Shawnee County Kansas 2020 Benefits Guide

2020

Benefit Guide Effective 1/1/20 – 12/31/20

Table of Contents Welcome to 2020 Open Enrollment Benefit Basics & Costs

3 4 -5

Medical/Rx Plans

6

Telehealth

7

Dental Plan

8

Vision Plan

9

Pharmacy Advocate Program

10

Flexible Spending Accounts

11

Life/Disability & Retirement

12

Additional Benefits

As a Shawnee County employee, we want to take the time for you to be aware of the many health and wellness benefitsoffered through our organization. Shawnee County cares about our employees and invests in them by offering a variety of quality benefit plans for you and your family.

In the following pages, you will find information which will assist you in enrolling in the benefit plans of your choice or making changes.

13 - 17

Glossary

18

Contacts

19

Employees who fail to complete their

10enrollment within the allotted

timeframe may be denied coverage until the 2020 open enrollmentperiod.

Open Enrollment will be held beginning 10/21/19 through 11/1/19 with meetings at the following locations: 10/21 1:00 - 3:00 p.m.

Reynolds Lodge, Lake Shawnee

10/22 10:00 – 11:00 a.m.

1:00 - 2:00 p.m.

Adult Detention Center Training Room A Adult Detention Center Training Room A

10/23 6:30 – 9:30 a.m.

1:00 – 3:00 p.m.

North Annex Main Conference Room EOC Courthouse Sub-basement

10/24 9:00 – 10:00 a.m.

1:00 – 4:00 p.m.

Health Department Training Room A Law Enforcement Center BreakRoom

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Welcome to Shawnee County 2020 Open Enrollment Welcome to the 2020 Open Enrollment. As an employee of Shawnee County, you may be eligible for certain benefits such as medical, dental, vision and life insurance at group rates.

Shawnee County pays for the majority of the monthlycost of the benefits you choose to enroll in, and you pay aportion as well.

The information in this guide will provideinformation on whether Shawnee County pays the cost, youpay the cost or we share in thecost.

Your company-sponsored benefits are more valuable than ever before and they account for a large portion of the total compensation you receive as an employee of Shawnee County.

Rest assured that we are working hard to provide the best pay and benefits for you and for your family.

It’s important that you read through this benefits guide carefully so that you can understand what each benefit provides, and how to access coverage when you need it. You may want to share this information with family members as well.

After you read this information, you maycontact hrinfo@snco.us with questions or call 785-251-4435.

Remember that the open enrollment window opens on October 21, 2019 and ends on November 1, 2019. It’s important you enroll during this time period as you will not have an opportunity to enroll afterwards unless you havea qualifying life event (keep reading to learnmore).

Thank you for taking the time to learn about your benefits choices and for enrolling on time.

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Benefit Basics Eligibility The County health benefit allocation for full time permanent employees (working 2080 hours per year) is $840 per month. For permanent threequarters (3/4) time employees (at least1,560 hours per year) is $630 per month. For permanent half- time (1/2) employees (at least 1,040 hours per year) is $420.00 per month.

Dental insurance can be obtained as stand-alone coverage if an individual can prove they have group health insurance elsewhere. Any additional premiums (for spouse, children and/or family) over the benefit allocation provided by the County can be paid by either pre-tax or post-tax dollars at the choice of the employee. Your dependents can also enroll for coverage,including:  Your legal spouse

 Your domestic partner (eligible for benefits if he or she is not a relative and has lived with you for at least six months in a committed relationship.

Additional form must be signed to enroll)  Your children up to age 26 Your benefits will take effect on January 1, 2020 and will remain in effect until December 31, 2020.

Remember that you may only change coverage if you experience a qualifying life event, as described below.

For more information about your benefits:

At Shawnee County you have access to a variety of valuable benefits designed to provide financialpeace of mind for you and your family. Please read this guide to learn more about your benefits, and make sure to enroll by November 1, 2019.

Qualifying Life Events Generally, you may only make or change your existing benefit elections during the open enrollment window. However, you may change your benefit elections during the year if you experience an event such as:  Marriage  Divorce or legal separation  Birth of your child or your domestic partner’s child  Death of your spouse, domestic partneror dependent child  Adoption of or placement for adoption of your child  Change in employment status of employee, spouse/domestic partner or dependent child  Qualification by the Plan Administrator ofa child support order for medical coverage  New entitlement to Medicare or Medicaid You must notify Human Resources within 30 days of a qualifying life event. Depending on the type of event, you may need to provide proof of the event, such as a marriage license. Human Resources will let you know what documentation you should provide. If you do not contact Human Resources within 30 days of the qualified event, you will have to wait until the next open enrollment window to make changes (unless you experience another qualifying life event).

Phone: 785-251-4435 Email: HRinfo@snco.us

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Shawnee County pays for some of yourbenefits and you share the cost for others, as shown below.

Benefit Basics Benefit

Who Pays

Tax Treatment

Medical Coverage

Shawnee County & You

Pretax

Dental Coverage

Shawnee County & You

Pretax

Vision Coverage

You

Pretax

Shawnee County

N/A

You

After-tax

Shawnee County

Benefits are taxable

You

Pretax

Shawnee County & You

Pretax

Shawnee County

N/A

Aflac (Accident, Hospital, Critical Care, STD)

You

After-tax

Loyal American Life Ins. Co. (Cancer)

You

Pretax

Life Insurance (Minnesota Life)

Shawnee County

N/A

Tria Health Pharmacy AdvocateProgram

Shawnee County

N/A

Telehealth (First Stop Health)

Shawnee County

N/A

Basic (KPERS) Voluntary Life Insurance (KPERS) Long Term Disability Coverage(KPERS) Flexible Spending Accounts (Surency) Retirement Benefits (KPERS) Employee Assistance Plan (EAP)

2020 Monthly Rates

Employee

Employee Child

Employee Spouse

Family

Total Medical/Dental/ Prescription

$865.00

$1,060.00

$1,230.00

$1,402.00

Shawnee County Contribution

$840.00

$840.00

$840.00

$840.00

Employee Contribution

$25.00

$220.00

$390.00

$562.00

Pay Period Cost

$12.50

$110.00

$195.00

$281.00

Dental Only

$1.00

$21.00

$31.00

$41.00

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Medical/Rx Plans

Basic plan provisions of the Shawnee County Medical and Rx plans are shown below

Blue Cross of KansasPPO Plan Provision Annual Deductible (Individual/Family) Coinsurance Maximum Out-of-Pocket Maximum (Includes Deductible)

In-Network

Out-of-Network

$1,000/$2,000

$1,000/$2,000

80/20% $3,000 Individual $9,000 Family

Lifetime Maximum Preventive Care

60/40% $ 5,000 Individual $13,000 Family Unlimited

100%

80% after deductible

Primary PhysicianOffice Visit

$30 copay

60% after deductible

Specialist Office Visit

$30 copay

60% after deductible

100% up to $300

60% after deductible

Inpatient Hospital Services

80% after deductible

60% after deductible

Outpatient Hospital Services

80% after deductible

60% after deductible

Urgent Care

80% after deductible

60% after deductible

$200 copay

$200 copay thendeductible and coinsurance

MedTrak In Network

MedTrak Out of Network

X-Ray and Lab

Emergency Room Care PrescriptionDrug Deductible Retail Prescription Drugs (30-day supply) • Generic < $100 – Tier1 • Generic > $100 – Tier 2 • Brand Preferred • Brand Non-preferred • Specialty Drugs

$10copay $20copay $35copay $60copay $150 copay

Retail 90 (90 day supply) • Generic < $100 – Tier1 • Generic > $100 – Tier2 • Brand Preferred • Brand Non-preferred

$25copay $50copay $87.50 copay $150 copay

No coverage out-of-network

$3,600 Individual $4,200 Family

No coverage out-of-network

Prescription Drug Out-ofPocket (Includes all Rx copays)

No coverage out-of-network

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Telehealth

Free Telehealth Benefit!

First Stop Health You can now access Physicians at no cost to you! Thatâ&#x20AC;&#x2122;s right, there are no copays or costs associated with this new benefit.All employees participating in the medical program will have this exciting new benefit available for you, your spouse and dependent children up to age 26.

Access a doctor for common ailments 24/7/365 with phone and video access to U.S.-based physicians.

Call 888-691-7867.

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Dental Plan

Your dental plan provides coverage for routine exams and cleanings and pays for a portion of other services, as shown in the chart below.

Provision Annual deductible (Individual/Family) Annual Maximum per person Diagnostic and Preventive, to include cleanings, fluoride treatments, sealantsand x-rays

Delta Dental of Kansas None $1,500 100%, no deductible (Does not count towardsannual maximum)

Basic Services to include fillings, endodontics (root canals),periodontics (treatment to gums) and oral surgery

50%

Major Services to include inlays and onlays, crowns, dentures and fixed bridgework

50%

Maximum Rollover

Orthodontia

Allowed to rollover 25% of unused maximum to the next calendar year.

Must have had at least one dental service during the benefityear.

Not Covered

2020 Benefit Enhancements: 1. Right Start 4 Kids: Children, age 12 and under, receive coverage at 100% for all services covered under the plan.

Not subject to deductible, but planâ&#x20AC;&#x2122;s annual maximum and frequencies/limitations apply.

Excludes orthodontics. Must see a Participating Premier or PPO Dentist or the planâ&#x20AC;&#x2122;s underlying contract applies including waiting periods, deductibles and coinsurance levels.

2. Unlimited Cleanings: Effective at your 2020 renewal date, your plan will allow for unlimited cleanings. This includes regular/prophylaxis cleanings and periodontal maintenance cleanings.

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Your vision plan is provided through Surency. It provides coverage for routine eye exams and pays for all or a portion of the cost of glasses or contact lenses. You can see in or out-of-network providers; however, you always save money if you see in-network providers.

Vision Plan Benefit

In-Network You Pay

Out-Of-Network Plan Pays

Exam (once every 12 months)

$10 copay

$35

Hardware

See below

See below

Frequency • Exam • Lenses • Frames

Every 12 months

Every 12 months

$130 Allowance/ every 12 months

$65

Covered 100% after $25 copay Covered 100% after $25 copay Covered 100% after $25copay

$25 $40 $55

0%

$200

$130 allowance for contactsand contact lens exam

$100

Frames Lenses • Single vision lenses • Bifocal lenses • Trifocal lenses Medically necessary contactlenses Elective contact lenses in lieu of glasses

2020 Voluntary Vision Payroll Deductions Status

Monthly

Employee

$6.84

Employee & Spouse

$15.21

Employee & Child(ren)

$12.97

Family

$21.38

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Tria Pharmacy Advocate Program – No Cost to You!

The Tria Pharmacy Advocate Program (PA) is designed to provide you with the opportunity to speak confidentially with a clinical pharmacist to review your current medications and any vitamin supplements. As an advocate for your health, the Tria Pharmacists work with you and your physician to ensure you receive the best results from your medications.

Members who qualify to participate in the program are currently taking four or more medications and have at least one chronic condition, or have diabetes. You will receive an invitation to participate in the program from Tria if you are identified as qualifying for the program.

Want to save money? Members who engage in the program may be eligible to receive reduced co-pays or coinsurance. Refer to your Summary Plan Description for details on co-pays.

Tria Help Desk The Tria Help Desk is a toll-free resource where all plan participants can speak directly with a Tria Pharmacist regarding questions about your medications.

Call the Help Desk when: • You start taking a new medication and/or have questions on a current medication. This includes over-thecounter medications and dietary supplements.

• You experience side effects or poor results from your medications and would like information about other options.

• You have trouble affording your medications and would like to know more about generic or less expensive options.

All members can access the Help Desk toll-free at 1-888-799-TRIA (8742). The Tria Help Desk is open Monday through Friday 8 a.m. to 9 p.m., and Saturday from 9 a.m. to 6 p.m.

For more information visit www.triahealth.com.

Tria Health Circle ofCare

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Flexible Spending Accounts

NEW! 2020 FSA will now be administrated by Surency!

2020 Flexible Spending Accounts will be administered by Surency

Same great benefit with Surency!

A Flexible Spending Account (FSA) is a program that helps you pay for health care and dependent care costs using tax free dollars. Each pay period, you decide how much money you would like to contribute to one or both accounts. Your contribution is deducted from your paycheck on a pretax basis and is put into the Health Care FSA, the Dependent Care FSA, or both. When you incur expenses, you can access the funds in your account to pay for eligible health care or dependent care expenses.

Surency Offers: • Debit Cards • Online Claim Submission • Direct Deposit Reimbursement • Access to pay yourself or your doctor directly • Mobile App

2019 Annual Contribution Limits

Benefit

Health Care FSA Most medical, dental and vision care expenses that are not covered by your health plan (such as copayments, coinsurance, deductibles, eyeglasses anddoctorprescribed over the counter medications)

Maximum contributionis $2,650 per year

Saves on eligible expenses not covered by insurance; reduces your taxableincome

Dependent Care FSA Dependent care expenses (such as day care, after school programs or elder care programs) so you and your spouse can work or attend school full-time

Maximum contribution is $5,000 per year ($2,500 if married and filing separate tax returns)

Reduces your taxableincome

Account Type And Eligible Expenses

Be sure to use all your 2019 funds with ASI. Remaining 2019 funds up to $500 will be transferred to Surency in January 2020.

More details to follow.

Example Here’s a look at how you can save when you use an FSA to pay for your healthcare and dependentcare expenses.

AccountType

With FSA

Without FSA

$30,000

$30,000

Pretax contribution to Health Care and DependentCare FSA

$2,400

$0

Federal and Social Securitytaxes*

$8,280

$9,000

After-tax dollars spent on eligibleexpenses

$0

$2,400

Spendable income after expenses andtaxes

$19,320

$18,600

$720

$0

Your Taxable Income

Tax savings with the Medical and Dependent CareFSA

*This is an example only, and may not reflect your actual experience. It assumes a 30% Federal income tax rate marginal rate and a 7.7% FICA marginal rate. State and local taxes vary, and are not included in this example. However, you will also save on any state and local taxes as well.

Important Information about FSAs Your Flexible Spending Account (FSA) elections are effective from January 1 through December 31, 2020. Please plan your contributions carefully. Our Health Care FSA allows you to carry over $500 in unused funds into the next plan year. These unused 2019 funds will be transferred to Surency in December of 2019. Any money remaining in your Health Care FSA over $500 and any amount in your Dependent Care FSA after 3/31/20 will be forfeited. This is known as the “use it or lose it” rule and it is governed by IRS regulations. Note that FSA elections do not automatically continue from year to year; you must actively enroll each year.

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Life/Disability & Retirement

What would your family do if your income was lost due to death or disability? Life and disability insurance are an important piece to provide financialsecurity.

Life Insurance - KPERS

Long Term Disability Insurance Coverage -KPERS

Life insurance is an important part of your financial security, especially if you support a family.

Disability insurance provides income replacement should you become disabled and unable to work due to a nonwork-related illness or injury. Shawnee County provides eligible employees with disability income benefits at no cost as shown below. Coverage is automatic. You do not need to enroll.

Shawnee County provides basic life insurance to all eligible employees at no cost. Coverage is automatic.

Account Type

Benefit

Coverage and Benefits

Employer-providedbasic life insurance

• 150% of yourbase annual earnings.

Long-Term Disability • Covers 60% of your base annualearnings.

• Benefit begins after 180 days ofdisability.

For job-related death

• 50% of your finalaverage salary, less any Worker’s Compensation. The minimum benefit is $100/month. In addition your spouse will receivea $50,000 lump sum benefit.

Additional Life Insurance – MinnesotaLife In addition to the KPERS life insurance shown above, Shawnee County also provides a flat $15,000 of life insurance insured through Minnesota Life at no cost to all eligible employees. Coverage is automatic.

Retirement Benefits - KPERS Throughout your career, you make contributions to KPERS. KPERS invests the money and pays you interest. You will also build retirement credits while you work. When you retire, KPERS pays you a guaranteed monthly benefit. Please refer to the KPERS “Benefits at a Glance” included in this guide.

KPERS 457 Retirement Plan Saving through your KPERS 457 plan is a simple way to help supplement your KPERS and Social Security. It can help you bridge the gap between your financial goals and your destination in retirement. Please refer to the “Benefits of Enrolling in Your KPERS 457 Plan” included in this guide.

Additional benefits, such as optional life insurance are available through KPERSbased upon your date of hire. Additional information about KPERS benefits are included in this guide. For additional information visit kpers@kpers.org or call at 1-785-296-6166 in Topeka or toll free at 1-888-275-5737.

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Additional Benefits

Shawnee County offers you and your family additional benefits through AFLAC and Loyal American Life Insurance Company to enhance your benefitspackage through convenient payroll deductions.

Aflac offers various options of coverage for you to select from: Accident Policy 24 hour coverage for any type of accident. Also includes accidental life coverage.

Benefit per accident, per calendar year, per covered person

OPTION 2

OPTION 3

Initial Accident Hospitalization

$1,000 reg admission $1500 ICU, Confined 18hrs

$1,000 reg admission $2,000 ICU Confined 18 hr

Accident Hospital Confinement

$200 per day (at least 18 hrs), up to 365

$250 per day, (at least 18 hr up to 365 days

ICU Confinement

$400, up to 15 days

$400, up to 15 days

$200 ERw/X-Ray $170 ER noX-Ray $150 Officew/X-Ray $120 Office noX-Ray

$200 ERw/X-Ray $170 ER noX-Ray $150 Officew/X-Ray $120 Office noX-Ray

$120 ground; $1,000 air

$200 ground/ $1,500 air

Blood/Plasma/Platelets

$100

$200

Major Diagnostic and Imaging Exams

$150

$200

Accident Follow-up Treatment

$25 up to six

$35, up to six

Therapy

$25, up to ten

$35, up to ten

Accident Treatment payable once per 24-hourperiod Hospital ER with X-ray Hospital ER without X-ray Office or facility with X-ray Office or facility without Xray Ambulance

Appliances

$25-$300

Prosthesis Prosthesis Repair or Replacement Rehabilitation Facility Home Modification Accident Specific-Sum Injuries Dislocations: Burns Skin Grafts Eye Injuries Lacerations Fractures Concussion (brain) Emergency Dental Work

$25-$300

$25-$250

$800

$500

$800

$100 per day

$150 per day

$2,000

$3,000

$75-$3,000 $100-$10,000 50% of Burn Benefit $50-$250 $25-$400 $100-$2,750 $100 $100-$300

$100 - $3,750 $125 - $12,500 50% of the burns benefit $65-$300 $35-$500 $125 - $3,500 $150 $130-$400

OPTION 2

OPTION 3

Employee

$21.32

$26.91

Employee & Spouse

$28.47

$35.88

Employee & Child(ren)

$33.54

$41.73

Family

$42.25

$52.52

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Additional Benefits continued Hospital Policy: This policy covers all hospital stays.

Benefit

Description

Hospital Confinement

Pays $500; $1,000; or $2,000. You choose the benefit amount at the time of application. Payable once per calendar year, per coveredperson.

Rehabilitation Facility

Pays $100 per day; limited to 15 days per confinement. Limited to 30 days per calendar year, per coveredperson.

Hospital Emergency Room

Pays $100 for treatment in a hospital emergency room. Limited to 2 payments per calendar year, per coveredperson.

Waiver of Premium

Yes

Continuation of Coverage

Yes

OPTIONAL RIDERS Extended Benefits Rider

Description Pays $25 for visits (including telemedicine) from an attending physician or psychologist while confined in a hospital.

Attending Physician Benefit Individual Coverage

Limited to 3 visits per calendar year, perpolicy.

Insured/Spouse & Family Coverage

Limited to 6 visits per calendar year, perpolicy.

Laboratory Test and X-Ray Benefit

Pays $35; limited to 2 payments per covered person, per calendaryear.

Medical Diagnostic and Imaging ExamBenefit

Pays $150 for a covered exam, limited to 2 exams per covered person, per calendar year. Benefits payable for a variety of medical diagnostic and imaging exams, including sleep studies.

Ambulance Benefit

Pays $200 (ground) or $2,000 (air) for transportation to or from a hospital.The benefit is limited to two trips, per calendaryear, per covered person.

Hospital Stay and Surgical CareRider

Description

Initial Assistance Benefit

Pays $100 once per calendar year, per rider, when a covered person requires a hospital admission.

Surgery Benefit

Pays $50 - $1,000 for a covered surgery. Limited to one payment per 24-hour period, per covered person.

Invasive Diagnostic Exams Benefit

Pays $100 for one covered exam, per coveredperson, 24-hour period.

Hospital Intensive Care Unit Confinement Benefit

Pays $500 per day, per covered person, for up to 30 days.

Daily Hospital Confinement Benefit

Pays $100 per day, per covered person, for up to 365days.

Second Surgical Opinion Benefit

Pays $50 once per covered person, per calendar year.

Age

18-49

50-59

60-75

Employee

$27.56

$28.08

$28.99

Employee & Spouse

$39.13

$41.34

$44.20

Employee & Child

$34.97

$35.62

$36.14

Family

$41.47

$41.86

$44.72

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Additional Benefits continued Critical Care Protection: Heart attack, stroke, coma, paralysis and more. You will receive a lump sum benefit upon diagnosis of a covered event plus additional benefits for other services such as ambulance, lodgingand therapy.

Benefit

Description

First-Occurrence Named Insured/Spouse Dependent Children

$7,500; lifetime maximum $7,500 per covered person $10,000; lifetime maximum $10,000 per coveredperson

Subsequent Specified Health EventBenefit

$3,500; payable once per covered person, per lifetime

Coronary AngioplastyBenefit

$1,000; payable once per covered person, per lifetime

Hospital Confinement Benefit

$300 per day; no lifetime maximum

Ambulance Benefit

$250 ground or $2,000 air; no lifetimemaximum $125 each day when a covered person is charge for any of the following treatments: • Rehabilitation therapy • Home health care • Physical therapy • Dialysis • Speech therapy • Hospice care • Occupational therapy • Extended care • Respiratory therapy • Physician visits • Dietary therapy/consultation • Nursing home care

Continuing Care

Treatment is limited to 75 days for continuing care received within 180 days following the occurrence of the most recent covered loss. No lifetime maximum.

Transportation Benefit

$.50 per mile, per covered person whom special treatment in prescribed, for a covered loss. Limited to $1,500 per occurrence; no lifetime maximum.

Lodging Benefit

Up to $75 per day, for covered lodging charges. Limited to 15 days per occurrence; no lifetime maximum.

Waiver of Premium Benefit

Premium waived, from month to month, during total inability (after 180 continuous days) Waives all monthly premiums for up to 2 months, when all conditions for this benefit are met.

Continuation of Coverage Benefit

Age

18-35

36-45

46-55

56-70

Employee

$9.36

$14.56

$20.28

$27.30

Employee & Spouse

$13.39

$22.36

$33.54

$49.14

Employee & Child

$10.40

$15.08

$20.93

$27.95

Family

$15.47

$24.70

$36.40

$52.52

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Additional Benefits continued Short Term Disability • Individual Plan • • •

Guarantee issued disability policy. No Medical QuestionnaireRequired Cash benefit for each day you aredisable Aflac does not coordinate benefits. Regardless of any other disability insurance you may have including SocialSecurity

Rates are included in this guide. For additional information, questions, to request a brochure or sign up for coverage, call Frank King IV at 816-550-0402 or at frank_kingiv@us.Aflac.com.

Annual Income Benefit Amount

$9,000

$12,000

$12,000

$16,000

$18,000

$20,000

$22,000

$24,000

$26,000

$28,000

Age

$500

$600

$700

$800

$900

$1,000

$1,100

$1,200

$1,300

$1,400

18-49

$11.05

$13.26

$15.47

$17.68

$19.89

$22.10

$24.31

$26.52

$28.73

$30.94

50-64

$13.65

$16.38

$19.11

$21.84

$24.57

$27.30

$30.03

$32.76

$35.49

$38.22

65-74

$16.25

$19.50

$22.75

$26.00

$29.25

$32.50

$35.75

$39.00

$42.25

$45.50

Supplemental Cancer Insurance provided through All American Associates Information and rates are included in this guide. For further information you may contact them toll free at 1-800-715-1702.

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Additional Benefits continued Compliance One Employee Assistance Program is Provided At No Cost to You! If you find yourself in need of some professional support to deal with personal, work, financial or family issues, your Employee Assistance Program (EAP) can help and is simply a phone call away. Please call them a 1-800-999-1196. The EAP phone lines are answered 24 hours a day, seven days a week and 365 days a year by qualified professional counselors. You and your family members may access this phone line as often as needed with no annual restrictions.

Your EAP provides up to three face-to-face visits per issue for you and each of your family members. You and your immediate family (spouse and dependent children) can use the EAP for help with:

           

Personal problems Marriage and family problems Job-related issues Harassment Stress, anxiety and depression Alcohol and drug abuse Parent and child relationships Legal and financial counseling Identity theft counseling Balancing work and family Problem gambling Various other related issues

If you need help or guidance, call a counselor with Compliance One at 1-800-999-1196. All calls and visits are strictly confidential.

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Glossary Brand Name Drugs: Drugs that have trade names and are protected by patents. Brand name drugs are generally the most costlychoice.

Coinsurance: The percentage of a coveredcharge paid by the plan.

Copayment (Copay): A flat dollar amount you pay for medical or prescription drug services regardless of the actual amount charged by your doctor or health care provider.

Deductible: The annual amount you andyour family must pay each year before the plan pays benefits.

Domestic Partner: An unrelated and unmarried person who shares common living quarters with an employee and lives in a committed, intimate relationship that is not legally defined as marriage by the state in which the partners reside. Eligible for benefits if have been in the relationship for at least six months.

Eligible Dependent: Spouse, domestic partner, children. Dependent children are eligible forcoverage until the age of 26.

Generic Drugs: Generic drugs are less expensive versions of brand name drugs that have the same intended use, dosage, effects, risks, safety and strength. The strength and purity of generic medications are strictly regulated by the FederalFood and Drug Administration.

This glossary is provided to help you betterunderstand terms that are used by your plans.

Mail Order Pharmacy: Mail order pharmacies generally provide a 90-day supply of a prescription medication for the same cost as a 60-day supply at a retail pharmacy. Plus, mail order pharmacies offerthe convenience of shipping directly to your door.

Inpatient: Services provided to an individual during an overnight hospital stay.

Outpatient: Services provided to an individual at a hospital facility without an overnight hospitalstay.

Out-of-Pocket Maximum: The maximum amount you and your family must pay for eligible expenses each plan year. Once your expenses reach the out-ofpocket maximum, the plan pays benefits at 100% of eligible expenses for the remainder of the year, except for prescriptions under all medical plans except the HSA Plan.

Preventive Benefits: Covered services that are intended to prevent disease or to identify disease while it is more easily treatable.

Primary Care Physician (PCP): Physician (generally a family practitioner, internist or pediatrician) who provides ongoing medical care. A primary care physician treats a wide variety of health-related conditions and refers patients to specialists as necessary.

Specialist: A physician who has specialized training in a particular branch of medicine (e.g., a surgeon, gastroenterologist or neurologist).

HIPPAA (Health Insurance Portability and Accountability Act of 1996): Legislation mandating specific privacy rules and practices for medical care providers and health insurance companies, designed to streamline the healthcare and insurance industries and to protect the privacy and identity of healthcare consumers. HIPAA also provides additional protections for consumers, designed to help them obtain or retain health insurance coverage in certaincircumstances.

In-Network: Use of a health care provider that participates in the planâ&#x20AC;&#x2122;s network. When you use providers in the network, you lower your out-of-pocket expenses because the plan pays a higher percentage of covered expenses.

18

Contact information is provided to help you utilize the resources shown below for questions about your benefits, network providers, claims, etc.

Contacts Plan

Provider

Phone Numbers

Website

Blue Cross Blue Shield of KS

800-432-3990

www.bcbsks.com

MedTrak

800-771-4648

www.medtrakservices.com

Dental

Delta Dental of KS

800-234-3375

www.deltadentaltalks.com

Vision

Surency Vision

866-818-8805

www.surency.com

Flexible Spending Accounts

Surency

866-818-8805

www.surency.com

Life, Long Term Disability and Retirement

KPERS

888-275-5737 Topeka 785-296-6166

kpers@kpers.org

Aflac

1-800-992-3522

frank_kingiv@us.aflac.com

Cancer

Loyal American

John Copeland and Denise Moriarty / All American 800-715-1702

Employee Assistance Program (EAP)

Compliance One

800-999-1196

N/A

Group Life Insurance

Minnesota Life InsuranceCo.

1-800-392-7295 (Ochs)

ochs@ochsinc.com email only

Tria Health

1-888-799-8742

www.triahealth.com

Telehealth

First Stop Health

888-691-7867

www.fshealth.com

More InformationAbout Your Benefits

Shawnee County

785-251-4435

HRinfo@snco.us email only

Medical Prescription Drugs (Rx)

Accident, Hospital, Critical Care and ShortTerm Disability

Pharmacy Advocate Plan

jcopeland@allamericancorp.com admin@allamericancorp.com email only

About This Guide This benefit summary provides selected highlights of the Shawnee County employee benefits program. It is not a legal document and shall not be construed as a guarantee of benefits nor of continued employment at the Company. All benefit plans are governed by master policies, contracts and plan documents. Any discrepancies between any information provided through this summary and the actual terms of such policies, contracts and plan documents shall be governed by the terms of such policies, contracts and plan documents. Shawnee County, as the plan administrator, reserves the right to amend, suspend or terminate any benefit plan, in whole or in part, at any time. The authority to make such changes rests with the Plan Administrator. You may want to refer to benefit information provided by each carrier/vendor for more information about plans, exclusions and/or any limitations that may apply.

19

WHAT IS A HEALTH CARE FLEXIBLE SPENDING ACCOUNT? SET ASIDE MONEY FOR FUTURE HEALTH CARE EXPENSES PAY LESS IN TAXES Putting money into a Health Care Flexible Spending Account (FSA) before you pay taxes on it saves you money by lowering your amount of taxable income. The result? You pay less in taxes each year.

TAKE CONTROL OF YOUR HEALTH CARE COSTS Use money in your Health Care FSA to pay for out-of-pocket medical expenses, such as eyeglasses, contacts, copays, deductibles, prescription medicines and routine exams.

The entire amount you set aside is available to use on the first day of your plan year.

INCREASE YOUR TAKE-HOME PAY Annual Income: Pre-Tax FSA Contributions: Taxable Income: Taxes (assumes 30% tax bracket): Take-Home Pay: Out-of-Pocket Health Care Expenses: Spendable Income:

Savings Each Year:

WITH FSA

WITHOUT FSA

$30,000

$30,000

$2,400

$0

$27,600

$30,000

$8,280

$9,000

$19,320

$21,000

$0

$2,400

$19,320

$18,600

$720

$0

Savings amount in the example are provided by Surency for illustrative purposes only. You may save more or less based on your own tax situation. Some states do not recognize these tax exclusions for this program. No part of this document is tax, financial or legal advice. You should consult your own legal and tax advisors regarding your personal situation and whether this is the right program for you.

When you use the Surency

You have 24/7 access to

Flex Benefits Card to pay

your account through

for qualified expenses, the

the Surency Flex

amount is deducted from

mobile app or on your

your account - no need to

Member Account at

file claims!

Surency.com.

866-818-8805 Surency Flex is administered by Surency Life & Health Insurance Company.

SURENCY © 2018 2/2018

Surency.com

ELECTION WORKSHEET HOW MUCH SHOULD I CONTRIBUTE? Use this worksheet to help estimate your annual FSA or HSA election*: Medical Expenses not Covered by Insurance

Current Year’s Next Year’s Estimated Out-of-Pocket Expenses ($) Out-of-Pocket Expenses ($)

Annual Physical/Routine Exam Copays/Coinsurance

When deciding how much to set aside for next year’s medical expenses, think about the following:

Deductibles

Does anyone in your family have any medical, dental or vision expenses that will not becovered by insurance?

Diabetic Supplies Immunizations (flu shots,etc.)

Laboratory Fees Maternity Expenses Over-the-Counter Drugs Prescription Drugs Psychiatric/Psychologist Fees Other: Dental Expenses not Covered by Insurance

Does anyone in your family need prescription eyeglasses, contact lenses and contact solutions or cleaners?

Check Ups/Cleanings

Is anyone in your family currently in orthodontics (braces) or do you expect anyone to begintreatment in the next year?

Copays/Coinsuranc e Crowns/Bridges/Dentures Deductibles Filling

Does anyone in your family have an ongoing illness that requires frequent doctor visits and/or medication?

s Oral Surgery Orthodontia (braces) Root Canals Other: Vision Expenses not Covered by Insurance Contact Lenses Contact Cleaners/Solutions Copays/Coinsurance Corrective Eye Surgery Deductibles Eye Exams Eyeglasse

*Election amount may not exceed your plan’s cap or the maximum contribution amount allowed by the IRS, whichever is less.

s Other:

Total Out-of-Pocket Expenses:

866-818-8805 Surency Flex is administered by Surency Life & Health Insurance Company.

SURENCY © 2018 2/2018

Surency.com

WHAT IS A DEPENDENT CARE FSA? SET ASIDE MONEY TO COVER CHILD CARE EXPENSES, PRE-TAX! PAY LESS IN TAXES Putting money into a Dependent Care Flexible Spending Account (DC FSA) before you pay taxes on it saves you money by lowering your amount of taxable income. The result? You pay less in taxes each year.

TAKE CONTROL OF YOUR DEPENDENT CARE COSTS Use money in your Dependent Care FSA to pay for day care, general purpose day camps or after school programs while you are at work for your dependents who are under 13 years old.

Pay for adult day care services for dependent adults who are unable to care for themselves. (Must live with you for more than half of the year.)

INCREASE YOUR TAKE-HOME PAY Annual Income: Pre-Tax Contributions: Taxable Income: Taxes (assumes 30% tax bracket): Take-Home Pay: Out-of-Pocket Dependent CareExpenses: Spendable Income:

Savings Each Year:

WITH DC FSA WITHOUT DC FSA $40,000

$40,000

$5,000

$0

$35,000

$40,000

$10,500

$12,000

$24,500

$28,000

$0

$5,000

$24,500

$23,000

$1,500

$0

Savings amount in the example are provided by Surency for illustrative purposes only. You may save more or less based on your own tax situation. Some states do not recognize these tax exclusions for this program. No part of this document is tax, financial or legal advice. You should consult your own legal and tax advisors regarding your personal situation and whether this is the right program for you.

We make it easy for you to get reimbursed!

You have 24/7 access to

Use the Surency Flex mobile app to file claimsand

your account through

take pictures of your receipts, or complete one

the Surency Flex

form for the entire year if your dependent care

mobile app or on your

expenses are for the same amount, from the same

Member Account at

provider, and for the same length of time. Go to

Surency.com.

Surency.com to download the Dependent Care Reimbursement Form.

Refer to the back of this page for plan rules and regulations.

Surency Flex is administered by Surency Life & Health Insurance Company.

SURENCY Š 2018 2/2018

DEPENDENT CARE FSA PLAN RULES & REGULATIONS SET ASIDE MONEY TO COVER CHILD CARE EXPENSES, PRE-TAX! RULES & REGULATIONS A Dependent Care FSA can help you save money. If both you and your spouse work, or you are a single parent, a Dependent Care FSA may be right for you. However, if you have a stay-at-home spouse, you should not enroll in a Dependent Care FSA.

MAXIMUM CONTRIBUTION $5,000 for married couples filing joint federal taxes or single persons filing as head of household. $2,500 for married couples filing separate federaltaxes.

If you are single or a married couple filing separately and your earned income is less than $5,000, then you may not contribute more than your earned income.

ELIGIBLE EXPENSES Use the funds in your Dependent Care FSA to pay for qualified child care expenses for dependents under the age of 13. Some examples include day care and general purpose day camps.

You may also use the funds for adult day care services if you have an older dependent who lives with you at least 8 hours each day and requires daily care services. Adult day care services are qualified expenses if you work and your spouse is working, looking for work, is a full-time student, or is physically or mentally incapable of self-care.

Dependent care services must have been “incurred”, or fully provided and completed, for the service period before you can be reimbursed for your dependent care expenses. This is important to remember because most providers require prepayment of dependent care services at the beginning of the service period before they provide dependent care services. In order to follow IRS requirements, you may only be reimbursed at the end of the service period even if you prepaid the provider for dependent care services.

Ineligible expenses include, but are not limited to, overnight camps, care provided by your dependent, spouse or child under the age of 19, and care provided while you are not at work.

In order for your child care expenses to qualify, you must maintain the residence that you live in for more than half of the year with the qualified child or dependent.

TAX CREDITS Before you enroll, you should evaluate the tax advantages, as well as the impact on your tax liability and your ability to take advantage of the Dependent Care Tax Credit.

866-818-8805 Surency Flex is administered by Surency Life & Health Insurance Company.

SURENCY © 2018 2/2018

Surency.com

ACCESSING YOUR ACCOUNT FUNDS USING YOUR SURENCY FLEX ACCOUNT HAS NEVER BEEN EASIER Your Surency Flex Benefits Card is a special-purpose Visa® Card that gives you an easy, automatic way to pay for eligible expenses. The Benefits Card lets you electronically access the pre-tax amounts set aside in your Surency Flex accounts. Use it when paying for eligible expenses at a provider or merchant that accepts Visa Cards and uses an inventory control system. These transactions may be automatically substantiated, meaning you don’t have to file a claim and may not have to submit a receipt. However, always keep all documentation for tax purposes or in case Surency requests further documentation.

HOW TO USE YOUR BENEFITSCARD 1. Have the cashier ring up all of your items together.

2. When it’s time to pay, swipe your Surency Flex Benefits Card first. Select ‘credit’ and sign for your purchase. Optional: In addition to your signature, you can set up a PIN number to access your funds by calling 866-898-9795. If you have a PIN number, select ‘debit’ and enter your PIN. 3. All eligible expenses will be paid for from your account and deducted from your total.

4. If you are purchasing non-eligible items, you will need to have a second form of payment available for those items.

5. Keep your receipts in the event that further validation is needed.

DID YOU PAY OUT-OF-POCKET FOR AN ELIGIBLEEXPENSE? Submit a claim to get paid back using money from your accout. There are three ways to submit a claim: 1. SURENCY FLEX APP 3. PAPER CLAIM FORM 2. MEMBER ACCOUNT AT SURENCY.COM Download the Surency Flex Visit Surency.com to download Log into your Member Account mobile app and submit the claim a paper claim form. Complete at Surency.com to upload your by taking a photo of your receipt. and return to Surency. receipt.

WANT TO GET PAID BACK AUTOMATICALLY? Sign up for Direct Deposit and after you submit a claim, Surency will automatically deposit those dollars back into your bank account. There are two ways to set up Direct Deposit: 1. MEMBER ACCOUNT AT SURENCY.COM Log into your Member Account at Surency.com to input bank information.

866-818-8805 Surency Flex is administered by Surency Life & Health Insurance Company.

SURENCY © 2018 2/2018

2. PAPER DIRECT DEPOSIT FORM Visit Surency.com to download a Direct Deposit form. Complete and return to Surency.

Surency.com

BENEFITS OF THE SURENCY FLEX MEMBER ACCOUNT MANAGE YOUR BENEFITS ONLINE AT SURENCY.COM ACCESS THE INFORMATION YOU NEED: Check balances on your Health Care Flexible Spending Account (FSA), Dependent Care Flexible Spending Account (DC FSA), Health Reimbursement Arrangement (HRA), Health Savings Account (HSA) and Commuter Benefit account.

View account activity, payment history and tax statements.

Access FSAStore.com to purchase eligible items like contact lenses, first

aid kits, sunscreen and more. Use your Surency Flex Benefits Card to pay.

Access forms.

TAKE ACTION: Submit claims for Health Care FSAs, Dependent Care FSAs, HRAs and Commuter Benefit expenses.

Add a dependent or spouse.

Add or update a bank account to receive direct deposit reimbursements.

Request HSA distributions, make HSA contributions and set HSA investment sweeps.

Access account funds to pay yourself back or to pay your doctor.

Report a Surency Flex Benefits Card as lost or stolen.

You can also manage your benefits through the Surency Flex mobile app.

Easily access your account from anywhere, and snap photos of your receipts to submit with new or existing claims. Go to Surency.com to learn more.

866-818-8805 Surency Flex is administered by Surency Life & Health Insurance Company.

SURENCY © 2018 4/2018

Surency.com

ELIGIBLE MEDICAL EXPENSES WHAT CAN ISPEND MY DOLLARS ON? Use money set aside in your account for eligible medical expenses incurred by you, your spouse or your children.

Remember to keep your receipts in case it is needed to verify the medical expense. Use the lists below for reference, but keep in mind these lists do not include all eligible/ineligible expenses.

Visit FSAStore.com/Surency to access the largest selection of FSA-eligible expenses online and use your Surency Flex Benefits Card to purchaseitems!

Questions? Call 866-818-8805 or visit Surency.com to view a complete list of eligible expenses.

ELIGIBLE EXPENSES Adult Diapers Ambulance Athletic Care (ACE Bandages, Braces, etc.)

Blood Pressure Monitors Catheters Cholesterol Testing Chiropractic Manipulations Contact Lenses, Solutions & Cleaners Contraceptives Corn & Callus Treatments (Foot Care)* Crutches

Dental Treatment Denture Adhesives & Repair Denture Pain Relief & Cleansers Diabetes Testing, Diabetes Supplies Doctor’s Office Visits Eyeglasses (Prescription & Reading) First Aid Supplies* Glucosamine and/or Chondroitin Hearing Aids (& Batteries) Hospital Services Hot/Cold Therapy Packs

Immunizations Infertility Treatments Insulin Nasal Sprays, Drops & Inhalers* Oral Treatments (Orajel, Mouth Sore Treatment, etc.)* Orthodontia Orthopedic Supports Ovulation Kits Pap Smears Physical Therapy Prescription Drugs Prenatal Care (Vitamins)

Psychiatric/Psychologist Care Smoking Deterrents (Nicorette, etc.)

Special Education Costs* Splints & Casts Thermometers Therapeutic Shoe Insoles* Transplants Vision Exams Wart Removers* Wheel Chairs X-ray Fees *requires a letter of necessity or valid prescription

ELIGIBLE EXPENSES THAT REQUIRE A PRESCRIPTION These over-the-counter medications require a doctor’s prescription to be purchased with account dollars.

Acid Controllers Allergy & Sinus Medications Antibiotic Products (Neosporin, etc.)

Anti-Gas Treatments Anti-Itch & Insect Bite Treatments Baby Rash Ointments/Creams Cold Sore Remedies

Cough, Cold & Flu Medications Digestive Aids Feminine Anti-Fungal & Anti-Itch Hemorrhoidal Preparations Laxatives Motion Sickness Treatments Pain Relievers (Aspirin, Tylenol, Advil)

Respiratory Treatments & Vapor Products Rogain Sleep Aids & Sedatives Stomach Remedies (Mylanta, Tums, etc.)

INELIGIBLE EXPENSES Burial Expenses Cosmetic Procedures Dance Lessons Diapers Exercise Equipment (unless prescribed) Facelifts Fitness Programs

Funeral Expenses Health Club Fees Household Help Illegal Treatments Insurance Premiums Items Covered by Insurance Marriage Counseling Maternity Clothes

866-818-8805 Surency Flex is administered by Surency Life & Health Insurance Company.

SURENCY © 2018 3/2018

Nutritional Supplements Vitamins (Over-the-Counter) Piercings Vacations Sunglasses (non-prescription) Warranties (for Eyeglasses or Swimming Lessons Hearing Aids) Tanning Weight Loss Programs Teeth Whitening or Bleaching (unless prescribed) Toiletries (Toothbrush, Toothpaste, etc.)

Surency.com

BENEFITS OF THE SURENCY FLEX MOBILE APP ACCESS YOUR ACCOUNT FROM ANYWHERE ACCESS THE INFORMATION YOU NEED: Check your Health Care Flexible Spending Account (FSA), Dependent Care Flexible Spending Account (DC FSA), Health Reimbursement Arrangement (HRA), Health Savings Account (HSA) and Commuter Benefit balances.

View account activity.

Access FSAStore.com to purchase eligible items like contact lenses, first aid kits, sunscreen and more. Use your Surency Flex Benefits Card to pay.

TAKE ACTION: Submit claims for Health Care FSAs, Dependent Care FSAs, HRAs and Commuter Benefit expenses.

Snap a photo of receipts within the app to submit with new or existing claims.

Request HSA distributions and make HSA contributions.

Access account funds to pay yourself back or to pay your doctor.

Report a Surency Flex Benefits Card as lost or stolen.

NEED HELP LOGGING IN? Contact us for any questions you may have when logging in for the first time.

Give us a call at 866-818-8805 or email Customer Service at flex@surency.com.

866-818-8805 Surency Flex is administered by Surency Life & Health Insurance Company.

SURENCY © 2018 2/2018

Surency.com

Required Notices For 2020 Open Enrollment Index to Notices Medicare Part D Creditable Coverage Notice Special Enrollment Rights Notice Women’s Health and Cancer Rights Annual Notice Notice of Availability of Privacy Practices Children’s Health Insurance Program Information

Page 1-3 Page 4 Page 5 Page 5 Page 6

Important Notice from Shawnee County About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Shawnee County 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. Shawnee County has determined that the prescription drug coverage offered by the Shawnee County Health Plan 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.

1

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.

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.

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 the Shawnee County coverage will not be affected. You can retain your existing coverage under the Shawnee County Group Health Plan and choose not to enroll in Part D plan; or you can enroll in Part D plan as a supplement to, or in lieu of, the other coverage.

If your existing prescription drug coverage is under a Medigap policy, you cannot have both your existing prescription drug coverage and Part D coverage. If you enroll in Part D coverage, you should inform your Medigap insurer of that fact, and the Medigap insurer must remove the prescription drug coverage from the Medigap policy and adjust the premium as of the date the Part D coverage starts.

If you do decide to join a Medicare drug plan and drop your current The Shawnee County coverage, be aware that you and your dependents will not be able to get this coverage back.

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 [Insert Name of Entity] and donâ&#x20AC;&#x2122;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.

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 2

to wait until the following October to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage…

Contact the person listed below for further information or call Medtrak Services at 800-7714648. NOTE: You’ll 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 through Shawnee County changes. You also may request a copy of this notice at any time. For more Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage: Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Date: Name of Entity/Sender: Contact--Position/Office: Address: Phone Number:

October 14, 2019 Shawnee County Angela Lewis, Director of Human Resources 200 SE 7th, Room B-28, Topeka KS 66603 785-25-4440

3

Sample HIPAA Special Enrollment Notice 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 or your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards 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 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 [insert “60 days” or any longer period that applies under the plan] 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.

Note: The 60-day for requesting enrollment applies only in these last two listed circumstances relating to Medicaid and state CHIP. As described above, a 30-day period applies to most special enrollments.

As stated earlier in this notice, a special enrollment opportunity may be available in the future if you or your dependents lose other coverage. This special enrollment opportunity will not be available when other coverage ends, however, unless you provide a written statement now explaining the reason that you are declining coverage for yourself or your dependent(s). Failing to accurately complete and return this form for each person for whom you are declining coverage may eliminate this special enrollment opportunity for the person(s) for whom a statement is not completed, even if other coverage is currently in effect and is later lost. In addition, unless you indicate in the statement that you are declining coverage because other coverage is in effect, you may not have this special enrollment opportunity for the person(s) covered by the statement. (See the paragraphs above, however, regarding enrollment in the event of marriage, birth, adoption, placement for adoption, loss of eligibility for Medicaid or a state CHIP, and gaining eligibility for a state premium assistance subsidy through Medicaid or a state CHIP.) To request special enrollment or obtain more information, contact Human Resources at 785251-4435 or by email at HRinfo@snco.us.

4

Women’s Health and Cancer Rights Act Notice Did you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy (including lymphedema)? Call your Blue Cross Blue Shield of Kansas at the telephone number on your health plan ID care for more information. Plan Administrator [insert phone number] for more information.

Our Plan complies with these requirements. Benefits for these items generally are comparable to those provided under our Plan for similar types of medical services and supplies. Of course, the extent to which any of these items is appropriate following mastectomy is a matter to be determined by consultation between the attending physician and the patient. Our Plan neither imposes penalties (for example, reducing or limiting reimbursements) nor provides incentives to induce attending providers to provide care inconsistent with these requirements.

Notice of Availability Shawnee County Notice of Privacy Practices THIS NOTICE DESCRIBES HOW YOU MAY OBTAIN A COPY OF THE PLAN’S NOTICE OF PRIVACY PRACTICES, WHICH DESCRIBES THE WAYS THAT THE PLAN USES AND DISCLOSES YOUR PROTECTED HEALTH INFORMATION.

Shawnee County (the “Plan”) provides health benefits to eligible employees of Shawnee County (the “Company”) and their eligible dependents as described in the summary plan description(s) for the Plan. The Plan creates, receives, uses, maintains and discloses health information about participating employees and dependents in the course of providing these health benefits. The Plan is required by law to provide notice to participants of the Plan’s duties and privacy practices with respect to covered individuals’ protected health information and has done so by providing to Plan participants a Notice of Privacy Practices, which describes the ways that the Plan uses and discloses protected health information. To receive a copy of the Plan’s Notice of Privacy Practices you should contact Angela Lewis who has been designated as the Plan’s contact person for all issues regarding the Plan’s privacy practices and covered individuals’ privacy rights. You can reach this contact person at HRinfo@snco.us or at 785-251-4435.

5

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed 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 July 31, 2019. 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

FLORIDA – Medicaid Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268

GEORGIA – Medicaid Website: https://medicaid.georgia.gov/healthinsurance-premium-payment-program-hipp Phone: 678-564-1162 ext 2131

INDIANA – Medicaid 6

Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

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

KANSAS – Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512

KENTUCKY – Medicaid Website: https://chfs.ky.gov Phone: 1-800-635-2570

LOUISIANA – Medicaid Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

MAINE – Medicaid Website: http://www.maine.gov/dhhs/ofi/publicassistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711

MASSACHUSETTS – Medicaid and CHIP

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: http://www.indianamedicaid.com Phone 1-800-403-0864

IOWA – Medicaid Website: http://dhs.iowa.gov/Hawki Phone: 1-800-257-8563

NEW HAMPSHIRE – Medicaid Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-8523345, 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 7

Website: http://www.mass.gov/eohhs/gov/departments/masshealth / Phone: 1-800-862-4840

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid / Phone: 1-844-854-4825

MINNESOTA – Medicaid

OKLAHOMA – Medicaid and CHIP

Website: https://mn.gov/dhs/people-we-serve/seniors/healthcare/health-care-programs/programs-and-services/otherinsurance.jsp Phone: 1-800-657-3739

MISSOURI – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

MONTANA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

NEBRASKA – Medicaid Website: http://www.ACCESSNebraska.ne.gov Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-1178

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

OREGON – Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

PENNSYLVANIA – Medicaid Website: http://www.dhs.pa.gov/provider/medicalassistance/he althinsurancepremiumpaymenthippprogram/index.ht m Phone: 1-800-692-7462

RHODE ISLAND – Medicaid and CHIP Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347, or 401-462-0311 (Direct RIte Share Line)

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NEVADA – Medicaid Medicaid Website: https://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900

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

SOUTH CAROLINA – Medicaid Website: https://www.scdhhs.gov Phone: 1-888-549-0820

WASHINGTON – Medicaid Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022 ext. 15473

WEST VIRGINIA – Medicaid Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

WISCONSIN – Medicaid and CHIP Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.p df Phone: 1-800-362-3002

WYOMING – Medicaid Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531

VIRGINIA – Medicaid and CHIP Medicaid Website: http://www.coverva.org/programs_premium_assistance. cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance. cfm CHIP Phone: 1-855-242-8282

To see if any other states have added a premium assistance program since July 31, 2019, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)

U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565

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