BENEFITS OVERVIEW APRIL 1, 2024 TO MARCH 31, 2025
2024 SOUTHERN CALIFORNIA
What’s New! •
SIMNSA dental plan now available for San Diego area employees.
•
The Kaiser HMO medical plan design has changed. Some changes include an added deductible, lower office visit copays, etc.
•
Healthcare Reimbursement Account (HRA) providing members reimbursement to help offset Specialty Rx medication costs.
•
401K annual allowed contribution amount has increased to $23,000 and for employees over the age of 50, the catch up contribution has increased to $7,500.
•
Medical FSA annual contribution amount has increased to $3,200.
Table of Contents Continuing Life: BENEFITS OVERVIEW Introduction to Your Benefits .......................................................................................................................................4 Eligibility .............................................................................................................................................................................. 5 Enrollment .......................................................................................................................................................................... 6 Registration.........................................................................................................................................................................7 STAR Fund ......................................................................................................................................................................... 8 Wellness Program ........................................................................................................................................................... 9 Medical Coverage .......................................................................................................................................................... 11 Health Reimbursement Account (HRA)..................................................................................................................16 Blue Shield Wellness Resources & Tools ............................................................................................................. 17 Kaiser Permanente Wellness Resources & Tools .............................................................................................18 Dental Coverage ............................................................................................................................................................19 Vision Coverage .......................................................................................................................................................... 20 Basic Life / Supplemental Term Life / AD&D Coverage .................................................................................21 Disability Insurance ......................................................................................................................................................22 Flexible Spending Accounts (FSA) .........................................................................................................................24 Employee Assistance Program (EAP) & Travel Assistance ...........................................................................25 Retirement Savings Plan - 401(k) .............................................................................................................................26 Retirement Savings Plan - Roth 401(k) ...................................................................................................................27 DailyPay ............................................................................................................................................................................28 University of Arizona Global Campus ...................................................................................................................29 Member Support ...........................................................................................................................................................30 Medicare Part D Notice ............................................................................................................................................... 31 Legal Information Regarding Your Plans ..............................................................................................................32 Children’s Health Insurance Program (CHIP) ......................................................................................................40 Plan Guidelines and Evidence of Coverage ......................................................................................................44 Notice Regarding Wellness Plan.............................................................................................................................46 Directory & Resources ................................................................................................................................................ 47
Benefit Guide 2024 3
Introduction to Your Benefits COSTS SHARED BY YOU AND THE COMPANY MEDICAL Blue Shield, Kaiser & SIMNSA
• Blue Shield HMO Trio (Low), HMO Access+ (High), PPO • Kaiser HMO • SIMNSA HMO (San Diego work locations only)
DENTAL Guardian & SIMNSA
• Guardian DHMO • Guardian DPPO
VISION VSP
• PPO
• SIMNSA DHMO
100% OF COSTS PAID BY THE COMPANY BASIC LIFE /AD&D Guardian
• 1 times annual salary to a maximum of $50,000
LONG TERM DISABILITY (LTD) • Provides a portion of your income when you are unable to Guardian – Director & Manager Benefit work due to major illness or disability. EMPLOYEE ASSISTANCE PROGRAM (EAP) Guardian
• Up to 3 face-to-face counseling sessions per incident for you or any member of your household. Legal and financial counseling is also available.
TRAVEL ASSISTANCE Guardian/TravelAid
• Travel, medical, legal, and financial assistance plus emergency medical evacuation benefits when traveling 100 or more miles away from home.
HEALTHCARE REIMBURSEMENT ACCOUNT (HRS) • Reimbursement for Specialty Rx medication copays under the SPECIALTY Rx REIMBURSEMENT (HRA) Blue Shield or Kaiser medical plans. Maximum reimbursement per plan year is $3,000 for an individual and $6,000 for a BCC family enrollment. 100% VOLUNTARY COSTS PAID BY YOU
SUPPLEMENTAL BENEFITS Guardian
• Guardian Voluntary Life /AD&D - Employee: $10,000 to a maximum of $500,000; Spouse: up to 50% of the employee amount not to exceed $250,000; Child: up to 100% of employee amount not to exceed $10,000. Guaranteed Issue limits in place for Employee & Spousal coverage. • Guardian Short-Term Disability (STD) - Helps reduce a portion of your income when you are unable to work.
FLEXIBLE SPENDING ACCOUNT (FSA) • Healthcare Account - $3,200 / year maximum Wex • Dependent Care Account - $5,000 / year maximum 401 (k) 401(k) RETIREMENT SAVINGS PLAN ADP
• Eligible after 6 months of employment and over age 21. • You may contribute up to 80% of your pre-tax earnings up to the 2024 federal maximum of $23,000. • Catch-up contributions of $7,500 if age 50 or over. EMPLOYEE SUPPORT
STAR Fund
To help those in need due to 1) Medical issues 2) Unforeseen housing challenges or 3) Death or funeral expenses
Eligibility Who Can Enroll Regular full-time employees are eligible to participate in the benefits program. Eligible employees may also choose to enroll eligible family members. New employees must enroll within the first 30 days of employment. Eligible dependents are: • Your lawful spouse or domestic partner. • You or your spouse’s unmarried children, stepchildren, adopted or foster children, up to age 26. • You or your spouses children of any age who are incapable of self-support due to a mental and/or physical disability. PLEASE NOTE: Employee and employer payroll contributions made for the enrollment of a Domestic Partner is considered taxable income by the IRS. This imputed income is automatically reported on your payroll via ADP. For additional information or questions regarding the tax impact to you, please contact your personal tax professional.
When Coverage Begins • Your initial benefits will start on the 1st of the month following your date of hire. • Your open enrollment choice will remain in effect for the benefits plan year, April 1, 2024 - March 31, 2025.
Changes During the Year You are permitted to make changes to your benefits outside of the Open Enrollment period if you have a qualified change in status as defined by the IRS. Generally, depending on the type of event, you may add or remove dependents from your benefits, as well as add, drop or change coverage if you submit your request for change within 30 days of the date of the event. Examples of qualified life events include: • Marriage, divorce or legal separation • Birth or adoption of a child • Death of a dependent • You or your spouse lose or gain coverage through our organization or another employer • Change in residence affecting eligibility or access • Loss of eligibility due to Medicaid, Medicare or state health insurance programs. For a complete list of qualified status changes, contact HR.
IMPORTANT NOTE: Employees have an open enrollment period every year that provides an opportunity to enroll or make changes to your benefits. If you miss the enrollment period, you may not enroll in the benefits program unless you have a qualified change in status during the plan year.
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Enrollment Informing You of Health Care Reform Although the Federal government no longer requires individuals to obtain medical insurance, the State of California has implemented its own Individual Coverage Mandate effective January 1, 2020. The State of California will collect penalties if an individual or family does not obtain healthcare coverage in 2020 and thereafter. You can obtain health insurance through our benefits program or purchase coverage elsewhere, such as a State Health Insurance Exchange – Covered California. For more information regarding Health Care Reform, please contact your Human Resources Department or visit www.cciio.cms.gov. You can also visit www.coveredca.com to review information specific to the Covered California State Health Insurance Exchange.
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Registration Registration Quick Reference Card for Employees Option 1: Using a Personal Registration Code
1 On your ADP service website, enter the registration code (for example, b9a7q6re) received in an email from
ADP (SecurityServices_NoReply@adp.com) when first hired or from your administrator. This code will expire in 15 days from the date of hire. If you did not register for an ADP account at the time of hire, please contact your local human resource department for assistance.
2 Enter your personal identity information. 3 Add your frequently used contact email address(s) and mobile number(s) in order to receive account notifications.
4 Set up your user ID and password for your account. Note: Users providing a unique email and a unique phone number will not be required to set up security questions and answers.
Benefit Guide 2024 7
2024
STAR Wellness Program Guide Rewards, Challenges, Recipes and More
Join your Program: Get started at continuinglife.livehealthyignite.com
Earn Rewards: Qualify for a discount on your health insurance contributions for the 2025 plan year.
WELLNESS PORTAL
Welcome to your 2024 STAR Wellness Program Why participate in a wellbeing program?
Eligibility: All employees may utilize platform
Important Dates: Program: January 1 – December 31, 2024
Tools & Resources:
Caring for your mental, emotional and physical health is about more than numbers. It’s about personal growth. Your portal is jam packed with resources that help you continue your wellbeing journey, no matter where you are on the path. And the program is a place to connect with others—as you learn and grow, you’ll also get to know your teammates, support each other’s successes and find plenty of opportunity for fun, friendly competition. Log in today and take the next step toward a healthier, happier future!
Go beyond the program requirements and focus on your physical, mental and emotional health all year long.
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How to Participate in the Wellness Program
Create an Account
Complete program activities to earn rewards. Throughout the year you will have the opportunity to earn Wellness Points by participating in various wellness programs and activities geared to help you achieve your wellness goals and stay on track with healthy lifestyle choices. By participating in these programs and activities throughout the year, Wellness Points will add up toward a discount on your health insurance contributions for the 2025 plan year.
1.
Visit continuinglife.livehealthyignite.com
2. Select JOIN NOW and follow the on screen prompts.
• Bronze Status: 0 - 149 total points (no discount on your employee health care cost)
Returning User
• Silver Status: 150 - 299 total points to earn 15% discount on your employee health care cost • Gold Status: 300 or more total points to earn 30% discount on your employee health care cost.
If you are a returning user, enter your username and password.
Your Resources
Your Program Activities Visit the activities table on your platform dashboard for more detail about completion requirements and to track your progress in the program.
Activity
Points
Flu Vaccination Physical Exam Dental Visit 1 Dental Visit 2 Vision Exam Tobacco Free Wellbeing Survey Financial Wellness - 401K
25 100 25 25 25 10 75 35 10 35 35 5-15 35 35 35 35 10-30 20 605
Sync a Device/Download Navigate Wellbeing App
Community Event 1 Community Event 2 Choose up to 3 Navigate Resources, 5 pts. each
Group Challenge 1 - Smart Cents Group Challenge 2 - Discover Your Spark Group Challenge 3 - Don’t Wait, Hydrate Group Challenge 4 - Walk It Out Complete up to 3 Personal Challenges, 10 points each
Video Learning Total Possible Points
Better health is the gift that keeps on giving. Go beyond the program requirements and use your wellness portal all year long to focus on your physical, mental and emotional health. • Download the Navigate Wellbeing app. • Complete video learning courses • Participate in group and personal wellbeing challenges. • Create your own Snap Challenge to fit your goals. • Spark friendly competition with Challenges Stakes with your peers. • Browse recipes, videos and articles. • Sync a device or manually track your step count, activity minutes, sleep hours, nutrition information and more!
24 Hour Fitness Discounted Memberships As a corporate partner, employees will have the opportunity to enroll in discounted memberships to 24 Hour Fitness! • Your choice of membership options: (Month-to-Month or 12 month memberships) • Access to over 425 clubs throughout the U.S. • Access to 24 Life e-magazine To join, visit: 24HourFitness.com/Corporate. Enter your corporate ID: 112513
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We are proud to offer the STAR Fund, which is an employee assistance fund for those in dire straits. We frequently talk about “taking care of our own.” Now is the opportunity for all employees to help provide tax-deductible support to our co-workers during challenging times. Hence the STAR acronym that here stands for “Supporting Team members At Risk.”
Purpose of the Fund: To help those in need due to 1) medical issues, 2) unforeseen housing challenges or 3) death or funeral expenses.
Your Donation Will Help in the Following Ways: When an employee loses a family member, the fund might be able help assist with unexpected burial expenses. Furthermore, if an employee or their immediate family member was to be hospitalized, the fund could assist with medical bills. Last, if there was a flood, fire, earthquake or other damage to the primary residence of our employee, the fund might be able to assist with recovery from these unfortunate events.
How to Contribute to the Fund: Login to your ADP account > click Myself > Benefit > Enrollments > click on Enroll Now (Year Round Enrollment). You can make this election or change it at any time. If every employee contributed just $2/paycheck, this could provide well over $100,000 in assistance… per year!
How Would You Be A Recipient of the Fund? The fund will be available to all employees with 6 months of service. Claims must be of a significant nature expected to be between $2,000 - $4,000. An outside organization that is unrelated to the community, America’s Charities, is responsible for reviewing, determining, and processing these claims. To apply for a claim please go to www.charities.org/CLSTARfund
Questions: Contact your Human Resources Department
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Medical Coverage Your Medical Plan Options The medical options available through the company include: • Blue Shield of CA • Kaiser Permanente • SIMNSA - Carlsbad & Scripps Ranch work locations only To help guide your plan selection, the following pages include details concerning how the plans will operate, as well as plan highlights and features.
Using an HMO Plan A Health Maintenance Organization (HMO) plan requires you and enrolled dependents to select a Primary Care Physician (PCP) who will direct the majority of your health care needs. Generally, an HMO operates as follows: • With the exception of an OB/GYN specialist who is affiliated with your selected medical group, you must receive a referral from your PCP before receiving services from a specialist. • You and your enrolled dependent(s) are not required to see the same PCP, and you may change your PCP at any time. • Preventive Care is covered 100% with In-Network providers. • Services may require a co-pay or deductable up front. • You do not have to submit claim forms to your insurance company. • Any services rendered out-of-network or outside of your assigned medical group will not be covered unless prior aurthorization is obtained from the medical carrier.
Using a PPO Plan A Preferred Provider Organization (PPO) allows you to see physicians both in network and out of network. You will pay a different co-insurance to see doctors and/or hospitals outside of the network. • You do not need a referral to see a specialist. You may see any physician in network or a physician who agrees to bill out of network. • You do not need to select a PCP, nor do your dependents. • Preventive Care is covered 100% when seen by an in-network provider. • Services may require a co-pay and/or deductible up front. • If your physician does not bill the carrier directly, you may submit claim forms for reimbursement directly to your insurance carrier (Blue Shield) if services are medically necessary. • Be sure to ask your physician/hospital if they are “In-Network” to take advantage of the lower co-insurance.
PRESCRIPTION DRUG COVERAGE Many FDA-approved prescription medications are covered through the benefits program. Regardless of the plan you have, you will save money by filling prescription requests at participating pharmacies. Please refer to your medical card for mail order information or call the carrier. For a current version of the prescription drug lists, visit the applicable carrier’s website. A resource listing is included at the end of this benefit guide.
PRESCRIPTION TIPS Watching Your Wallet? Where can you find more Preferred Drug List information? You and your doctor can search for a drug, find out if it’s covered and see what tier it falls under. You can also see if there are alternatives that cost less. Make sure your doctor knows that you pay more for tier 2 and tier 3 drugs. He or she can consider this before writing a prescription.
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HMO Plan Options Blue Shield HMO TRIO Network
Blue Shield HMO Access+ Network
Kaiser HMO
In-Network Only
In-Network Only
In-Network Only
(San Diego) In-Network Only
None
None
$750 / $1,500
None
$4,000 / $8,000
$4,000 / $8,000
$3,000 / $6,000
$6,350 / $12,700
Primary Care Physician
$40 co-pay
$40 co-pay
$25 co-pay
$10 co-pay
Specialist
$40 co-pay
$40 or $50 co-pay
$25 co-pay
$10 co-pay
Preventive Care
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Well-baby Care
Covered 100%
Covered 100%
Covered 100%
Covered 100%
X-ray and Lab Complex Diagnostics (MRI / CT Scan) Rehab / Physical Therapy
Covered 100%
Covered 100%
$10 co-pay
Covered 100%
Covered 100%
Covered 100%
20% up to $150
Covered 100%
$40 co-pay
$40 co-pay
$25 co-pay
$10 co-pay
40% coinsurance
40% coinsurance
20% after deductible
Outpatient Services
30% or 40% coinsurance
30% or 40% coinsurance
20% after deductible
$100 co-pay per day $0 - $10 co-pay
Emergency Room
$150 co-pay
$150 co-pay
20% after deductible
Urgent Care
$40 co-pay
$40 co-pay
$25 co-pay
$10 co-pay (30 visits a year)
$10 co-pay (30 visits a year)
Not Covered
Plan Highlights
SIMNSA HMO
Calendar Year Deductible Individual / Family Maximum Out of Pocket Individual / Family Professional Services
Hospital Services Inpatient
Chiropractor Services* Acupuncture Services* Maternity Care
$250 co-pay $25 co-pay, $50 out of area Not Covered $10 co-pay
Physician Services
$0 co-pay
$0 co-pay
$0 co-pay
$10 co-pay
Hospital Services
40% coinsurance
40% coinsurance
20% after deductible
Covered 100%
40% coinsurance
40% coinsurance
20% after deductible
Covered 100%
$40 co-pay
$40 co-pay
$25/$12 co-pay
$10 co-pay
40% coinsurance
40% coinsurance
20% after deductible
Covered 100%
$40 co-pay
$40 co-pay
$25/$5 co-pay
$10 co-pay
Mental Health Inpatient Outpatient - Individual / Group Substance Abuse Inpatient Outpatient - Individual / Group Retail Drugs (30 day supply) Generic Drugs (Tier 1)
$15 co-pay
$15 co-pay
$10 co-pay
$15 co-pay
Preferred Brand Drugs (Tier 2)
$30 co-pay
$30 co-pay
$30 co-pay
$15 co-pay
20% up to $250
20% up to $250
20% up to $250
$15 co-pay
Generic Drugs (Tier 1)
$30 co-pay
$30 co-pay
$20 co-pay
Not Covered
Preferred Brand Drugs (Tier 2)
$60 co-pay
$60 co-pay
$60 co-pay
Not Covered
20% up to $500
20% up to $500
Not Covered
Not Covered
Specialty Drugs Mail Order (90 day supply)
Specialty Drugs
The above information is a summary only. Please refer to your Evidence of Coverage for complete detail of Plan benefits, limitations and exclusions. *Note: Benefits are provided through a contract with American Specialty Health Plans of California, Inc. (ASH Plans)
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HMO Plan Rates - Per Pay Period PLAN
BRONZE - 0% Wellness Discount
SILVER - 15% Wellness Discount
GOLD - 30% Wellness Discount
POINTS
0 to 149
150 to 299
300 & above
Blue Shield TRIO HMO
New Employees
Employee Only
$46
$36
$25
Employee + Spouse
$291
$279
$269
Employee + Child(ren)
$210
$198
$188
Employee + Family
$477
$466
$453
Employee Only
$94
$78
$61
Employee + Spouse
$435
$418
$402
Employee + Child(ren)
$319
$304
$289
Employee + Family
$691
$674
$657
Employee Only
$86
$74
$62
Employee + Spouse
$378
$363
$352
Employee + Child(ren)
$329
$315
$304
Employee + Family
$596
$581
$569
Blue Shield Access+ HMO
Kaiser HMO
SIMNSA HMO (Carlsbad & Scripps Ranch work locations only) Employee Only
$22
$19
$16
Employee + Spouse
$104
$101
$97
Employee + Child(ren)
$91
$88
$85
Employee + Family
$196
$193
$190
The above rates are inclusive of the ACA / Government healthcare fees.
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PPO Plan Options Plan Highlights Calendar Year Deductible Individual / Family Maximum Out of Pocket (OOP) Individual / Family
First Dollar Services
Professional Services Primary Care Physician Specialist Preventive Care Exam Well-baby Care Diagnostic X-ray and Lab Complex Diagnostics (MRI / CT Scan) Rehab / Physical Therapy Chiropractor (12 visits per year max)* Acupuncture (20 visits per year max)* Hospital Services Inpatient Outpatient Services (free standing) Emergency Room Urgent Care Maternity Care Physician Services Hospital Services Mental Health Inpatient Facility Physician Services Residential Care Substance Abuse Inpatient Facility Physician Services Residential Care Prescription Drugs (30 day supply)
Blue Shield Active Choice PPO In-Network
Out-of-Network
None
None
$3,000 / $6,000
$10,000 / $20,000
$850 / $1,700 Applies to: Office Visits, Diagnostic X-ray, Labs, Other Testing, DME, Therapy, Prosthetics and Diabetes care. You choose from the above covered areas how to spend the first dollar amount. Once spent, you pay 100% of cost up to max out of pocket. First dollar, then 100% to max OOP First dollar, then 100% to max OOP Covered 100% Covered 100% First dollar, then 100% to max OOP First dollar, then 100% to max OOP First dollar, then 100% to max OOP First dollar, then 100% to max OOP First dollar, then 100% to max OOP
First dollar, then 100% to max OOP First dollar, then 100% to max OOP Not Covered Not Covered First dollar, then 100% to max OOP First dollar, then 100% to max OOP First dollar, then 100% to max OOP First dollar, then 100% to max OOP First dollar, then 100% to max OOP
$500 per admission + 20% $250 per admission + 20% $100 per visit + 20% First dollar, then 100% to max OOP
40% with limits 40% with limits $100 per visit + 20% First dollar, then 100% to max OOP
20% $500 per admission + 20%
40% with limits 40% with limits
$500 per admission + 20% Covered 100% $500 per admission + 20%
40% with limits 40% 40% with limits
$500 per admission + 20% Covered 100% $500 per admission + 20%
40% with limits 40% 40% with limits
Generic Drugs Preferred Brand Drugs Non-Preferred Brand Drugs Specialty Drugs Mail Order (90 day supply)
$15 co-pay $30 co-pay $45 co-pay 30% up to $250 co-pay
$15 co-pay + 25% $30 co-pay + 25% $45 co-pay + 25% 30% up to $250 co-pay + 25%
Generic Drugs Preferred Brand Drugs Non-Preferred Brand Drugs Specialty Drugs
$30 co-pay $60 co-pay $90 co-pay 30% up to $500 co-pay
Not Covered
The above information is a summary only. Please refer to your Evidence of Coverage for complete details of Plan benefits, limitations and exclusions. *Note: Benefits are provided through a contract with American Specialty Health Plans of California, Inc. (ASH Plans)
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PPO Plan Rates - Per Pay Period PLAN
BRONZE - 0% Wellness Discount
SILVER - 15% Wellness Discount
GOLD - 30% Wellness Discount
POINTS
0 to 149
150 to 299
300 & above
Blue Shield Active Choice PPO
New Employees
Employee Only
$168
$145
$117
Employee + Spouse
$743
$716
$691
Employee + Child(ren)
$551
$526
$500
Employee + Family
$1,170
$1,146
$1,119
The above rates are inclusive of the ACA / Government healthcare fees.
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Health Reimbursement Account (HRA) Provided by Benefit Coordinators Corp. (BCC) Continuing Life will provide an HRA to help offset the cost of drugs classified as Specialty medication for employees and their family members enrolled in the Blue Shield or Kaiser medical plans. The maximum reimbursement for a single Specialty Rx medication will be $250. The maximum for an individual per calendar year is $3,000 and for a family is $6,000.
How Does It Work? When an employee or family member is prescribed an eligible Specialty Rx medication, they may submit for reimbursement subject to the maximum limits listed above.
How Do I Submit A Reimbursement Request? • To start the process contact Nicola Quinn with our Gallagher support team at Nicola_Quinn@ajg.com or Samantha Lukas of the HR team at LukasS@continuinglife.com, so they can start the enrollment process. All communication is confidential. • Enrollment takes place after you have been prescribed a Specialty Rx medication under your medical plan. • Nicola or Samantha will email the HRA welcome kit. The kit will include an enrollment form, a claim form and details about the reimbursement process. • You may submit your first completed claim form and the completed enrollment form together and email to either Nicola_Quinn@ajg.com or LukasS@continuinglife.com. The following items should accompany the claim form: 1. Copy of prescription showing the Specialty medication name, date prescribed and patient’s name. 2. Copy of the receipt for payment 3. Completed claim form • BCC will review the submitted information and process payment for eligible Specialty prescription medication. • BCC can issue payments by check or direct deposit. Direct deposits are the quickest method to receive the reimbursement payment. • For on-going Specialty prescription drugs, you will be able to submit a copy of the prescription, receipt and claim form directly to BCC. • For new or a change of Specialty prescription drug, please email a copy of the prescription, receipt, and claim form to either Nicola_Quinn@ajg.com or LukasS@continuinglife.com
NOTE: Any expenses other than Specialty Rx medication copays are not eligible for HRA reimbursements. You can not use both FSA funds and HRA reimbursement funds for the same Specialty Rx. You must choose to use one or the other, FSA or HRA.
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Blue Shield Resources and Tools Manage Your Health Online • Check out all the time-saving tools and resources, view most lab results and more • Register to get started at blueshieldca.com; Select Log in / Register; Select Register now; Enter your member ID
Find a Doctor • Trio HMO go to www.blueshieldca.com/networktriohmo • Access+ HMO go to www.blueshieldca.com/networkhmo • PPO go to www.blueshieldca.com/networkppo
Teladoc for HMO Members • Access licensed doctors 24/7 by phone or video for a $0 copay with Trio and $5 copay with Access+ • Can treat many medical conditions including cold and flu symptoms, allergies, bronchitis, and more • Set up an account at www.blueshieldca.com/teladoc or call 1.800.835.2362
Life Referrals 24/7 • Offers convenient and confidential support to help you meet life’s challenges • Services include personal counseling, legal assistance, financial coaching, identity theft • Call 24/7 at 1.800.985.2405 or visit www.lifereferrals.com and enter code: bsc
Condition Management • Nurse support to be your healthiest and feel your best – at no additional cost • If you have a chronic condition, these programs can help you improve your quality of life by showing you how to take an active role in managing your health • Call 1.866.954.4567 [TT: 711] or enroll online at www.blueshieldca.com/carecenter
Nursehelp • Get reliable information about minor illnesses and injuries, chronic conditions, medical tests, preventive care and more. • Call 1.877.304.0504 or go to www.blueshieldca.com/nursehelp
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Kaiser Permanente Resources and Tools Manage Your Health Online • Check out all the time-saving tools and resources, view most lab results and more Register to get started at www.kp.org/registernow; Sign in to www.kp.org, once registered, download Kaiser Permanente App.
Find a Doctor • https://healthy.kaiserpermanente.org/southern-california/doctors-locations#/search-form
Healthy Lifestyles Program • Free, customized online programs designed to help individuals succeed in creating a healthier lifestyle • Healthy Lifestyle Programs focus on total health – mind, body, and spirit • To see a list of all program options visit www.kp.org/healthylifestyles; for programs in Spanish www.kp.org/vidasana
Wellness Coaching by Phone • Reach your goals with a personalized action plan and one-on-one support • Coaching offered in English and Spanish, no referral needed – no charge for Kaiser Permanente members • Call 1.866.862.4295 or visit www.kp.org/coaching
Mental Health • Get connected with caring providers all licensed by the California Board of Behavior Sciences or the California Board of Psychology to access a range of therapy and treatment choices • Get care advice 24/7 at www.kp.org or call 1.800.900.3277
Personal Action Plan • Get important health information – personalized, up-to-date, and all in one place • Know what preventive screenings you may need, keep track of specific care needs, learn how about services at local Kaiser Permanente facility and more • Get started at www.kp.org
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Summary of Dental Insurance Options Your Dental Plan You and your eligible dependents have the opportunity to enroll in a Dental Health Maintenance Organization (DHMO) plan with Guardian or SIMNSA (San Diego Only), or the Dental Preferred Provider Organization (PPO) plan offered by Guardian.
Using the Dental HMO Plan In order to receive benefits while enrolled in the Dental HMO plan, you and your enrolled eligible dependents must obtain services from your assigned primary care dentist who participates in the Guardian network. If you receive services from a different provider, you would be responsible for paying the entire dental bill yourself.
Using the Dental PPO Plan The Dental PPO plan is designed to give you the freedom to receive dental care from any licensed dentist of your choice. Keep in mind, you’ll receive the highest level of benefit from the plan if you select an in-network PPO dentist versus an out-of-network dentist who has not agreed to provide services at the negotiated rate. Additionally, no claim forms are required when using in-network PPO dentists.
Plan Highlights Annual Calendar Year Deductible Individual / Family Calendar Year Maximum Office Visit Fee Examinations X-rays (Bitewing) Cleanings (twice a year) Basic Services Extractions Fillings Scaling Major Services Root Canal Periodontal Surgery Bridges & Dentures Orthodontia Child / Adult
Guardian DHMO
Guardian PPO
SIMNSA DHMO
In-network Only
In-network / Out-of-network
San Diego
None None $0 co-pay $0 co-pay $0 co-pay $0 co-pay
$50 / $150 $2,500 per member
None None $0 co-pay $0 co-pay $0 co-pay $0 co-pay
20% after deductible
$8 - $50 co-pay $5 - 37 co-pay $0 co-pay
$70 - $140 co-pay $60 - $155 co-pay $90 - $140 co-pay
50% after deductible
$5 - $50 co-pay $7 - $36 co-pay $10 - $70 co-pay
$1,500 / $2,800
50% up to $1,500 lifetime maximum
assumes monthly visits over 24 month period
Per Pay Period
DHMO
PPO
SIMNSA DHMO
Employee only
$1 $3
$5
$1
$11
$4
Employee + Spouse Employee + Child(ren) Family
$10 - $85 co-pay $0 co-pay $15 - $25 per quadrant
Covered 100% up to the plan’s annual maximum benefit
$3 $4
$50 co-pay per visit
$12
$4
$16
$5
Benefit Guide 2024 19
Vision Coverage Your Vision Option Vision coverage is offered by VSP as a Preferred Provider Organization (PPO) plan.
Using the Plan As with a traditional PPO, you may take advantage of the highest level of benefit by receiving services from in-network vision providers and doctors. Continuing Life is in the VSP Choice Network. You would be responsible for a co-payment at the time of your service. However, if you receive services from an out-of-network doctor, you may pay all expenses at the time of service and submit a claim to VSP for reimbursement up to the allowed amount.
Plan Highlights
Vision Service Plan In-network
Out-of-network
Exams - Every 12 months
$10 co-pay
Up to $45 co-pay
Materials
$25 co-pay
Not applicable
Lenses (per pair) - Every 24 months Single Vision
$0
Up to $30
Bifocal
$0
Up to $50
Trifocal
$0
Up to $65
Standard Progressive Lenses
$0
Up to $50
Premium Progressive Lenses
$95 - $105
Up to $50
Custom Progressive Lenses
$150 - $175
Up to $50
Glasses (additional pair of frames and lenses)
20% off retail price
20% off retail price
Contacts (in lieu of glasses) - Every 24 months
$130 allowance
Up to $105
Contact lens exam (fitting and evaluation)
Up to $60
Not applicable
$130 allowance + 20% savings on the amount over the allowance $150 allowance for featured frame brands + 20% savings on the amount offer allowance
Up to $70
Frames - Every 24 months
Laser Correction Surgery Discount
Average 15% of the regular price or 5% off the promotional price; discounts only available from contracted facilities
The above information is a summary only. Please refer to your Evidence of Covereage for complete details of Plan benefits, limitations and exclusions.
Pay Period Employee only Employee + Spouse
VSP $0.50 $1
Employee + Child(ren)
$1
Family
$2
Benefit Guide 2024 20
Basic Life / Supplemental Term Life / AD&D Coverage Company Paid Basic Life/AD&D Insurance The company provides employees with an insurance policy of 1x times base annual salary up to $50,000 with Guardian. Even if you decline other benefits, this policy is still provided by the company at no cost to you. Be sure to keep your beneficiary updated at all times in the event of your death. Note: The life benefit reduces as follows: 35% benefit reduction at age 65, 60% benefit reduction at age 70, 75% benefit reduction at age 75, and 85% benefit reduction at age 80.
Select Your Beneficiary • You can change your beneficiary designation at any time. Your beneficiary(ies) must live in the U.S. • You may designate a sole beneficiary or multiple beneficiaries to receive payment in the amount you specify. • Minor children: If the named beneficiary is a minor, the benefit is put ‘On Hold’ for Age of Majority (legal adult age is 18) or until Guardianship/Conservatorship Paperwork is received. For the state of CA, benefits may be paid if the benefit is under $10,000. • Spouse: There is a community property signoff form. It is not mandatory that this form be used. However, if this form is not signed by the spouse and the insured does not designate the spouse, the carrier will pay the person that has been named as the beneficiary. The spouse would have the right to contest this in court after the fact. The spouse is actually entitled to 50% of the death benefit. Contact your local HR Department for the signoff form.
Supplemental Employee Paid Term Life/AD&D – Voluntary To supplement the coverage provided by your employer, you can purchase additional term life insurance through Guardian. • Employees: Increments of $10,000 up to a $500,000 maximum benefit. • Spouse: Increments of $5,000 up to a $250,000 maximum benefit. It cannot exceed 50% of the employee’s Voluntary Life coverage. Note: The employee must enroll in a policy to be able to elect a policy for your spouse and/or child(ren) • Child(ren): $2,000 increments to maximum of $10,000. Up to age 26. Note: In order to have coverage on your spouse or child(ren), you must elect coverage on yourself. Please be advised the life benefit reduces as follows: 35% benefit reduction at age 65, 60% benefit reduction at age 70, 75% benefit reduction at age 75, and 85% benefit reduction at age 80. Spouse’s life coverage will terminate at age 70. Employee and Spouse rates are age banded. Spouse rates are based on employee age. You will remain at that rate for the plan year. Rates will change annually upon plan anniversary when you enter the next age bracket. Please refer to ADP for age rates and coverage amounts.
Guaranteed Issue Amounts Coverage up to the Guaranteed Issue amounts are available when first eligible for the plan without medical underwriting questions. Guarantee issue is available up to the following amounts: • Employee: $200,000 • Spouse: $50,000 • Child(ren): $10,000 If you wish to become insured for an amount of Supplemental Employee Paid Term Life/AD&D in excess of the Guaranteed Issue amount, the excess will be subject to medical underwriting approval. All late applications are also subject to medical underwriting approval.
Please refer to ADP for Per Paycheck Premiums
Benefit Guide 2024 21
Short Term Disability Insurance - Voluntary Short Term Disability (STD) - Guardian Short term disability is intended to protect your income for a short duration in case you become ill or injured.
STD Benefits Weekly Benefit Percentage
20% of weekly salary up to $1,500 per week (Non-integrated with CA SDI)
Elimination Period (Accident / Illness)
14 days - Benefits begin on the 15th day
Maximum Benefit Duration
26 weeks
Pre-Existing Condition
You will not be covered if you received medical treatment, care or services for a diagnosed condition or took prescribed medication for a diagnosed condition in the 3 months immediately prior to the effective date of coverage. Also, if the Disability caused or substantially contributed to the condition begins in the first 12 months after the effective date, coverage may not be covered.
Pregnancy
• IS NOT covered if your pregnancy is diagnosed and/or you have received treatment/medication for the pregnancy prior to the coverage effective date • IS covered if you become pregnant and/or are diagnosed pregnant after the coverage effective date
Waiver of Premium
You will not be required to pay premium during any time of approved total or partial disability.
Additional Benefits
• Survivor Income Benefit • Rehabilitation Assistance Benefit • See the Schedule of Benefits on your Certificate for more information
Eligibility
• All Employees in an eligible class. • You are able to take advantage of this coverage now without a health examination. You may not be offered this opportunity again until your annual open enrollment.
PLEASE NOTE: All late applicants are subject to medical underwriting to determine if coverage is approved. A late applicant is anyone who waived this coverage when they first became eligible to enroll.
Please refer to ADP for Per Paycheck Premiums. Did You Know?
State Disability Insurance California Employees are covered under the California State Disability Insurance (SDI) program. If you become disabled due to an accident or illness you may be entitled to receive benefits under the SDI program. The benefits are approximately 70% of your earnings with a maximum weekly benefit up to $1,620 for 2024. Benefits under this program may continue up to 52 weeks. For more information please visit: www.edd.ca.gov/Disability or call 1-800-480-3287.
Benefit Guide 2024 22
Long Term Disability Insurance Company Paid Long Term Disability – Directors & Managers Benefit Guardian offers long term disability which is intended to protect your income for a long duration after you have depleted short term disability or any paid time off your company may offer.
LTD Benefits - COMPANY PAID Monthly Benefit
60% of monthly income
Maximum Benefit
$6,000 a month
Maximum Benefit Duration
To age 65 or SSNRA (Social Security Normal Retirement Age)
Own Occupation Period
24 Months
Elimination Period
180 Days
Pre-Existing Condition
You may not be eligible for benefits if you have received treatment for a condition within 3 months prior to your effective date under this policy until your have been covered under the policy for 12 months.
Benefit Limitations
Mental Illness /Substance Abuse (24 months during lifetime)
Additional Benefits
• Survivor Income Benefit • Rehabilitation Assistance Benefit • See the Schedule of Benefits on your Certificate for more information
Eligibility
Director Eligibility Class
Benefit Guide 2024 23
Flexible Spending Accounts - Voluntary Plan Period: April 1, 2024 to March 31, 2025
• Health FSA • Dependent Day Care Account FSA A Flexible Spending Account (FSA) allows you to set aside a portion of your earnings from payroll on a pretax basis. These funds can be utilized to pay for qualified health care expenses or for qualified dependent care expenses. The benefit is to allow these expenses to be paid on a pretax basis. An FSA has two allocation options – the health care expense account and the dependent care expense account. One or both can be selected for utilization.
How a Health FSA Works The health care expense account can have a maximum plan year allocation of $3,200. The amount you select to allocate will be equally divided by the number of pay periods in the plan period. You will receive a debit card that can be utilized to pay for qualified expenses. Please maintain a copy of all receipts as from time to time the plan administrator will request copies of these receipts or you will have to repay any transaction not substantiated. Unused funds will be forfeited.
How Your Card Works The FSA Debit card allows you to pay at point-of-sale for approved out-of-pocket expenses, such as prescriptions and co-pays. The card can be used at healthcare related facilities, which include hospitals, physicians offices, dental offices, and vision offices. This card can also be used for Dependent Care expenses. Check with your Dependent Care provider to confirm. If you do not use your Flexible Spending Account Benefits Debit Card, you may file claims for FSA reimbursement in one of three ways: 1. File your claim online 2. File your claim using the FSA Reimbursement Request Form and submit it to Discovery 3. File your claim via our Mobile App
Eligible Expenses • Deductibles, co-pays and co-insurance for medical, dental or vision. • Orthodontia services • Eyeglasses, contact lenses, and supplies • Prescription drugs • Treatment of alcoholism or drug dependency • Menstrual products • Over-the-counter drugs (cold medicine, antacids, pain relievers)
Ineligible Expenses • Cosmetics and cosmetic procedures • Vitamins and supplements • Health plan premiums Please keep receipts for 2-3 months after incurring the expense. In the event you cannot use your debit card, you can submit online for reimbursement.
How a Dependent Day Care FSA Works The dependent care expense account can have a maximum plan year allocation of $5,000. The amount you select to allocate will be equally divided by the number of pay periods in the plan year. These funds are provided on a reimbursement basis when Discovery Benefits receives copies of receipts for the qualified expenses. If funds are not utilized by plan year end they are forfeited. Qualified expenses are dependent care expenses necessary for you (and your spouse) to work, actively look for work, or attend school full-time. Examples of these expenses are daycare tuition, late pick-up fees, registration fees.
How To Get Reimbursed The Claims Sync tool helps automate the process by syncing insurance claims directly into your portal dashboard and instantly searching for matches within your debit card transactions or allows you to pay and submit supporting documentation into the portal.
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Benefit Guide 2024 24
Employee Assistance Program (EAP) & Travel Assistance Employee Assistance Program Problems are just a part of everyday life. In addition to the benefits provided under your Guardian Life Insurance coverage, you and your household members will have access to an Employee Assistance Program (EAP). This program provides you with services to help with the everyday challenges of life that may affect your health, family, life and desire to excel at work. EAP services will be provided by a third party, WorkLife Matters, under an agreement with Guardian Life Insurance. Your EAP may be used to address a broad range of issues including: • Marriage, Relationship, and Family Problems • Problems at Work • Legal and Financial Issues • Stress and Anxiety • Alcohol and Drug Dependency • Identity Theft • Health and Wellness Concerns
Using the Program You and the members of your household are entitled to up to 3 in-person consultations with a licensed clinician per issue, per individual, per calendar year. You have unlimited telephonic consultations for maximum convenience and anonymity. Please call 1-800-386-7055 anytime to speak with a clinician or schedule an appointment.
ONLINE MEMBER SERVICES WorkLife’s EAP website and app that will be available to you features a wide range of tools and information to help you take charge of your well-being and simplify your life.
Additional Counseling Services Debra Lobatz In addition to EAP services, your community has contracted with a Licensed Marriage and Family therapist, Debra Lobatz. She works with individual adults, couples, and families. Debra will be available to all employees for 3 counseling sessions. You can reach her at 760-634-3188 or by visiting her website: www.debralobatz.com
Travel Assistance You, your spouse and dependent children (whether traveling together or separately) have access to travel, medical, legal, and financial assistance provided through TravelAid/United Healthcare Global, plus emergency medical evacuation benefits when traveling 100 or more miles away from home. The Travel Assistance Program can provide information and assistance with: • Visa and passport requirements • Travel advisories • Cultural information • Consular location and referrals • Lost and stolen documents • Lost luggage • Emergency telephone interpretation • Urgent relay message • Medical / dental referrals • Hospital admission • Lost prescription • Shipment of medication • Emergency medical transportation (up to $5,000) • Repatriation (up to $10,000)
TRAVEL SERVICES TravelAid’s Travel Assistance Services: 1-800-527-0218 ONLINE: www.ibhtravelaid.com
Log on to www.ibhworklife.com User name: matters and Password: 70101
Benefit Guide 2024 25
Retirement Savings Plan - 401(k) Plan for retirement by contributing to the company 401(k) Retirement Savings Plan on a pre-tax and post-tax basis. It offers a wide variety of investment funds so you can choose what best meets your needs.
Eligibility Eligible employees are employees who have worked at the company for 6 months and are least 21 years of age. Full time, part time, and per diem employees can participate in this benefit.
Automatic Enrollment All eligible employees will be auto-enrolled in the 401K plan with a 3% deduction. Prior to auto-enrollment, you will receive an email prompting you to opt-out if you would like. There will be a 90 day period after autoenrollment where contributions can be reimbursed, taxes will apply.
Advantages of Contributing The 401(k) Retirement Savings Plan helps you meet your financial goals with the following advantages: • Company match is on a per pay period basis • Tax savings on pre-tax contributions - You may contribute up to 80% of your pay - Maximum - $23,000 - Catch-up contributions over age 50 - $7,500 • Choice of investment funds • Convenient payroll deductions • Access to advice from financial planner to make investment choices
Company Match (Safe Harbor) The company makes a Safe Harbor matching contribution on a per pay period basis. The match is based on the schedule listed below.
Employee Contribution
Company Match
First 3%
100%
Next 2%
50% Example:
5% Contribution
4% Match
If you are eligible (over the age of 21 with six months of service) the company matching contribution is 100% immediately vested.
Receiving Benefits Because 401(k) plans are designed for retirement savings, there are rules that specify when you can receive funds from the plan. Before age 59 ½, you may withdraw funds only if you: • Leave the company • Become disabled • Experience a financial hardship Any funds you receive before age 59 ½ may be subject to current taxes and possibly a financial penalty. You are able to borrow from your 401(k) at an interest rate of prime + 2%. The loan terms are as follows: • Maximum of 2 loans • $500 minimum / $50,000 maximum or 50% of your vested account balance • Maximum loan term is 5 years for general use, 30 years for residential loans
Taxes With any tax-deferred 401(k), you are able to set aside part of your pay before federal and state income taxes are withheld. These plans save you taxes today: Money taken from your take-home pay and put into a 401(k) lowers your taxable income so you pay less income tax. Using a tax-deferred 401(k) does not mean you never pay taxes, however. You will pay those taxes when you withdraw your earnings and contributions. The benefit is that as a retiree, your income often drops, putting you into a lower tax bracket than you had as an employee. Money you take from a tax-deferred 401(k) during retirement years therefore, gets taxed at a rate lower than what you pay while fully employed. If you leave employment, you may make arrangements for a direct rollover to another tax-qualified retirement plan or an IRA. For more information, contact your Human Resources Department.
Changes, Access & Support You may change the amount you are contributing to your 401(k) and your investment allocations at any time by logging on to the ADP website at https://workforcenow.adp.com and clicking on the 401(k) link on the home page or via the app. You can also call the ADP Participant Service Center at 800-695-7526. Please reference group policy number 426430.
Benefit Guide 2024 26
Retirement Savings Plans - Roth 401(k) Roth 401(k) Your retirement plan options includes another feature to help you save for your retirement, the Roth 401(k) option. Unlike a traditional Roth option, there is no income limit imposed in a plan sponsored Roth 401(k). This option allows you to pay the income taxes on your contributions while you’re working, rather than when you retire and under certain circumstances receive earnings free of federal income tax. You also have the flexibility to contribute into both Roth and pre-tax on a per pay period basis, however, your combined deferral rates cannot exceed the plan limit of 90% or the 2024 annual contribution maximum limit of $23,000. If you are 50 years of age or older, you may contribute an additional $7,500, also referred to as a catch up contribution, not to exceed $30,500.
What is a Roth 401(k) A Roth 401(k) is a retirement plan option that allows you to designate all or part of your elective deferrals on an after-tax basis. There is no tax incentive while you are working, but if certain conditions are met; your contributions and earnings are entirely free from federal income tax when you withdraw them from the plan.
It’s a Matter of Tax Whether you choose a traditional 401(k) or a Roth 401(k), if your tax rate remains the same at retirement your savings results may be the same. That’s why the most important consideration is your current tax rate versus your tax rate at the time of distribution. Keep in mind, this is dependent on the future tax rates, your income now versus at retirement, and changes in the government’s tax policy.
Is a Roth 401(k) the right choice for me? Historically, we have been encouraged to save through pre-tax contributions in a traditional 401(k) plan. However, the Roth 401(k) option may be worth considering if: • You believe your federal income tax rate will be higher when you retire. • You are young and expect to invest for many years and plan to reach a higher tax bracket later. To obtain more information about the Roth 401(k), please log onto the website at https://workforcenow.adp.com.
Benefit Guide 2024 27
DailyPay Resources and Tools Access Your Pay When You Need It.
Make Any Day Payday You can now access your pay when you need it. Point your camera here to get the free app
dailypay.tm/signup
Go to dailypay.tm/signup to get started
What is DailyPay? DailyPay is a voluntary benefit that allows you access to your earned pay when you need it, with additional ways to help you save. Get started free today! Go to dailypay.tm/signup or text START to 66867.
Why should I sign up for DailyPay? When you sign up for DailyPay, you can access your pay on-demand. No more waiting for payday!
How can I reach DailyPay? You can contact DailyPay by phone, email or chat from Monday - Sunday 6am - 11pm EST. Phone: (866) 432-0472 Email: employee.support@dailypay.com
Benefit Guide 2024 28
Higher Education, Lower Cost The University of Arizona Global Campus Your community and the University of Arizona Global Campus (UAGC), an accredited online university, has partnered to provide an education benefit to all eligible employees to save on tuition and other educational costs. The UAGC Tuition Benefit provides employees and immediate family members a quality college degree at a reduced cost while working full-time. Tuition Benefit program includes: • $408 per credit for associate and bachelor’s programs • $532/$592 per credit for master’s programs • Students are responsible for the cost of course materials/books and fees. Visit: https://www.uagc.edu/tuition-financial-aid/education-partnerships/continuinglife Call: 855-805-6911
Talent Development Review: Your Community and leadership team is committed to your career development. Your annual review is the opportunity to discuss your short and long term career goals. Career development can be additional responsibilities, learning new skills, promotion, moving departments or location.
Tuition Assistance In order to encourage professional growth, the Community will provide full time* employees who have at least six months of continuous service tuition assistance up to a maximum of $1,500 per calendar year for certain courses which are either job related, part of Talent Development Review (TDR) plan, or a health care related degree program. Eligible expenses under this policy are registration expenses, tuition, mandatory school fees and books. Parking fees, health fees or recreation fees are not included in this Assistance policy. The following procedures apply to full-time employees requesting tuition assistance: • Employee must complete a request form and receive approval from Department Director. • Approval for Tuition Assistance is not guaranteed year to year. A new application needs to be submitted for continuation in program each year. • Forgiveness of the assistance is dependent upon continued employment of at least one year following the grant. Otherwise, assistance is due and payable 100%. This is not a guarantee of continued employment. Please contact your HR Department for additional information. *Executive Director reserves the right to extend this benefit to part time employees at their discretion.
Benefit Guide 2024 29
Member Support Understanding your employee benefits options can be confusing and complicated. Your Account Manager, the Benefits Advocate Center (BAC), through Gallagher, and your Human Resources Department are here to provide answers and information at your fingertips.
QUESTIONS?
You’re Not Alone
Contact the
Gallagher’s Benefit Advocate Center (BAC) is here to help you get the most from your benefits!.
Benefit Advocate Center
The BAC can help you with:
Dedicated Email:
Dedicated Team Phone: 1-833-266-2135 BAC.continuinglifebenefitadvocatecenter@ajg.com
• Insurance ID Cards - If you have lost or did not receive your ID cards Hours of Opertation: 8:00am – 6:00pm PST • Benefits Questions - Do you need help with specific questions relating to your coverage? • Eligibility Rules - Who can be covered under the plan and when? • Provider Search - Do you need help finding an in-network or specialty provider? • Prescription/Pharmacy Issues - Is the pharmacy telling you that your medication is not covered or charging you full price? Do you need help getting a pre-authorization on your medication? • Claims - Are you unsure if your insurance will pay for a certain procedure? Did you receive a bill from a doctor and don’t know why?
Call your Dedicated BAC team: 1-833-266-2135 Didn’t get the help you needed from the BAC? Call our Gallagher team members directly: As a company-sponsored benefit, Gallagher gives you unlimited direct access to insurance professionals who are dedicated to knowing our plan options inside and out. Whether you’re a new employee, looking for information on how to continue your coverage or your insurance needs are changing, you’re bound to have questions on your plan options and programs. Bilingual Member Support is available Monday through Friday, 8:00 am – 5:00 pm Pacific Time. Nicola Quinn Senior Client Manager • Phone: 619-704-3503 • Email: nicola_quinn@ajg.com
Jennifer Moses Account Executive • Phone: 858-997-7672 • Email: jennifer_moses@ajg.com
Belen Mendoza Account Service • Phone: 858-481-8692 • Email: belen_mendoza@ajg.com
Benefit Guide 2024 30
2024 Annual Notices
Medicare Part D Notice Important Notice About Your Prescription Drug Coverage and Medicare
Please contact Human Resources for more information about what happens to your coverage if you enroll in a Medicare prescription drug plan.
Model Individual Creditable Coverage Disclosure
Your medical benefits brochure contains a description of your current prescription drug benefits.
(for use on or after 04/01/2001)
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with your employer and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Your employer has determined that the prescription drug coverage offered is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information about This Notice or Your Current Prescription Coverage contact your Human Resources Department for further information. NOTE: You will get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage: More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
Visit www.medicare.gov
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current coverage will be affected.
Call 1-800-MEDICARE (1-800-633-4227).
If you do decide to join a Medicare drug plan and drop your current coverage, be aware that you and your dependents will not be able to get this coverage back.
Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help. TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov or call them at 1-800-772-1213 (TTY 1 -800-325-0778).
Benefit Guide 2024 31
Legal Information Regarding Your Plans Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).
receipt of health care, medical history, genetic information, evidence of insurability (including conditions arising out of acts of domestic violence and participation in activities such as motorcycling, snowmobiling, all-terrain vehicle riding, horseback riding, skiing, and other similar activities), and disability. Special Enrollment Rights
Required Notices Women’s Health & Cancer Rights Act If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (“WHCRA”). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: • All stages of reconstruction of the breast on which the mastectomy was performed; • Surgery and reconstruction of the other breast to produce a symmetrical appearance; • Prostheses; and • Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under the plan. Therefore, the following deductibles and coinsurance apply. If you would like more information on WHCRA benefits, please call your Plan Administor. Newborn’s and Mother’s Health Protection Act Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, 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 dependents’ other coverage). However, you must request enrollment within “30 days” after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within “30 days” after the marriage, birth, adoption, or placement for adoption. Special enrollment rights also may exist in the following circumstances: • If you or your dependents experience a loss of eligibility for Medicaid or a state Children’s Health Insurance Program (CHIP) coverage and you request enrollment within 60 days after that coverage ends; or • If you or your dependents become eligible for a state premium assistance subsidy through Medicaid or a state CHIP with respect to coverage under this plan and you request enrollment within 60 days after the determination of eligibility for such assistance. “Change in Status” Permitted Mid-year Election Changes The IRS regulations for mid-year health insurance changes (i.e. outside of open enrollment period) restrict any changes to your plan or coverage unless you have a qualified “change in status.” The following are considered qualified changes in status by the IRS: 1. Change in legal marital status, including marriage, divorce, legal separation, annulment, and death of a spouse 2. Change in number of dependents, including birth, adoption, placement for adoption, or death of a dependent child
Health Insurance Portability & Accountability Act Non-Discrimination Requirements (HIPAA)
3. Change in employment status, including the start or termination of employment by you, your spouse, or your dependent child
Health Insurance Portability & Accountability Act (HIPAA) prohibits group health plans and health insurance issuers from discriminating against individuals in eligibility and continued eligibility for benefits and in individual premium or contribution rates based on health factors.
4. Change in work schedule, including an increase or decrease in hours of employment by you, your spouse, or your dependent child, including a switch between part-time and full-time employment that affects eligibility for benefits
These health factors include: health status, medical condition (including both physical and mental illnesses), claims experience,
5. Change in a child’s dependent status, either newly satisfying the requirements for dependent child status or ceasing to satisfy them 6. Change in place of residence or worksite, including a change that affects the accessibility of network providers
Benefit Guide 2024 32
7. Change in your health coverage or your spouse’s coverage attributable to your spouse’s employment 8. Change in an individual’s eligibility for Medicare or Medicaid 9. A court order resulting from a divorce, legal separation, annulment, or change in legal custody (including a Qualified Medical Child Support Order) requiring coverage for your child or dependent foster child
can exercise those rights. Please review it carefully. If you have any questions about this Notice, please contact Human Resources. OUR COMMITMENT REGARDING YOUR PERSONAL HEALTH INFORMATION
• Termination of employer contributions toward the other coverage, OR
Your company is committed to maintaining and protecting the confidentiality of our employees’ personal information. This Notice of Privacy Practices applies to your company and the health plan you enroll in. The Plans are required by federal and state law to protect the privacy of your individually identifiable health information and other personal information. We are required to provide you with this Notice about our policies, safeguards and practices. When the Plans use or disclose your PHI, the Plans are bound by the terms of this Notice, or the revised Notice, if applicable. We are required by law to: • Maintain the privacy of protected health information
• If the other coverage was COBRA Continuation Coverage, exhaustion of the coverage
• Give you this notice of our legal duties and privacy practices regarding health information about you
• Two other rules apply to making changes to your benefits during the year:
• Follow the terms of our notice that is currently in effect
10. An event that is a special enrollment event under HIPAA (the Health Insurance Portability and Accountability Act), including acquisition of a new dependent or spouse or loss of coverage under another health insurance policy or plan if the coverage is terminated because of: • Voluntary or involuntary termination of employment or reduction in hours of employment or death, divorce, or legal separation,
• Any changes you make must be consistent with the change in status, AND • You must make the changes within 31 days of the date the event (marriage, birth, etc.) occurs. Pre-existing Condition Exclusion A group health plan (or issuer) may not impose a pre-existing condition exclusion with respect to an individual before notifying the participant, in writing, of the following – The existence and terms of any pre-existing condition exclusion under the plan. This includes – • The length of the plan’s look-back period, • The maximum pre-existing condition exclusion under the plan, and • How the plan will reduce the maximum pre-existing condition exclusion by creditable coverage. • A description of the rights of individuals to demonstrate creditable coverage, and any applicable waiting periods, through a certificate of creditable coverage or other means. This includes – • A description of the right of the individual to request a certificate from a prior plan or issuer, if necessary, and • A statement that the current plan or issuer will assist in obtaining a certificate from a prior plan or issuer, if necessary. A person to contact (including an address or telephone number) for obtaining additional information or assistance regarding the pre-existing condition exclusion. HIPAA Privacy Notice This Notice describes how health information about you may be used and disclosed and how you can get access to this information. This Notice provides you with information to protect the privacy of your confidential health care information, hereafter referred to as protected health information (PHI). The Notice also describes the privacy rights you have and how you
The Plan will use Your Health Information for: For Treatment: We may use and disclose Health Information for your treatment and to provide you with treatment-related health care services. For example, we may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care. For Payment: We may use and disclose Health Information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment. For Health Care Operations: We may use and disclose Health Information for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the obstetrical or gynecological care you receive is of the highest quality. We also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities. As Required by Law: We will disclose Health Information when required to do so by international, federal, state or local law. Workers’ Compensation: We may release Health Information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness. Public Health Risks: We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence.
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We will only make this disclosure if you agree or when required or authorized by law. Law Enforcement: We may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime. Your Rights Regarding Your Health Information You have the following rights regarding Health Information we have about you: Right to Inspect and Copy: You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in writing, to Human Resources. We have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies employed with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state of federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review. Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communications, you must make your request, in writing, to Human Resources. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests. The Plan’s Responsibilities The Plans may change the terms of this Notice at any time. If the Plans change this Notice, the Plans may make the new Notice terms effective for all of your PHI that the Plans maintain, including any information the Plans created or received before we issued the new Notice. If the Plans change this Notice, the Plans will make it available to you.
Department of Health and Human Services. To file a complaint with our office, contact Human Resources. All complaints must be made in writing. You will not be penalized for filing a complaint. Important Information on how Health Care Reform Affects Your Plan Primary Care Provider Designations For plans and issuers that require or allow for the designation of primary care providers by participants or beneficiaries: • Your HMO generally requires the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact your Human Resources office. For plans and issuers that require or allow for the designation of a primary care provider for a child. • For children, you may designate a pediatrician as the primary care provider. For plans issuers that provide coverage for obstetric or gynecological care and require the designation by a participant or beneficiary of a primary care provider: • You do not need prior authorization from your insurance provider of from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact your Human Resources department. Grandfathered Plans As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan or policy may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.
For More Information or to Report a Problem
Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator. You may also contact the Employee Benefits Security
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the
Administration, U.S. Department of Labor at 1-866-444-3272 or dol.gov/ebsa/healthreform.
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Important Information about Your COBRA Continuation Coverage Rights
employee’s or retiree’s spouse or domestic partner, and the dependents of the covered employee or retiree.
Note: For use by single employer groups, please read the information contained in this notice very carefully.
COBRA continuation coverage is identical to the group coverage provided to employees and retirees (the same coverage the qualified beneficiary had immediately before qualifying for continuation coverage). Any change in benefits under the plan for active employees or retirees will also apply to COBRA qualified beneficiaries.
To elect COBRA continuation coverage, contact your Human Resource Representative to obtain a copy of the COBRA election form. If you do not elect COBRA continuation coverage, your coverage under the plan will end on the last day of the month in which the following “qualifying events” occur: • Termination of employment (18 months of COBRA) • Reduction in hours (18 months of COBRA) • Death of employee (36 months of COBRA for the spouse and dependents) • Divorce or legal separation (36 months of COBRA for the exspouse) • Entitlement to Medicare (36 months of COBRA for the spouse and dependents) • Loss of dependent child status (36 months of COBRA for the dependent) Each person (“qualified beneficiary”) in the category(ies) checked below is entitled to elect COBRA continuation coverage, which will continue group health care coverage under the plan for up to 18 or 36 months. (Extensions under state continuation coverage of due to disability may also be available. Contact Human Resources to find out more). The following are eligible to elect COBRA: • Employee or former employee • Spouse of former spouse • Dependent child(ren) covered under the plan on the day before the event that caused the loss of coverage • Child who is losing coverage under the plan because he or she is no longer a dependent under the plan. If elected, COBRA continuation coverage will begin on the date specified by your plan administrator. You may elect any coverage you currently were enrolled in for COBRA continuation coverage. COBRA continuation coverage will cost the amount determined at the time of the loss as specified by your plan administrator. You do not have to send any payment with the Election Form. Important additional information about payment for COBRA continuation coverage is included in the following pages. If you have any questions about this notice or your rights to COBRA continuation coverage, you should contact HumanResources. What is continuation coverage? Federal law requires that employers give employees and their families the opportunity to continue their health care coverage when there is a “qualifying event” that would result in a loss of coverage under an employer’s plan. Qualifying events are situations that would ordinarily cause an individual to lose group health coverage. Depending on the type of qualifying event, “qualified beneficiaries” can include the employee or retiree covered under the group health plan, the covered
How long will continuation coverage last? Coverage generally may be continued for up to 18 months in the case of the employee’s loss of coverage due to termination of employment or reduction in hours of employment (includes leave without pay or layoff). Coverage may be continued for up to 36 months in the case of a loss of coverage due to the employee’s or retiree’s divorce/ legal separation/annulment or termination of domestic partnership, the employee’s or retiree’s death, or a dependent’s loss of eligibility. If a covered employee becomes entitled to Medicare (due to age) within 18 months before a termination of employment or reduction of hours, family members who are qualified beneficiaries may continue COBRA continuation coverage for up to 36 months counted from the date of the employee’s Medicare entitlement. Continuation coverage will be terminated before the end of the maximum period if: • Any required premium is not paid in full on time. • A qualified beneficiary becomes covered, after electing continuation coverage, under another group health plan that does not impose any pre-existing condition exclusion for a pre-existing condition of the qualified beneficiary. • The employer ceases to provide any group health plan for its employees. Continuation coverage may also be terminated for any reason to plan would terminate coverage of a participant or beneficiary not receiving continuation coverage (such as fraud). How can you extend the length of COBRA continuation coverage? If you elect continuation coverage, an extension of the maximum period of coverage may be available if a qualified beneficiary is a disabled or a second qualifying event occurs. You must notify Human Resources of a disability or a second qualifying event within 60 days in order to extend the period of continuation coverage. Failure to provide notice of a disability or second qualifying event may affect the right to extend the period of continuation coverage. Disability An 11-month extension of coverage may be available if a qualified beneficiary is determined by the Social Security Administration (SSA) to be disabled. The disability must have started at some time before the 60th day of COBRA continuation coverage. It is the qualified beneficiary’s responsibility to obtain the disability determination from the SSA and provide a copy of the Social Security disability determination to the Plan within 60 days of the date of determination and before the original 18 months of COBRA expire. Each qualified beneficiary who has elected continuation coverage will be entitled to the 11-month disability extension even if only one of them qualifies. If the qualified beneficiary does not comply with these time frames, the additional 11-month extension of COBRA coverage
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will not be provided. If the qualified beneficiary is determined by SSA to no longer be disabled, he or she must notify the Plan of that fact within 30 days after the SSA’s determination. Second Qualifying Event An 18-month extension of coverage will be available to a spouse or domestic partner and dependents who elect continuation coverage if a second qualifying event occurs during the first 18 months of continuation coverage. The maximum amount of continuation coverage available when a second qualifying event occurs is 36 months from the date of the original qualifying event. Such second qualifying events may include the death of a covered employee or retiree, divorce/legal separation/ annulment or termination of domestic partner relationship from the employee or retiree, or a dependent losing eligibility. These events will be considered to be second qualifying events only if they would have caused the qualified beneficiary to lose coverage under the Plan if the first qualifying event had not occurred. The qualified beneficiary must notify the Plan within 60 days after a second qualifying event occurs if he or she wants to extend continuation coverage. How can you elect COBRA continuation coverage? To elect continuation coverage, you must complete the Election Form and furnish it according to the directions on the form. Each qualified beneficiary has a separate right to elect continuation coverage. For example, the employee’s spouse may elect continuation coverage even if the employee does not. Continuation coverage may be elected for only one, several, or for all dependent children who are qualified beneficiaries. A parent may elect to continue coverage on behalf of any dependent children. The employee or the employee’s spouse can elect continuation coverage on behalf of all of the qualified beneficiaries. In considering whether to elect continuation coverage, you should take into account that you have special enrollment rights under federal law. You have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your spouse’s employer) within 30 days after your group health coverage ends because of the qualifying event listed above. You will also have the same special enrollment right at the end of continuation coverage if you get continuation coverage for the maximum time available to you. You must notify Human Resources within 30 days of any of the following COBRA triggering events: • Entitlement to Medicare • Termination of Employment • Reduction in hours You must notify Human Resources within 60 days of the following resulting in a loss of coverage: • Divorce or Legal Separation • Loss of Dependent Child Status How much does COBRA continuation coverage cost? Generally, each qualified beneficiary is required to pay the entire cost of continuation coverage. The amount a qualified beneficiary is required to pay may not exceed 102 percent (or,
in the case of an extension of continuation coverage due to a disability, 150 percent) of the cost to the group health plan (including both employer and employee contributions) for coverage of a similarly situated plan participant or beneficiary who is not receiving continuation coverage. When and how must payment be made for COBRA continuation coverage? First payment for continuation coverage If you elect continuation coverage, you do not have to send any payment with the Election Form. However, you must make your first payment for continuation coverage not later than 45 days after the date of your election. (This is the date the Election Notice is post-marked, if mailed.) If you do not make your first payment for continuation coverage in full not later than 45 days after the date of your election, you will lose all continuation coverage rights under the Plan. You are responsible for making sure that the amount of your first payment is correct. You may contact [enter appropriate contact information, e.g., the Plan Administrator or other party responsible for COBRA administration under the Plan] to confirm the correct amount of your first payment. Periodic payments for continuation coverage After you make your first payment for continuation coverage, you will be required to make periodic payments for each subsequent coverage period. The amount due for each coverage period for each qualified beneficiary is shown in this notice. The periodic payments can be made on a monthly basis. Under the Plan, each of these periodic payments for continuation coverage is due on the specified date for that coverage period. If you make a periodic payment on or before the first day of the coverage period to which it applies, your coverage under the Plan will continue for that coverage period without any break. The Plan will not send periodic notices of payments due for these coverage periods. Grace periods for periodic payments Although periodic payments are due on the dates shown above, you will be given a grace period of 30 days after the first day of the coverage period to make each periodic payment. Your continuation coverage will be provided for each coverage period as long as payment for that coverage period is made before the end of the grace period for that payment. However, if you pay a periodic payment later than the first day of the coverage period to which it applies, but before the end of the grace period for the coverage period, your coverage under the Plan will be suspended as of the first day of the coverage period and then retroactively reinstated (going back to the first day of the coverage period) when the periodic payment is received. This means that any claim you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated. If you fail to make a periodic payment before the end of the grace period for that coverage period, you will lose all rights to continuation coverage under the Plan. For More Information This notice does not fully describe continuation coverage or other rights under the plan. More information about continuation coverage and your rights under the plan is available in your summary plan description from the plan Administrator.
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If you have any questions concerning the information in this notice, your rights to coverage, or if you want a copy of your summary plan description, you should contact Human Resources. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website. Keep Your Plan Informed of Address Changes In order to protect your and your family’s rights, you should keep the plan administrator informed of any changes in your address and the addresses of family members. You should also keep a copy, for your records, of any notices you send to the plan administrator. Employee Rights & Responsibilities Under the Family Medical Leave Act The Family and Medical Leave Act (FMLA) entitles eligible employees of covered employers to take unpaid, job-protected leave for specified family and medical reasons. This fact sheet provides general information about which employers are covered by the FMLA, when employees are eligible and entitled to take FMLA leave, and what rules apply when employees take FMLA leave. COVERED EMPLOYERS The FMLA only applies to employers that meet certain criteria. A covered employer is a: • Private-sector employer, with 50 or more employees in 20 or more workweeks in the current or preceding calendar year, including a joint employer or successor in interest to a covered employer; • Public agency, including a local, state, or Federal government agency, regardless of the number of employees it employs; or • Public or private elementary or secondary school, regardless of the number of employees it employs. ELIGIBLE EMPLOYEES Only eligible employees are entitled to take FMLA leave. An eligible employee is one who: • Works for a covered employer; • Has worked for the employer for at least 12 months; • Has at least 1,250 hours of service for the employer during the 12 month period immediately preceding the leave*; and • Works at a location where the employer has at least 50 employees within 75 miles. The 12 months of employment do not have to be consecutive. That means any time previously worked for the same employer (including seasonal work) could, in most cases, be used to meet the 12-month requirement. If the employee has a break in service that lasted seven years or more, the time worked prior to the break will not count unless the break is due to service covered by the Uniformed Services Employment and
Re-employment Rights Act (USERRA), or there is a written agreement, including a collective bargaining agreement, outlining the employer’s intention to rehire the employee after the break in service. See “FMLA Special Rules for Returning Reservists”. LEAVE ENTITLEMENT Eligible employees may take up to 12 work weeks of leave in a 12-month period for one or more of the following reasons: • The birth of a son or daughter or placement of a son or daughter with the employee for adoption or foster care; • To care for a spouse, son, daughter, or parent who has a serious health condition; • For a serious health condition that makes the employee unable to perform the essential functions of his or her job; or • For any qualifying exigency arising out of the fact that a spouse, son, daughter, or parent is a military member on covered active duty or call to covered active duty status. An eligible employee may also take up to 26 workweeks of leave during a “single 12-month period” to care for a covered servicemember with a serious injury or illness, when the employee is the spouse, son, daughter, parent, or next of kin of the servicemember. The “single 12-month period” for military caregiver leave is different from the 12-month period used for other FMLA leave reasons Under some circumstances, employees may take FMLA leave on an intermittent or reduced schedule basis. That means an employee may take leave in separate blocks of time or by reducing the time he or she works each day or week for a single qualifying reason. When leave is needed for planned medical treatment, the employee must make a reasonable effort to schedule treatment so as not to unduly disrupt the employer’s operations. If FMLA leave is for the birth, adoption, or foster placement of a child, use of intermittent or reduced schedule leave requires the employer’s approval. Under certain conditions, employees may choose, or employers may require employees, to “substitute” (run concurrently) accrued paid leave, such as sick or vacation leave, to cover some or all of the FMLA leave period. An employee’s ability to substitute accrued paid leave is determined by the terms and conditions of the employer’s normal leave policy. NOTICE Employees must comply with their employer’s usual and customary requirements for requesting leave and provide enough information for their employer to reasonably determine whether the FMLA may apply to the leave request. Employees generally must request leave 30 days in advance when the need for leave is foreseeable. When the need for leave is foreseeable less than 30 days in advance or is unforeseeable, employees must provide notice as soon as possible and practicable under the circumstances. When an employee seeks leave for a FMLA-qualifying reason for the first time, the employee need not expressly assert FMLA rights or even mention the FMLA. If an employee later requests additional leave for the same qualifying condition, the employee must specifically reference either the qualifying reason for leave or the need for FMLA leave. See Fact Sheet 28E: Employee Notice Requirements under the FMLA.
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Covered employers must: (1) Post a notice explaining rights and responsibilities under the FMLA (and may be subject to a civil money penalty of up to $110 for willful failure to post); (2) Include information about the FMLA in their employee handbooks or provide information to new employees upon hire; (3) When an employee requests FMLA leave or the employer acquires knowledge that leave may be for a FMLA-qualifying reason, provide the employee with notice concerning his or her eligibility for FMLA leave and his or her rights and responsibilities under the FMLA; and
discharge or discriminate against any individual for opposing any practice, or because of involvement in any 4 . The Wage and Hour Division is responsible for administering and enforcing the FMLA for most employees. Most federal and certain congressional employees are also covered by the law but are subject to the jurisdiction of the U.S. Office of Personnel Management or Congress. If you believe that your rights under the FMLA have been violated, you may file a complaint with the Wage and Hour Division or file a private lawsuit against your employer in court. : Protections for Individuals under the FMLA For additional information: (866) 4US-WAGE / (866) 487-9243 TTY: (877) 889-5627 www.wagehour.dol.gov
(4) Notify employees whether leave is designated as FMLA leave and the amount of leave that will be deducted from the employee’s FMLA entitlement.
Uniformed Services Employment & Re-employment Rights Act Notice of 1994, Notice of Right to Continued Coverage Under USERRA
CERTIFICATION
The Uniformed Services Employment and Re-employment Rights Act (USERRA) provides certain protections for employees who must be absent from work due to uniformed service. These protections include re-employment rights, protection from discrimination and the right to the continuation of group health coverage.
When an employee requests FMLA leave due to his or her own serious health condition or a covered family member’s serious health condition, the employer may require certification in support of the leave from a health care provider. An employer may also require second or third medical opinions (at the employer’s expense) and periodic recertification of a serious health condition. • Certification of a Serious Health Condition under the FMLA • Certification requirements for military family leave • Qualifying Exigency Leave under the FMLA • Military Caregiver Leave for a Current Servicemember under the FMLA • Military Caregiver Leave for a Veteran under the FMLA. JOB RESTORATION AND HEALTH BENEFITS Upon return from FMLA leave, an employee must be restored to his or her original job or to an equivalent job with equivalent pay, benefits, and other terms and conditions of employment. An employee’s use of FMLA leave cannot be counted against the employee under a “no-fault” attendance policy. Employers are also required to continue group health insurance coverage for an employee on FMLA leave under the same terms and conditions as if the employee had not taken leave. OTHER PROVISIONS Special rules apply to employees of local education agencies. Generally, these rules apply to intermittent or reduced schedule FMLA leave or the taking of FMLA leave near the end of a school term. Salaried executive, administrative, and professional employees of covered employers who meet the Fair Labor Standards Act (FLSA) criteria for exemption from minimum wage and overtime under the FLSA regulations, 29 CFR Part 541, do not lose their FLSA-exempt status by using any unpaid FMLA leave. This special exception to the “salary basis” requirements for FLSA’s exemption extends only to an eligible employee’s use of FMLA leave. ENFORCEMENT It is unlawful for any employer to interfere with, restrain, or deny the exercise of or the attempt to exercise any right provided by the FMLA. It is also unlawful for an employer to
Under USERRA, you have the right to continue the coverage that you (and your covered dependents, if any had under the Company Medical Plan if the following conditions are met: • You are absent from work due to service in the uniformed services (defined below): • You were covered under the Plan at the time your absence from work began; and • You (or an appropriate officer of the uniformed services) provided your employer with the advance notice of your absence from work (you are excluded from meeting this condition if compliance is precluded by military necessity or is otherwise impossible or unreasonable under the circumstances) How to Continue Coverage If the conditions are met, you (or your authorized representative) may elect to continue your coverage (and the coverage of your covered dependents, if any) under the Plan by completing and returning an Election Form 60 days after date that USERRA election notice is mailed, and by paying the applicable premium for your coverage as described below. What Happens if You do not Elect to Continue Coverage? If you fail to submit a timely, completed Election Form as instructed or do not make a premium payment within the required time, you will lose your continuation rights under the Plan, unless compliance with these requirements is precluded by military necessity or is otherwise impossible or unreasonable under the circumstances. If you do not elect continuation coverage, your coverage (and the coverage of your covered dependents, if any) under the Plan ends effective the end of the month in which you stop working due to your leave for uniformed service. Premium for Continuing Your Coverage The premium that you must pay to continue your coverage depends on your period of service in the uniformed services. Contact Human Resources for more details.
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Length of Time Coverage Can Be Continued If elected, continuation coverage can last 24 months from the date on which employee’s leave for uniformed, service began. However, coverage will automatically terminate earlier if one of the following events takes place: • A premium is not paid in full within the required time • You fail to return to work or apply for re-employment within the time required under USERRA (see below) following the completion of your service in the uniformed services; or • You lose your rights under USERRA as a result of a dishonorable discharge or other conduct specified in USERRA. We will not provide advance notice to you when your continuation coverage terminates. Reporting to Work / Applying for Re-employment Your right to continue coverage under USERRA will end if you do not notify Human Resources of your intent to return to work within the time frame required under USERRA following the completion of your service in the uniformed services by either reporting to work (if your uniformed service was for less than 31 days) or applying for reemployment (if your uniformed service was for more than 30 days). The time for returning to work depends on the period of uniformed service, as follows: Period of Uniformed Service / Report to Work Requirement Less than 31 days – The beginning of the first regularly scheduled work period on the day following the completion of your service, after allowing for safe travel home and an eight-hour rest period, or if that is unreasonable or impossible through no fault of your own, then as soon as possible. 31-180 days – Submit an application for re-employment within 14 days after completion of your service or, if that is unreasonable or impossible through no fault of your own, then as soon as is possible. 181 days or more – Submit an application for re-employment within 90 days after completion of service.
Any period if for purposes of an examination for fitness to perform uniformed service – Report by the beginning of the first regularly scheduled work period on the day following the completion of your service, after allowing for safe travel home and an eight-hour rest period, or impossible through no fault of your own, then as soon as is possible. Any period if you were hospitalized for or are convalescing from an injury or illness incurred or aggravated as a result of your service – report or submit an application for reemployment as above (depending on length of service.) except that time periods being when you have recovered from your injuries or illness rather than upon your completion of your service. Maximum period for recovering is limited to two years from completion of service but may be extended if circumstance beyond your control make it impossible or unreasonable for you to report to work within the above time periods. Definitions For you to be entitled to continued coverage under USERRA, your absence from work must be due to “Service in the Uniformed Services”. • “Uniformed Services” means the Armed Forces, the Army National Guard, and the Air National Guard when an individual is engaging in active duty for training, or full time National Guard duty (i.e. pursuant to orders issued under federal law), the commission corps of the Public Health Service, and any other category of persons designated by the President in time of war or national emergency. • “Service in uniformed services” or “Service” means the performance of duty on a voluntary or involuntary basis in the Uniformed Services under competent authority, including active duty, active and inactive duty for training, National Guard duty under federal statues, a period for which a person is absent for employment for an examination to determine his or her fitness to perform any of these duties, and a period for which a person is absent from employment to perform certain funeral honors duty. It also includes certain service by intermittent disaster response appointees of the National Disaster Medical System (NDMS).
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Premium Assistance under Medicaid & the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2023. Contact your State for more information on eligibility.
ALABAMA-Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447
ALASKA-Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
ARKANSAS-Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)
CALIFORNIA-Medicaid Website: Health Insurance Premium Payment (HIPP) Program http://dhcs.ca.gov/hipp Phone: 916-445-8322 Fax: 916-440-5676 Email: hipp@dhcs.ca.gov
COLORADO-Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/child-healthplan-plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711 Health Insurance Buy-In Program (HIBI): https://www.colorado.gov/pacific/hcpf/healthinsurance-buy-program HIBI Customer Service: 1-855-692-6442
FLORIDA-Medicaid Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery. com/hipp/index.html Phone: 1-877-357-3268
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GEORGIA-Medicaid A HIPP Website: https://medicaid.georgia.gov/healthinsurance-premium-payment-program-hipp Phone: 678-564-1162, Press 1 GA CHIPRA Website: https://medicaid.georgia.gov/programs/third-partyliability/childrens-health-insurance-program-reauthorizationact-2009-chipra Phone: (678) 564-1162, Press 2
INDIANA-Medicaid Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: https://www.in.gov/medicaid/ Phone 1-800-457-4584
IOWA-Medicaid and CHIP (Hawki)
MAINE-Medicaid Enrollment Website: https://www.maine.gov/dhhs/ofi/applications-forms Phone: 1-800-442-6003 TTY: Maine relay 711 Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms Phone: -800-977-6740. TTY: Maine relay 711
MASSACHUSETTS-Medicaid and CHIP Website: https://www.mass.gov/masshealth/pa Phone: 1-800-862-4840
MINNESOTA-Medicaid
Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563 HIPP Website: https://dhs.iowa.gov/ime/members/medicaida-to-z/hipp HIPP Phone: 1-888-346-9562
Website: https://mn.gov/dhs/people-we-serve/children-andfamilies/health-care/health-care-programs/programs-andservices/other-insurance.jsp Phone: 1-800-657-3739
KANSAS-Medicaid
MISSOURI-Medicaid
Website: https://www.kancare.ks.gov/ Phone: 1-800-792-4884
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005
KENTUCKY-Medicaid
MONTANA-Medicaid
Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov
Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084
KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov
LOUISIANA-Medicaid Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-6185488 (LaHIPP)
NEBRASKA-Medicaid Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178
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NEVADA-Medicaid Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900
NEW HAMPSHIRE-Medicaid Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext 5218
NEW JERSEY-Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710
NEW YORK-Medicaid Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831
NORTH CAROLINA-Medicaid Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100
NORTH DAKOTA-Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825
OKLAHOMA-Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742
SOUTH CAROLINA-Medicaid Website: https://www.scdhhs.gov Phone: 1-888-549-0820
SOUTH DAKOTA-Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059
TEXAS-Medicaid Website: http://gethipptexas.com/ Phone: 1-800-440-0493
UTAH-Medicaid and CHIP Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669
VERMONT-Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427
VIRGINIA-Medicaid and CHIP Website: https://www.coverva.org/en/famis-select https://www.coverva.org/en/hipp Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-800-432-5924
WASHINGTON-Medicaid Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022
OREGON-Medicaid
WEST VIRGINIA-Medicaid and CHIP
Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075
Website: https://dhhr.wv.gov/bms/ http://mywvhipp.com/ Medicaid Phone: 304-558-1700 CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-6998447)
PENNSYLVANIA-Medicaid
WISCONSIN-Medicaid and CHIP
Website: https://www.dhs.pa.gov/Services/Assistance/Pages/HIPPProgram.aspx Phone: 1-800-692-7462
Website: https://www.dhs.wisconsin.gov/badgercareplus/p10095.htm Phone: 1-800-362-3002
RHODE ISLAND-Medicaid and CHIP
WYOMING-Medicaid
Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)
Website: https://health.wyo.gov/healthcarefin/medicaid/programsand-eligibility/ Phone: 1-800-251-1269
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To see if any other states have added a premium assistance program since January 31, 2022 or for more information on special enrollment rights, contact either:
U.S. Department of Labor
U.S. Department of Health and Human Services
Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)
Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, menu option 4, ext. 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting the burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov an reference the OMB Control Number 1210-0137.
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Plan Guidelines and Evidence of Coverage The benefit summaries listed in the previous pages are brief summaries only. They do not fully describe the benefits coverage for your health and welfare plans. For details on the benefits coverage, please refer to the plan’s Evidence of Coverage. The Evidence of Coverage or Plan Summaries are the binding document between the elected health plan and the member. A health plan physician must determine that the services and supplies are medically necessary to prevent, diagnose, or treat the members’ medical condition. These services and supplies must be provided, prescribed, authorized, or directed by the health plan’s network physician unless the member enrolls in the PPO plan where the member can use a non-network physician. The HMO member must receive the services and supplies at a health plan facility or skilled nursing facility inside the service are except where specifically noted to the contrary in the Evidence of Coverage. For details on the benefit and claims review and adjudication procedures for each plan, please refer to the plan’s Evidence of Coverage. If there are any discrepancies between benefits included in this summary and the Evidence of Coverage or Plan Summary description, the Evidence of Coverage or Plan Summary description will prevail. A copy can be obtained by contacting your local HR Department.
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Protections from Disclosure of Medical Information We are required by law to maintain the privacy and security of your personally identifiable health information. Although the wellness program and Continuing Life may use aggregate information it collects to design a program based on identified health risks in the workplace, Continuing Life’s program will never disclose any of your personal information either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment. Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information is Navigate and Gallagher in order to provide you with services under the wellness program. In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making any employment decision. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you immediately. You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate. If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact your Human Resources Department.
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Notice Regarding Wellness Plan Continuing Life’s wellness program (“Star Wellness”) is a voluntary wellness program available to all employees. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program you will be asked to complete a “Wellbeing Survey” that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You are not required to complete the Wellbeing Survey. However, employees who choose to participate in the wellness program will receive an incentive of reduced medical premiums for earning points by completing a health screening, Wellbeing Survey and additional programs available. Although you are not required to complete the Wellbeing Survey, only employees who do so will be rewarded points toward earning the incentive. Point earning opportunities may be available for employees who participate in certain health-related activities such as the quarterly challenges and community onsite events. If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive, you may be entitled to a reasonable accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by contacting your Human Resources Department. The information from your Wellbeing Survey will be used to provide you with information to help you understand your current health and potential risks, and may also be used to offer you services through the wellness program, such as programs targeted to aggregate health trends. You also are encouraged to share your results or concerns with your own doctor. Protections from Disclosure of Medical Information We are required by law to maintain the privacy and security of your personally identifiable health information. Although the wellness program and Continuing Life may use aggregate information it collects to design a program based on identified health risks in the workplace, Continuing Life’s Star Wellness program will never disclose any of your personal information either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment. Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information is Impact Health, Navigate and Gallagher ordered to provide you with services under the wellness program. In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making any employment decision. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you immediately. You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate. If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact your Human Resources Department.
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Directory & Resources Questions Regarding
Phone
Website
STAR Fund STAR Fund
Contact your local HR Dept.
www.charities.org/CLSTARfund
STAR Wellness Program Navigate
888-282-0822
continuinglife.livehealthyignite.com
Blue Shield of CA Access+ HMO & PPO
888-256-1915
www.blueshieldca.com
Blue Shield of CA Trio ACO HMO - Concierge Team
855-829-3566
www.blueshieldca.com
American Specialty Health Plan (Chiro/Acu)
800-678-9133
www.ashcompanies.com
Blue Shield RX Mail Order - CVS Caremark
866-346-7200
www.caremark.com
Medical Coverage - Blue Shield - Group Number: W0064522
Medical Coverage - Kaiser - Group Number: Nor Cal: 604513 / So Cal: 229192 Kaiser Permanente
800-464-4000
www.kp.org
800-424-4652
www.simnsa.com
SIMNSA - Group Number: 619 SIMNSA HMO (San Diego work locations only)
Healthcare Reimbursement Account (HRA) - Group Number: BCC1001 BCC Benefit Solutions
800-685-6100
www.bccbenefitsolutions.com
Guardian Dental HMO
888-600-1600
www.guardiananytime.com
Guardian Dental PPO
888-600-1600
www.guardiananytime.com
800-424-4652
www.simnsa.com
800-877-7195
www.vsp.com
888-600-1600
www.guardiananytime.com
866-451-3399
www.wexinc.com/login/benefits-login
Guardian
800-386-7055
www.ibhworklife.com
Debra Lobatz, Licensed Marriage and Family Therapist
760-634-3188
www.debralobatz.com
Supplemental Employee Paid Life / AD&D - Guardian
888-600-1600
www.guardiananytime.com
Disability - (STD) - Guardian
888-600-1600
www.guardiananytime.com
800-695-7526
https://workforcenow.adp.com
866-432-0472
www.dailypay.tm/signup
855-805-6911
http://www.uagc.edu/tuition-financial-aid/ education-partnerships/continuinglife
Nicola Quinn - Senior Client Manager
619-704-3503
nicola_quinn@ajg.com
Jennifer Moses - Lead Account Executive
858-997-7672
jennifer_moses@ajg.com
Dental Coverage - Guardian - Group Number: 465620
Dental Coverage - SIMNSA - Group Number: 619 SIMNSA HMO (San Diego work locations only) Vision Coverage - Group Number: 12188927 Vision Service Plan Basic Life / AD&D, LTD - Group Number: 465620 Guardian Long Term Disability (LTD) – Director & Managers Flexible Spending Accounts (FSA) WEX Benefits Employee Assistance Program
Supplemental Benefits - Group Number: 465620
Retirement Plans - Group Number: 426430 401(k) & Roth 401(k) - ADP DailyPay DailyPay University of Arizona Global Campus University of Arizona Global Campus Benefits Broker - Gallagher Benefit Services
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This brochure provides an overview of some of your benefit plan choices. It is for informational purposes only. It is not intended to be an agreement for continued employment. Neither is it a legal plan document. If there is a disagreement between this guide and the plan documents, the plan documents will govern. In addition, the plans described in this brochure are subject to change without notice. Continuation of any benefit plan or coverage is at the company’s discretion and in accordance with federal and state laws. If you need additional information or have any questions about the benefit program, please contact the Human Resources Department. Copyright © Gallagher – all rights reserved