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 was finalized for Plan Year 2021.

Table of Contents

• What’s

• What is Culturally and Linguistically Appropriate Manner?

• How do I meet

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

What’s an SBC and a Uniform Glossary?

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

• Out-of-pocket and annual limits 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 Why this Matters:

What is the overall deductible? $500 person / $1,000 family Doesn’t apply to preventive care

Are there other deductibles for specific services?

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

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

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

Yes. For participating providers $2,500 person / $5,000 family

For non-participating providers $4,000 person / $8,000 family

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

Is there an overall annual limit on what the plan pays? No.

Does this plan use a network of providers?

Yes. See www.[insert].com or call 1-800-[insert]

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

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.

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

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

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

• In- and out-of-network provider coverage

• Coverage of common medical events

• Excluded services

• 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?

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.

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 (adjusted for inflation) for each instance of willing non-compliance

• A fine of $100 per day per affected individual until compliant

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

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.

• 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.

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.

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.

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.

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).

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.

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

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.

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

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.

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 this 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, contact 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.aultcare.com or call 330-363-6360 or 1-800344-8858 to request a copy.

Important Questions Answers

For network providers

Why This Matters:

What is the overall deductible?

Are there services covered before you meet your deductible?

Are there other deductibles for specific services?

$200 Individual / $400 Family

For out-of-network providers

$600 Individual / $1,200 Family

Yes. Network preventive care and services that apply a copayment are covered before you meet your deductible.

Generally, you must pay all of the costs from providers up to the calendar year deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family 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/.

No.

For network medical providers

$700 Individual / $1,400 Family

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

What is the out-of-pocket limit for this plan?

For out-of-network providers

$2,100 Individual/ $4,200 Family

For Prescription Drugs

$8,000 Individual/ $16,000 Family

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

Premiums, balance-billing charges, Prescription medication coupon, discount, or other manufacturer assistance programs for Specialty or other qualified medications, and health care this plan doesn’t cover.

The out-of-pocket limit is the most you could pay in a calendar year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

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

Important Questions Answers

Why This Matters:

Will you pay less if you use a network provider?

Yes. See www.aultcare.com or call 330-363-6360 or 1-800-3448858 for a list of network providers.

Do you need a referral to see a specialist? No.

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.

For more information about limitations and exceptions, see the plan or policy document at www.aultcare.com.]

All coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at www.aultcare.com

Preferred Generic drugs (Tier 1)

Retail 1-34 day supply: $10 copayment or 20% coinsurance, whichever is greater; Retail 35-60 day supply: $20 copayment or 20% coinsurance, whichever is greater; Mail order 90-day supply: $25 copayment or 20% coinsurance, whichever is greater

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.

Preferred Brand / NonPreferred Generic drugs

(Tier 2)

Retail 1-34 day supply: $30 copayment or 30% coinsurance, whichever is greater; Mail order 90-day supply: $85 copayment or 25% coinsurance, whichever is greater, up to a maximum of $200

Non-Preferred Brand / NonPreferred Generic drugs

(Tier 3)

Retail 1-34 day supply: $45 copayment or 50% coinsurance, whichever is greater; Mail order 90-day supply: $130 copayment or 45% coinsurance, whichever is greater, up to a maximum of $400

Deductible does not apply. A 34-day supply is available at the retail pharmacy for brand name prescription drugs. Up to a 60-day supply of Preferred generic prescription drugs is available at the retail pharmacy, and a 90-day supply of generic or brand name prescription drugs are available at the mail order program. Specialty/Limited Distribution Medications are limited to a 30-day supply. If a prescription drug is purchased without using your card, this Plan will pay up to the allowed amount. Specialty Medications must be obtained from AultCare’s Preferred Specialty pharmacies. Prescription medication coupon, discount, or other manufacturer assistance programs for Specialty or

For more information about limitations and exceptions, see the plan or policy document at www.aultcare.com.] Page of

Common Medical Event Services You May Need

Specialty Generic (Tier 4)

**Limited to a 30-day fill

What You Will Pay

Retail or Mail order: $10 copayment or 20% coinsurance, whichever is greater other qualified medications will not apply toward your Deductible or Out-of-Pocket Maximum.

Specialty Brand (Tier 5)

***Limited to a 30-day fill

Retail or Mail order: $125 copayment or 20% coinsurance, whichever is greater If you have

Certain preventive medications may be covered at 100%, with no cost to You. Also, certain classes of medications require a Prior Authorization or Step Therapy. For a complete list of these medications please visit the AultCare website at www.aultcare.com.

If you need mental health, behavioral health, or substance abuse services

For more information about limitations and exceptions, see the plan or policy document at www.aultcare.com.] Page

May Need

What You Will Pay

Benefits paid based on the corresponding medical benefit.

Benefits paid based on the corresponding medical benefit.

If you are pregnant

If you need help recovering or have other special health needs

Benefits paid based on the corresponding medical benefit.

Benefits paid based on the corresponding medical benefit.

Cost sharing does not apply to certain preventive services. Depending on the type of service, a copayment, deductible or coinsurance may apply.

Must be injury/illness related. Manipulation therapy is limited to 35 treatments per calendar year.

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 including ABA at 20 hours per week; and Mental/ Behavioral Health Outpatient Services.

Preauthorization is required for a single item with a

For more information about limitations and exceptions, see the plan or policy document at www.aultcare.com.] Page

Common Medical Event Services You May Need

What You Will Pay

Children’s eye exam No cost share 30% coinsurance

If your child needs dental or eye care

Children’s glasses Not covered Not covered

Children’s dental check-up Not covered Not covered

Excluded Services & Other Covered Services:

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.

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

 Abortion (except in cases of rape, incest, or when the life of the mother is endangered)

 Acupuncture

 Bariatric Surgery

 Cosmetic Surgery

 Dental Care (adult)

 Hearing Aids

 Long Term Care

 Non-Emergency care when traveling outside the U.S.

 Routine Eye Care (Adult)

 Routine Foot Care

 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

 Habilitation Services

 Infertility Treatment

 Private Duty Nursing

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.

For more information about limitations and exceptions, see the plan or policy document at www.aultcare.com.] Page 6 of 8

Does this plan provide Minimum Essential Coverage? Yes

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. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet the 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 330-363-6360 / 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.

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 212441850.

For more information about limitations and exceptions, see the plan or policy document at www.aultcare.com.] Page

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

 The plan’s overall deductible $200

 Specialist copayment $10

 Hospital (facility) coinsurance 10%

 Other coinsurance 10%

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)

Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition)

 The plan’s overall deductible $200

 Specialist copayment $10

 Hospital (facility) coinsurance 10%

 Other coinsurance 10%

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)

Mia’s Simple Fracture (in-network emergency room visit and follow up care)

 The plan’s overall deductible $200

 Specialist copayment $10

 Hospital (facility) coinsurance 10%

 Other coinsurance 10%

This EXAMPLE event includes services like: Emergency room care (including medical supplies)

Diagnostic test (x-ray)

Durable medical equipment (crutches)

Rehabilitation services (physical therapy)

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

Attachment #1: Urgent Care and After-Hours Clinic Information

Attachment #2: AultLine

Attachment #3: Prescription Information Website

Attachment #4: A Guide to Our Services

A faster, easier way to see a provider.

The provider is always in _ midnight or midday, we’re available. Sign up today!

Consult with a provider by smartphone, tablet or computer.

• Affordable, easy and convenient

• Your choice of U.S. board-certified providers

• No appointment, no waiting

• 24/7/365 mobile or web access

• Consultation, diagnosis, and prescriptions (when appropriate)

Download Now!

Search the App Store or Google Play for “AultmanNow”

Step 1: Enroll to create your account

Step 2: Select the provider you’d like to see

If you are unable to use the mobile app, you can call 844-606-1603 for a telephonic appointment.

You have the right to assistance and information in your language at no cost. To speak with an interpreter, call 330-363-6360 (TTY 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 330-363-6360 (TTY: 711). 注意：

如果您使用繁體中文，您可以免費獲得語言援助服務。請致電330-363-6360（TTY：711）。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.

TELEHEAL TH www.aultmannow.com

You have the right to assistance and information in your language at no cost. To speak with an interpreter, call 330-363-6360 (TTY 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 330-363-6360 (TTY: 711). 注意： 如果您使用繁體中文，您可以免費獲得語言援助服務。請致電330-363-6360（TTY：711）。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.