverage period (usually one year) for your share of the costs of covered services. After you meet this limit the plan will usually pay 100% of the allowed amount. This limit helps you plan for healthcare costs. This limit never includes your premium, balance-billed charges or healthcare your plan does not cover. Some plans do not count all of your copayments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit.

Physician Services- Healthcare services

a licensed medical physician, including an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic Medicine), provides or coordinates.

Plan- Health coverage issued to you directly (individual plan) or through an employer, union or other group sponsor (employer group plan) that provides coverage for certain healthcare costs. Also called “health insurance plan,” “policy,” “health insurance policy” or “health insurance.” Preauthorization- A decision by your

health insurer or plan that a healthcare service, treatment plan, prescription drug or durable medical equipment (DME) is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization is not a promise your health insurance or plan will cover the cost.

Premium- The amount that must be paid for

your health insurance or plan. You and/or your employer usually pay it monthly, quarterly, or yearly.

Premium Tax Credits- Financial help that

lowers your taxes to help you and your family pay for private health insurance. You can get this help if you receive health insurance through the Marketplace and your income is below a certain level. Advance payments of the tax credit can be used right away to lower your monthly premium costs.

Prescription Drug Coverage- Coverage under a plan that helps pay for prescription drugs. If the plan’s formulary uses “tiers” (levels), prescription drugs are grouped together by type or cost. The amount you’ll pay in cost sharing will be different for each “tier” of covered prescription drugs. Prescription Drugs- Drugs and medications

that by law require a prescription.

Preventive Care (Preventive Service)-

Routine healthcare, including screenings, check-ups, and patient counseling, to prevent or discover illness, disease, or other health problems. Primary Care Physician (PCP)- A physician, including an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic Medicine), who provides or coordinates a range of healthcare services for you.

Primary Care Provider- A physician, including an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist, or physician assistant, as allowed under state law and the terms of the plan, who provides, coordinates, or helps you access a range of healthcare services. Provider- An individual or facility that

provides healthcare services. Some examples of a provider include a doctor, nurse, chiropractor, physician assistant, hospital, surgical center, skilled nursing facility, and rehabilitation center. The plan may require the provider to be licensed, certified, or accredited as required by state law.

Reconstructive Surgery- Surgery and

follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries, or medical conditions.

Referral- A written order from your

Primary Care Provider for you to see a specialist or receive certain healthcare services. In many Health Maintenance Organizations (HMOs), you need to obtain a referral before you can receive healthcare services from anyone except your Primary Care Provider. If you do not receive a referral first, the plan may not pay for the services.

Rehabilitation Services- Healthcare

services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Screening- A type of preventive care that includes tests or exams to detect the presence of something, usually performed when you have no symptoms, signs, or prevailing medical history of a disease or condition. Skilled Nursing Care- Services performed or supervised by licensed nurses in your home or in a nursing home. Skilled nursing care is not the same as “skilled care services,” which are services performed by therapists or technicians (rather than licensed nurses) in your home or in a nursing home. Specialist- A provider focusing on a

specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.

Specialty Drug- A type of prescription drug

that, in general, requires special handling or ongoing monitoring and assessment by a healthcare professional, or is relatively difficult to dispense. Generally, specialty drugs are the most expensive drugs on a formulary.

UCR (Usual, Customary and Reasonable)-

condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

P.O. Box 6910 Canton, Ohio 44706 6057/20

2019 Compliance Guide

CONTACT INFORMATION AND RESOURCES

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TYPE OF QUESTION

CONTACT INFORMATION

Billing and Enrollment

AultCare PO Box 6910 Canton, OH 44706 330-363-6360 or 800-344-8858

For questions regarding governance of the Canton Regional Chamber Health Fund MEWA

Canton Regional Chamber Health Fund Board of Trustees of the Canton Regional Chamber Health Fund 2600 Sixth St. SW Canton, OH 44710 330-363-6360 or 800-344-8858

Benefit Questions

AultCare Service Center PO Box 6910 Canton, OH 44706 330-363-6360 or 800-344-8858 www.aultcare.com

General questions about your renewal or Benefit Plans

Your broker, or, if no broker: AultCare Service Center 2600 Sixth St. SW Canton, OH 44710 330-363-6360 or 800-344-8858

Questions about all covered services or assistance with claim information, identification cards, and benefit books.

AultCare Service Center PO Box 6910 Canton, OH 44706 330-363-6360 or 800-344-8858 www.aultcare.com

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Canton Regional Chamber Health Fund Multiple Employer Welfare Arrangement This guide contains information to help Participating Employers in the Canton Regional Chamber Health Fund (the “Fund”) administer their plans while maintaining compliance with applicable State and Federal laws. Our goal is to provide support while you successfully deliver and manage the highest quality benefit programs for your employees. However, this guide is not legal advice and you should always seek the guidance of outside counsel if you have any questions about the legal obligations outlined within this document. GENERAL INFORMATION The Fund is a multiple employer welfare arrangement (“MEWA”) as defined in Section 3(40) of the Employee Retirement Income Security Act of 1974 (“ERISA”) and provides certain welfare benefits on a self-funded basis. The Fund is maintained pursuant to the Fund’s Plan Document, the Canton Regional Chamber Health Fund Trust Agreement, and the By-laws of the Board of Trustees of the Canton Regional Chamber Health Fund. AultCare Corporation (“AultCare”) is the entity responsible for processing the Fund’s medical claims (the “Claims Administrator”) along with other certain administrative responsibilities. AultCare Insurance Company provides stop loss insurance for the self-funded medical benefits offered through the Fund, which means AultCare Insurance Company provides reimbursement to the Fund when medical claims for a specific Covered Person exceed a threshold and when aggregate medical claims exceed a threshold. Additionally, AultCare will assist Participating Employers and other Fund service providers by preparing the Plan Documents that describe the covered services, benefits, eligibility requirements and other features and limitations of the Fund with respect to the enrollees. The Fund is a “non-plan MEWA,” which means that each Participating Employer is treated as sponsoring its own group health plan for purposes of complying with federal legal requirements, including those imposed under ERISA. This also means each Participating Employer is considered the formal Plan Sponsor and Plan Administrator for its own employee benefit plan, as those terms are defined under ERISA. As such, each Participating Employer is responsible for complying with all the duties of a Plan Sponsor and Plan Administrator under ERISA. This Guide is designed to support you in meeting your responsibilities as a Participating Employer. However, this Guide does not address all legal aspects of your participation in the Fund. Accordingly, you are encouraged to seek outside legal counsel if you have any additional questions regarding your responsibilities as a Participating Employer, Plan Sponsor, and Plan Administrator. It is also important you stay up to date with the variety of compliance responsibilities for your Plan.

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Eligibility for Participation in the Fund under Ohio Law In general, the Ohio Department of Insurance (“ODI”) requires a MEWA, such as the Fund, to maintain a minimum enrollment of 300 employees (which may include self-employed individuals), and to file various reports. For the purposes of the Fund, an employer must be a member of, and in good standing with, the Canton Regional Chamber of Commerce. Basic Financial Structure The Fund is also intended to operate in compliance with Chapter 1739 of the Ohio Revised Code and any other applicable Ohio laws. ODI has issued the Fund a certificate of authority evidencing that it is authorized to operate in Ohio pursuant to these legal requirements. The Fund’s assets (consisting of both participating employer and employee contributions) to support the claims costs and operating expenses of the benefits provided through the Fund’s benefits arrangement are held in a Trust on behalf of Participating Employers and their employees and beneficiaries. The Trustee of the Trust is the Board of Trustees of the Canton Regional Chamber Health Fund (the “Board of Trustees”), which is comprised of individuals elected by the Fund’s Participating Employers. The Trustee is empowered to determine the contributions necessary from Participating Employers to provide an adequate reserve of funds, as determined by the Trustee with the advice of actuarial advisors and in accordance with Ohio law, for payment of the benefits in the Fund. The Trustee is also responsible for ensuring compliance with certain federal and state laws and regulations. Participating Employers are obligated to pay a funding rate as determined by the Board of Trustees. The Fund will establish the monthly amounts due to the Fund to keep the coverage in force (the “Funding Rate”). The Funding Rate is your share of the Fund’s projected obligations for health benefit liabilities, administrative expenses, taxes, fees and other costs incurred by the Fund. The monthly Funding Rate supports the costs of providing medical and prescription drug benefits. Other benefits (vision and dental) may be funded through fully-insured policies. In accordance with Section 1739.15 of the Ohio Revised Code, Participating Employers are liable for all legal obligations of the Fund’s medical and prescription drug arrangements in proportion to the ratio of the total number of employees of the Participating Employer participating in the Fund on the first day of the month that obligation arose to the total number of employees of all Participating Employers participating in the Plan at the time the obligation arose. This liability will arise only if, and to the extent that, the total legal obligations of the Fund with respect to the medical and prescription drug benefits exceed the amount of any separate reserve fund established and designated for this purpose under the Trust. Participating Employers may be required to make additional payments to the Fund in the event the Fund has insufficient funds to cover its medical and prescription drug liabilities. Further, a Participating Employer will be responsible for its allocated portion of all liabilities and obligations of the Fund through the date of the Participating Employer’s withdrawal.

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Underwriting Guidelines In order to be a Participating Employer that obtains coverage through the Fund, you must have 50 or fewer full-time employees (or FTE’s) and the Participating Employer must contribute at least 50 percent of the single employee rate. Minimum Enrollment Requirements At least 75 percent of “net eligible enrollees” must be covered under this arrangement. An individual is excluded from the computation of net eligible enrollees if he or she would have been an eligible enrollee, but waives coverage because he or she is: i. In a spouse’s employer-sponsored health plan ii. An active eligible employee or retiree in another health plan sponsored by a second employer iii. Covered under a parent’s plan iv. Covered by Medicare and/or a Medicare supplement plan v. In a government-sponsored plan, such as TRICARE, Medicaid or Veteran’s Administration (VA) coverage vi. Enrolled in an individual plan

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It is your responsibility to read and review the following documents, as they are essential components of joining the Fund as well as important tools for maintaining your benefit plan and complying with state and federal law. If you have questions, you should reach out to your broker, AultCare representative, or outside counsel.        

Canton Regional Chamber Health Fund Employer Participation Agreement Canton Regional Chamber Health Fund Group Application Canton Regional Chamber Health Fund Employee Application HIPAA Business Associate Agreement Annual Attestation Summary Plan Document and Wrap Document Canton Regional Chamber Health Fund Administrative Guide Canton Regional Chamber of Commerce Health Fund Compliance Guide

Additional Compliance Information The following section has been put together to help the Fund’s Participating Employers in understanding their compliance obligations. This section is not intended to be exhaustive, but instead to bring awareness to potential compliance obligations. We understand each member’s situation is unique. If there are questions, we strongly suggest you contact your accountant, attorney, or outside benefit consultant for guidance. Nothing contained in this document should be considered legal advice. Participating Employers are potentially subject to various state laws (e.g., Chapter 1739 of the Ohio Revised Code) and federal laws, including, but not limited to, the Employee Retirement Income Security Act of 1974, as amended (“ERISA”), the Internal Revenue Code of 1986, as amended (“Code”), the Patient Protection and Affordable Care Act (“PPACA”), the Health Insurance Portability and Accountability Act (“HIPAA”), and each of their associated regulations. Each Participating Employer is responsible for complying with the duties under such laws, regulations and guidance.

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Counting Employees and Applicable Statutes Many state and federal laws differentiate between small and large employers and often require complex counting methods. Most of the rules first require an analysis of what, if any, legal entities must be combined to be treated as a single employer. Generally speaking, individual members of a “controlled group” or “affiliated service group” are treated as a single employer for purposes of complying with state and federal laws. Accordingly, each Participating Employer must determine if it belongs to a controlled group or an affiliated service group in order to determine if/how it is classified for purposes of complying with state and federal laws (i.e., for purposes of determining if it is a small or large employer). The following provides a basic overview of the complicated controlled group and affiliated service group rules, followed by a summary of applicable state and federal laws impacted by this determination. You are strongly advised to obtain the assistance of qualified outside legal counsel in order to determine how the controlled group and affiliated service group rules might impact your employee count. This analysis needs to be determined at the time the Participating Employer elects to join the Fund and on an annual basis at the time of renewal. Please be advised you will be asked to attest to the number of employees you have on an annual basis, so it is imperative you maintain accurate records. 

Identifying the Employer: Controlled Groups and Affiliated Service Groups A Controlled Group may exist when two or more companies have one of the following relationships: - Parent-Subsidiary - Brother-Sister - Combination Please see the following IRS Guidance for more information: https://www.irs.gov/pub/irs-tege/epchd704.pdf An Affiliated Service Group may exist if two or more organizations have a service relationship and/or ownership relationship. There are three tests that can be applied to determine if an affiliated service group exists and they are: - The A-Org Test - The B-Org Test - The Management Group Test Please see the following IRS Guidance for more information: https://www.irs.gov/pub/irs- tege/epchd704.pdf



Statutes with Legal Requirements that Vary Based on Employee Counts o After performing the controlled group and affiliated service group analysis, Participating Employers should review the following statutes to determine how they 7|Page

apply based on their employee count. This is not a comprehensive list, but instead provides a summary of some of the most relevant statutes applicable to group health plans. - Employee Retirement Income Security Act (“ERISA”): ERISA applies if a health plan covers 1 employee unless an exception is present (e.g. governmental or church plans). -

Patient Protection and Affordable Care Act (“PPACA”) – An employer with an average of 50 or more employees (including full-time equivalent employees) on business days during the preceding calendar year is an applicable large employer (“ALE”) for purposes of PPACA. ALEs are subject to the PPACA shared responsibility requirements and more information can be found here https://www.irs.gov/affordable-care-act/employers/determining-if-an-employeris-an-applicable-large-employer Because Fund participation is generally limited to employers with fewer than 50 employees, the Fund believes that no Participating Employers should be considered an ALE. Please notify AultCare if you believe you may be an ALE.

Ohio Small Employer Health Plan (ORC 3924)– Under Ohio law, a small employer is one that employs at least one but not more than 50 eligible employees on business days during the preceding calendar year and who employs at least one employee on the first day of the plan year. Eligible employee is defined as an employee who works a normal work week of 30 or more hours, but does not include temporary or substitute employees, or a seasonal employee who works only part of the calendar year. The Fund health plan design presumes the Ohio small employer health plan requirements are applicable. Additionally, the Ohio Department of Insurance reviews all plan designs available to Participating Employers in the Fund.

Continuation of Coverage Statutes: Counting employees accurately is important for determining what continuation of coverage requirements are applicable to you and your employees. o Consolidated Omnibus Budget Reconciliation Act (“COBRA”): Employers with 20 or more employees may be subject to federal continuation of coverage requirements as laid out in COBRA. Generally, COBRA applies to all private-sector group health plans maintained by employers that have at least 20 employees on more than 50% of its typical business days in the previous calendar year. Both full and part-time employees are counted to determine whether a plan is subject to COBRA. Each part time employee counts as a fraction of a full-time employee, with the fraction equal to the number of hours worked by the part-time employee divided by the number of hours an employee must work to be 8|Page

considered full-time ( i.e., if a company requires 40 hours to be full-time and an employee works 20 hours – they will be counted as ½ toward your final count). An employer may determine their own definition of full-time so long as it does not violate federal standards. o Ohio Health Care Continuation § 3923.38: If your total employee count does not meet the above standards, you may be held to state requirements listed under Ohio Revised Code 3923.38 with respect to the self-insured medical and prescription drug benefits provided through the Fund. ***Please note: Should a Participating Employer choose to withdraw from the Fund, that Participating Employer may be responsible for providing coverage continuation in certain circumstances. However, the Fund will have no ongoing COBRA obligation with respect to a withdrawing employer’s employees following the withdrawal. -

Health Insurance Portability and Accountability Act (“HIPAA”): Some HIPAA provisions do not apply to group health plans covering fewer than two current employees.

Medicare Secondary Payer (“MSP”): Medicare Secondary Payer rules require Medicare pay secondary unless certain criteria are met. MSP rules allow those employer groups with fewer than 20 employees to pay secondary to Medicare for Working Aged employees. However, Medicare rules require in the case of MEWAs, if any group within the MEWA has over 20 employees, then all groups within the MEWA will have to pay primary for those Working Aged individuals. Accordingly, the Fund will pay primary under the MSP rules.

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Reporting, Notice, and Disclosure Requirements IRS Reporting of Minimum Essential Coverage PPACA requires employers that provide healthcare coverage to report certain aspects of the coverage. Those employers not considered ALEs (as described above) are required to complete Forms 1094-B (to employees) and 1095-B (to IRS). Failure to comply with these requirements may result in IRS penalties. AultCare, as the Claims Administrator, will complete both of these forms as well as provide them to your employees and the IRS. If any of your employees believe their Form 1094-B is incorrect, they should promptly notify AultCare. ***Note – Additional reporting requirements apply to ALEs. As both the Fund and AultCare believe no Participating Employers should be considered ALEs, those requirements would not be handled by AultCare. Form 5500 An annual Form 5500 is required for all ERISA plans unless an exemption applies. An employer that is required to submit a Form 5500 is also required to provide a summary annual report to participants and certain other individuals. At this time, the Fund believes each Participating Employer will be treated as maintaining their own separate plan for Form 5500 filing requirements. Accordingly, each Participating Employer will be required to independently satisfy this reporting obligation by completing the Form 5500 as well as other applicable schedules and attachments (most likely, Schedules A and I). In order to assist you, AultCare will provide information needed to complete Schedules A and I. Please see the following FAQs for more information regarding Form 5500’s. 1.) What is a Form 5500? The Form 5500 is an annual reporting requirement under both ERISA and the Internal Revenue Code that applies to welfare benefits plans (e.g. employer sponsored plans that offer medical benefits). 2.) Do I need to file a Form 5500? Yes. Even though the Fund is treated as a single arrangement for certain legal purposes, the rules governing Form 5500 filings treat the Fund as a combination of individual plans maintained separately by each Participating Employer. For that reason, both AultCare and the Fund currently believe each Participating Employer is treated as a “Plan Sponsor” and “Administrator” of a separate ERISA plan with an independent obligation to annually submit Form 5500 and accompanying schedules. 3.) Which version of the Form 5500, and which schedules, should I use? Generally, you use the version of the Form 5500 that relates to the plan year for which

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you are filing (e.g. use the 2019 Form 5500 for a filing that covers plan year 1.1.19 to 12.31.19). The required schedules will depend on your particular situation, although most Participating Employers will need to include Schedules A and I. A form selection tool is available at https://www.askebsa.dol.gov/FormSelector/. 4.) Where do I get the information in order to complete Schedule A – Insurance Information and Schedule I Financial Information – Small Plan? AultCare will provide this information to each Participating Employer. 5.) How should I characterize my plan on Form 5500? While the Fund is a “Multiple Employer Welfare Arrangement,” you are treated as maintaining your own single-employer plan for purposes of Form 5500 filing requirements. Accordingly, you should characterize your plan as “a single-employer plan” on Part I, Line A of the Form 5500. 6.) What is the Plan Name? Canton Regional Chamber Health Fund. 7.) Who is the Plan Sponsor and Administrator? You, as the Participating Employer, are the Plan Sponsor and Administrator for Form 5500 filing purposes. 8.) Is this Plan subject to the Form M-1 filing required described in Part III of the Form 5500? No. MEWAs are subject to the Form M-1 filing requirement. Accordingly, the Fund (which is a MEWA) complies with the Form M-1 filing requirements. However, as explained above, each Participating Employer is treated as maintaining their own singleemployer plan for Form 5500 filing purposes. Single-employer plans are not subject to Form M-1 filing requirements. 9.) How do I file the Form 5500 and required schedules? You must submit the Form 5500, including all required schedules and attachments, electronically through either the EFAST2 or IFILE system (EFAST2 is available at https://www.efast.dol.gov/welcome.html). Please see these FAQs from the Department of Labor regarding the EFAST2 system. https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resourcecenter/faqs/efast2-form-5500-processing.pdf 10.) When is the Form 5500 due? Form 5500s are generally due the last day of the seventh month after the plan year ends (July 31 for a calendar-year plan). An extension of up to 2-1/2 months after the Form

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5500 due date is available for employers that request an extension using Form 5558 (Application for Extension of Time to File Certain Employee Plan Returns). Form 5558 must be filed with the IRS – not the Department of Labor. If the Form 5558 is filed on or before the normal due date (not including extensions) of the Form 5500, the extension request will automatically be granted; no approval is necessary. For a calendar-year plan, the 2-1/2 month extension will result in a Form 5500 due date of October 15. 11.) What happens if I miss the filing deadline (or do not file at all)? Under ERISA, the Department of Labor may assess a significant per-day civil penalty against a plan administrator starting from the date of the administrator’s failure or refusal to file a complete Form 5500. While the penalties are subject to annual increase, the current maximum per-day penalty is $2,194 per day. Note, that the Department of Labor maintains a “Delinquent Filer Voluntary Compliance (DFVC) Program,” which provides for much lower penalties for late and unfiled Form 5500s in the event the ERISA plan administrator identifies and voluntarily corrects the late or missed filing. More information about the DFVC Program can be found at https://www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-andcompliance/correction-programs/dfvcp. 12.) Where can I find more information regarding the Form 5500 filing requirements? https://www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-andcompliance/reporting-and-filing/forms https://www.irs.gov/retirement-plans/form-5500-corner 13.) What is a Summary Annual Report? The summary annual report is a statement that summarizes in narrative form the latest annual report (i.e. Form 5500) for a plan. 14.) Who is furnished with a Summary Annual Report and when? Subject to certain exemptions, plans that file a Form 5500 must furnish Summary Annual Reports to participants covered under the plan and to individuals in certain other categories. The summary annual report must be furnished within nine months of the close of plan year. If an extension of time to file the Form 5500 is obtained, the plan administrator must furnish the summary annual report within two months after the close of the period for which the extension was granted.

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Please review the following table for more guidance regarding required notices and their distribution. Document Summary Plan Description (SPD)

Timing Requirement A new plan has 120 days after first becoming subject to ERISA to provide an SPD to participants. For existing plans, the SPD must be provided to new participants within 90 days after the participant first becomes covered under the plan.

Purpose

Who is Responsible?

This describes the benefits and terms of coverage.

It is the Participating Employer’s responsibility for the content and distribution of the SPD; the Fund will create the SPD template for the Fund’s MEWA plan. AultCare will assist in this process and provide the document to Participating Employers. Participating Employers must distribute the SPDs (including attachments) to their employees.

Any amended SPD must be provided every 5 years if material changes are made; otherwise, every 10 years. Employers must also provide this document to participants within 30 days of request, to avoid penalties. Summary of This must be provided within Material Modifications 210 days of the end of the plan (“SMM”) year in which

This describes any amendments to the plan or other changes to

The Participating Employer is responsible for the content and distribution of any SMM. AultCare will provide assistance in creating the SMM.

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the modification is adopted. If the change results in a material reduction of benefits, the SMM must be provided within 60 days after the date of adoption of the modification or change.

information that are required to be included in a plan’s SPD.

The Participating Employer is responsible for distributing the SMM to their employees.

An SBC for each medical package offered must be provided (1) when an employee is initially eligible to enroll; (2) at open enrollment (i.e. renewal); (3) to special enrollees within 90 days after enrollment pursuant to a special enrollment right; and (4) upon request, as soon as practicable, but no later than 7 business days following the request.

Describes the benefits and coverage under each benefit package, highlighting certain cost sharing values and exclusions of each package. The standard format is part of PPACA requirements.

The Participating Employer is responsible for the content and distribution of the SBC while adhering to all regulatory requirements.

Notice of No later than 60 Material days prior to the Modifications date on which such change will become effective.

Describes any material modifications in the term of the plan that (1) would affect the

The Participating Employer is responsible for the content and distribution of the Notice of Material Modifications while adhering to all regulatory requirements. AultCare will prepare and provide all Notices of

Summary of Benefits and Coverage and Uniform Glossary (SBC)

AultCare will prepare and provide initial and subsequent SBCs to the Participating Employers. The Participating Employer is responsible for distributing the SBC to their employees. https://www.cms.gov/CCIIO/Programsand-Initiatives/Consumer-Support- andInformation/Summary-of- Benefits-andCoverage-and-Uniform- Glossary.html

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HIPAA Special Enrollment Notice

Women’s Health and Cancer Rights Act

At or before the time an employee is initially offered the opportunity to enroll in a group health plan.

Upon enrollment and annually.

content of the SBC, (2) is not reflected in the most recently provided SBC, and (3) occurs other than connected with a renewal (i.e., mid-plan year). Informs Participants of special enrollment opportunities available for certain situations including the right to special enroll within 30 days of the loss of other coverage, marriage, and birth of a child, adoption, or placement for adoption. Informs Participants of required benefits for mastectomyrelated reconstructive surgery, prostheses, and treatment of physical complications of mastectomy.

Material Modifications to the Participating Employers. The Participating Employer is responsible for distributing the Notice of Material Modifications to their employees.

Information about enrollment requirements are included in the Plan Document. Additionally, the Administrative Guide contains a Notice of HIPAA Special Enrollment Rights. Participating Employers are responsible for making information available to their employees, as well as, timely notifying AultCare of any special enrollment events.

Initial Participant notice will be included in the Plan Document. AultCare will also provide this document to Plan Participants on an annual basis.

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COBRA Notices (e.g. General Notice, Election Notice)

State Continuation of Coverage Notices

Marketplace Exchange Availability

COBRA General Notices are required when group health plan coverage commences.

Under federal law, COBRA continuation requirements (including notification requirements) apply to all COBRA Participating Election Notices Employers with must be over 20 provided by employees for plan more than half administrator of the prior within 14 days calendar year, after being COBRA applies notified by the with respect to employer or medical, qualified prescription beneficiary of a drug, vision, qualifying and dental event. benefits. Upon Participating involuntary Employers with termination of fewer than 20 an employee for employees for reasons other more than half than gross of the prior year conduct. are required to provide 12 months of coverage under Ohio law. This pertains to health benefits only. The Participating Employer is required to provide this notice to a new employee within 14 days of his or her date of hire.

This notice is intended to inform an employee of the existence of the Marketplace, the potential availability of a tax credit, and the possible loss of employer contribution if the employee

AultCare will provide all applicable employee notifications (if AultCare is designated to act as the COBRA Administrator). The Participating Employer is responsible for notifying AultCare within 30 days of the following qualifying events:  Death of the covered employee  Termination (other than by reason of gross misconduct) or reduction of hours of the covered employee;  Covered employee’s becoming entitled to Medicare; and  Commencement of a bankruptcy proceeding of the employer (causing a substantial elimination of retiree coverage) Participating Employers are required to provide State Continuation Coverage information to their participants. Note: AultCare has provided additional information in your Administrative Guide regarding State Continuation rules, but will not be providing information directly to participants.

The Participating Employer is responsible for making this notice available to their employees. AultCare does not provide this form. Please see the link below for more information. https://www.dol.gov/sites/default/files/ebsa/l aws-and-regulations/laws/affordable-careact/for-employers-and-advisers/modelnotice-for- employers-who-offer-a-healthplan-to-some-or-all-employees.pdf

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Medicare Part D Creditable Coverage

Various timing requirements apply depending on the type of disclosure.

purchases a qualified health plan through the Marketplace. Plan sponsors are required to send notifications to members on an annual basis notifying them if their current plan is expected to pay as much as the standard Medicare prescription drug coverage. Additionally, an online disclosure to CMS regarding creditable coverage status of the prescription drug plan is required.

AultCare will provide all applicable notices and disclosures regarding creditable coverage status. Additionally, AultCare will complete the annual disclosure to CMS on behalf of the Fund.

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Other Notices Many notices are provided in the SPD or by annual mailings provided by AultCare, including most of those notices listed below. If you have questions, please contact your AultCare representative, broker, or outside legal counsel. It is your responsibility to review and determine if any additional information should be provided to your employees. 

Uniformed Services Employment and Reemployment Rights Act. More information can be found at: https://www.dol.gov/vets/programs/userra/userra_fs.htm (Information is contained in the SPD provided by AultCare.)



Newborns and Mothers’ Health Protection Act. More information can be found at: https://www.dol.gov/general/topic/health-plans/newborns (Information is contained in the SPD provided by AultCare.)



Qualified Medical Child Support Order. More information can be found at: https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resourcecenter/publications/qualified-medical-child-support-orders.pdf (Information is contained in the SPD provided by AultCare.)



Michelle’s Law. More information can be found at:http://webapps.dol.gov/elaws/ebsa/health/employer/657.asp (AultCare provides an annual mailing regarding Michelle’s Law.)



Genetic Information Nondiscrimination Act (“GINA”). More information can be found at: https://www.eeoc.gov/laws/types/genetic.cfm (Basic information is provided in your SPD; however, additional requirements may apply if you have a voluntary wellness program.)



Children’s Health Insurance Program Reauthorization Act (“CHIPRA”). More information can be found at: http://www.ahrq.gov/policymakers/chipra/index.html (Employees residing in Ohio are not required to receive this notice; however, employees who reside in other states may have different requirements. Please notify AultCare immediately if you have employees residing outside of Ohio.)



PPACA Section 1557 nondiscrimination. More information can be found at: https://www.hhs.gov/civil-rights/for-individuals/section-1557/index.html (AultCare provides taglines and notices on all significant member documents.)

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Other Compliance Considerations: 1) HIPAA – Privacy & Security: As a self-funded group health plan, you are considered a “covered entity” under HIPAA. As such, you are expected to comply with certain requirements in order to maintain the privacy and security of protected health information. Such requirements include: a. Providing a Notice of Privacy Practices b. Appointing Privacy & Security Officials c. Establishing HIPAA-compliant processes and procedures to protect member information d. Investigating and tracking potential unauthorized disclosures of protected health information and completing appropriate breach reporting to individuals, the Office of Civil Rights and, if necessary, the media e. Creating appropriate forms to accommodate individual access requests as allowed under HIPAA f. Overall HIPAA Privacy & Security compliance Due to the nature of the Fund and each Participating Employer’s limited access to employee protected health information, AultCare in its role as the Claims Administrator will take certain steps to help Participating Employers meet these requirements. Specifically, AultCare will assist in the establishment of HIPAA-compliant privacy policies and procedures under the direction of the Board of Trustees. These policies will apply to both the Fund and Participating Employers as covered entities under HIPAA. It will be responsibility of each Participating Employer to review and adopt these policies. Additionally, AultCare will distribute a Notice of Privacy Practices to both Participating Employers and members. 2.) Internal Revenue Code §125 Cafeteria Plans: §125 of the Internal Revenue Code provides employers with the ability to establish programs to help employees pay for certain benefit expenses on a pre-tax basis.1 Such expenses may include health or accident plans, flexible spending accounts, group-term life insurance, and health savings accounts. These plans must be established and sponsored by the Participating Employer. One of the most important requirements is that your cafeteria plan be in writing and those written provisions are followed.2 Note that while the Fund provides for same sex domestic partner coverage (subject to certain threshold eligibility requirements as listed in the SPD) the cost of such coverage generally cannot be paid for on a pre-tax basis through a cafeteria plan, and the value of the domestic partner coverage is generally includable in the covered employee’s gross income and reportable on Form W-2. Each Participating Employer is responsible for ensuring proper tax treatment for their employees and you should seek guidance from a qualified tax professional if you have tax-related questions. 2 If you maintain a written cafeteria plan, that document may provide your employees with opportunities to change their pre-tax benefit elections in the middle of the plan year. For example, your document may allow participants to make mid-year election changes on account of a change in residence, a change in employment status, or upon certain other mid-year election change events. Participating Employers are responsible for determining if/how these rules apply to their employees and communicating these events to AultCare so that it can make corresponding changes to employees’ Fund coverage. 1

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An employer must adopt a formal document that captures certain information including, but not limited to, available benefits, participation rules, plan year, maximum contributions, and election processes. Additionally, a cafeteria plan may not discriminate in favor of highly compensated individuals in regards to their eligibility to participate and overall contributions and benefits. Because Participating Employers are solely responsible for establishing and operating their own cafeteria plans, neither the Fund nor AultCare will assume an active role with individual employer cafeteria plans. AultCare, in its role as Claims Administrator, has a very basic prototype cafeteria plan document that it can provide to Participating Employers. However, it is ultimately the responsibility of the Participating Employer to review and revise that document to meet their specific needs, to adopt the plan, and to take whatever other steps are necessary to establish and operate the cafeteria plan in a legally-compliant manner. 3.) Non-Discrimination: As a self-funded group health plan, you are subject to nondiscrimination laws including those imposed under Section 105(h) of the Internal Revenue Code. §105 contains two tests that must be met in order to ensure highly compensated employees (“HCEs”) are not receiving beneficial treatment. The two tests are the Eligibility Test and Benefits Test.  Eligibility Test: Under the Eligibility Test, the plan cannot discriminate in favor of HCEs (which includes the highest-paid 25% of all employees) as to eligibility to participate. There are three alternative tests—the 70% Test, the 70%/80% Test, and the Nondiscriminatory Classification Test.  Benefits Test: Under the Benefits Test, the benefits provided under the plan must not discriminate in favor of HCEs. Specifically, this requires that “all benefits provided for participants who are HCEs are provided for all other participants.” In addition, all the benefits available for the dependents of HCEs must also be available on the same basis for dependents of all non-HCE participants. There are two requirements embedded within this test: o The plan cannot provide discriminatory benefits on the face of the plan. o The plan cannot provide discriminatory benefits in operation (even if the face of the plan is nondiscriminatory). These tests should be taken into consideration by Participating Employers when creating employee classifications for the purpose of benefit administration. (e.g. imposing different waiting periods for different classes of employees.) This is a complex area of law that requires an analysis of employee demographics. As such, you should seek outside counsel if this is an option you are exploring.

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4.) Patient-Centered Outcomes Research Institute (PCORI): The PCORI Trust Fund fee is a fee on issuers that is based on the number of plan participants. The Board is responsible for filing the necessary forms. However, you may be responsible for your portion of the fee.

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AultCare/Aultra General Tag Lines for the State of Ohio English If you, or someone you are helping, have questions about AultCare/Aultra you have the right to get help and information in your language at no cost. To speak with an interpreter, call Local: 330.363.6360 Outside Stark County: 1.800.344.8858 TTY Local: 330.363.2393 Outside Stark County: 1.866.633.4752 Spanish Español Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca AultCare/Aultra tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al Local : 330.363.6360 Fuera del condado de Stark : 1.800.344.8858 TTY Local : 330.363.2393 Fuera del condado de Stark : 1.866.633.4752 Chinese 中文如果您，或是您正在協助的對象，有關於 AultCare/Aultra 保险公司方面的問題，您有權利免費以您的母語得到幫助和訊息。洽詢一位翻譯員，請撥電話本地： 330.363.6360 斯塔克縣外： 1.800.344.8858 TTY 線本地： 330.363.2393 斯塔克縣外： 1.866.633.4752。 German Deutsche Falls Sie oder jemand, dem Sie helfen, Fragen zum AultCare/Aultra haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer Local: 330.363.6360 Außerhalb von Stark County : 1.800.344.8858 TTY –Linie Local: 330.363.2393 Außerhalb von Stark County : 1.866.633.4752 an. Arabic

‫ال عرب ية‬

‫ للتحدث مع مترجم اتصل ب‬.‫ لديك الحق في الحصول على المساعدة والمعلومات الضرورية بلغتك من دون اية تكلفة‬،‫العربية‬ ‫ إن كان لديك أو لدى شخص تساعده أسئلة بخصوص شركة التأمين‬AultCare/Aultra 1.800.344.8858 : ‫ خارج مقاطعة ستارك‬TTY ‫ الخط‬330.363.2393 :‫ المحلي‬1.866.633.4752 . ‫خارج مقاطعة ستارك‬

Pennsylvania Dutch Deitsch Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut AultCare/Aultra hoscht du es Recht fer Hilf un Information in deinre eegne Schprooch griege, un die Hilf koschtet nix. Wann du mit me Interpreter schwetze witt, kannscht du Local: 330.363.6360 Außerhalb von Stark County: 1.800.344.8858 TTY –Linie Local: 330.363.2393 Außerhalb von Stark County : 1.866.633.4752 uffrufe. Russian русский Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Страховая компания AultCare/Aultra, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону Местный: 330.363.6360 Вне Старка County : 1.800.344.8858 TTY линия Местный: 330.363.2393 Вне Старка County : 1.866.633.4752. French Français Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Compagnie d'Assurance AultCare/Aultra, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, Appelez Locale 330.363.6360 En dehors du comté de Stark : 1.800.344.8858 ligne ATS Local : 330.363.2393 En dehors du comté de Stark : 1.866.633.4752. Vietnamese Việt Nam Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Công ty Bảo hiểm AultCare/Aultra quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi Địa phương: 330.363.6360 Bên ngoài của Stark County : 1.800.344.8858 TTY đường dây Địa phương: 330.363.2393 Bên ngoài của Stark County : 1.866.633.4752. Cushite-Oromo Isin yookan namni biraa isin deeggartan AultCare/Aultra, irratti gaaffii yo qabaattan, kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabdu. Nama isiniif ibsu argachuuf, lakkoofsa bilbilaa Local: 330.363.6360 Outside of Stark County: 1.800.344.8858 TTY Line Local: 330.363.2393 Outside of Stark County: 1.866.633.4752 tiin bilbilaa. AultCare/Aultra General Tag Lines

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Korean 한국어 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 AultCare/Aultra 보험 회사 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 지역 : 330.363.6360 스타크 카운티 의 외부 : 1.800.344.8858 TTY 라인 지역 : 330.363.2393 스타크 카운티 의 외부 : 1.866.633.4752 로 전화하십시오. Italian Italiano Se tu o qualcuno che stai aiutando avete domande su AultCare/Aultra, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare Locale: 330.363.6360 Al di fuori di Stark County : 1.800.344.8858 TTY linea Locale: 330.363.2393 Al di fuori di Stark County : 1.866.633.4752. Japanese 日本語ご本人様、またはお客様の身の回りの方でも AultCare/Aultra 保険会社についてご質問がございましたら、ご希望の言語でサポートを受けたり、情報を入手したりすることができます。料金はかかりません。通訳とお話される場合、ローカル： 330.363.6360 スターク郡の外： 1.800.344.8858 TTY ラインローカル： 330.363.2393 スターク郡の外： 1.866.633.4752 までお電話ください。 Dutch Nederlands Als u, of iemand die u helpt, vragen heeft over AultCare/Aultra, heeft u het recht om hulp en informatie te krijgen in uw taal zonder kosten. Om te praten met een tolk, bel Local : 330.363.6360 Buiten Stark County : 1.800.344.8858 TTY Line Local : 330.363.2393 Buiten Stark County : 1.866.633.4752. Ukrainian український Якщо у Вас чи у когось, хто отримує Вашу допомогу, виникають питання про Страхова компанія AultCare/Aultra, у Вас є право отримати безкоштовну допомогу та інформацію на Вашій рідній мові. Щоб зв’язатись з перекладачем, задзвоніть на Місцевий : 330.363.6360 Поза Старка County : 1.800.344.8858 TTY лінія Місцевий : 330.363.2393 Поза Старка County : 1.866.633.4752. Romanian Română Dacă dumneavoastră sau persoana pe care o asistați aveți întrebări privind Compania de Asigurari AultCare/Aultra, aveți dreptul de a obține gratuit ajutor și informații în limba dumneavoastră. Pentru a vorbi cu un interpret, sunați la Locale : 330.363.6360 In afara Stark Judet : 1.800.344.8858 TTY linie Locale : 330.363.2393 In afara Stark Judet : 1.866.633.4752. Non-Discrimination Notice: AultCare/Aultra complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. AultCare/Aultra does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. AultCare/Aultra provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). AultCare/Aultra provides free language services to people whose primary language is not English, such as: Qualified interpreters and information written in other languages. If you need these services, or if you believe that AultCare/Aultra has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can contact or file a grievance with the: AultCare/Aultra Civil Rights Coordinator, 2600 6th St. S.W. Canton, OH 44710, 330-363-7456, CivilRightsCoordinator@aultcare.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Civil Rights staff is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

AultCare/Aultra General Tag Lines

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P.O. Box 6910 Canton, Ohio 44706

Rev.906/17 10/08