2019 benefit options

Transcription

1 2019 benefit options

2 e n r o l l m e n t & e l i g i b i l i t y important dates open enrollment March 4 15, 2019 effective date April 1, 2019 plan year Apr 1, 2019 Dec 31, 2019 t i p Mark these dates on your calendar now so you don t forget! Schedule a time to review your current plan and identify what changes you d like to make. eligibility Full-time employees that work 30+ hours/week are eligible to participate in our Medical plan provided by Medica. Full-time employees that work 32+ hours/week are eligible to participate in our Dental plan provided by The Standard. Full-time employees that work 32+ hours/week are eligible to participate in our Vision plan provided by The Standard. 2

3 e n r o l l m e n t & e l i g i b i l i t y qualifying life events The choices you make during your New Hire period or Annual Open Enrollment period are irrevocable until either the next Annual Open Enrollment period or unless you experience a qualifying life event. Qualifying life events include changes to your legal marital status, giving birth or adopting a child, a change in you or your spouse s employment status or your entitlement to Medicare. If you anticipate any of these changes, please see Human Resources in advance of the event to verify your right to change plan coverage(s). You must elect your change in benefits within 30 days of the qualified life event. If you do not notify Human Resources within 30 days of a qualifying event, you will have to wait until the next annual open enrollment period to make benefit changes unless you have another qualifying event. 3

4 e n r o l l m e n t & e l i g i b i l i t y how to enroll Go to If you have trouble enrolling, contact the Benefits Call Center* at or Human Resources. Click on green ENROLL ONLINE button Click on red CLICK HERE TO LOGIN Enter Employee Number: 9 digit SSN PIN: last 4 SSN + last 2 birth year Click Login *The Benefits Call Center does have Spanish speaking enrollers available. You will be transferred to one upon your request. 4

5 b e n e f i t o v e r v i e w 2019 benefits Below is a comprehensive list of all benefits offered this year and each benefit provider. Benefit Carrier Medical Pharmacy Dental Vision Short Term Disability (6-months) Short Term Disability (12-months) Voluntary Life with AD&D Insurance Medica Medica The Standard The Standard Allstate Allstate The Standard Flexible Spending Account (FSA) Health Care Dependent Care Limited Use Medica Health Savings Account (HSA) Worksite Benefit Insurance Medica Allstate 5

6 b e n e f i t o v e r v i e w contact information Please refer to this list when you need to contact one of your benefit vendors. For general information contact Human Resources. Plan Insurance Carrier Phone Number Medical Medica Pharmacy Medica Dental The Standard Vision The Standard Short Term Disability (6-month) Short Term Disability (12-month) Voluntary Life with AD&D Insurance Flexible Spending Accounts (FSA/LPFSA/DCFSA) Health Savings Account (HSA) Allstate Allstate The Standard Website or or ndividual/insurance ndividual/insurance ndividual/insurance Medica Medica Worksite Benefit Insurance Allstate

7 m e d i c a l medical plans Employee well-being is a top priority at NHS. Through Medica, we re proud to offer you access to an extensive network of providers. You and your family will be able to maintain your well-being with preventive care and affordable prescription medication. Choosing the right medical plan is an important decision for you and your family. Take the time to review your family s past medical expenses and what expenses you are likely to incur during the upcoming plan year. Use this information to determine what kind of coverage is best for you and your family. t i p Look over your family s previous medical expenses to determine which plan will be best for you. Per Month Deductions Medica Choice Passport % HSA Medica Choice Passport % HSA Employee $ $ Employee + Spouse $1, $1, Employee + Child(ren) $ $ Family $1, $1,

8 m e d i c a l staying in-network If you choose to see an out-of-network provider or pharmacy, you will still be able to use insurance, however, your costs will be substantially higher and your deductible and out-of-pocket maximums will be higher. Your medical network is made up of: convenience care (quick) clinics physicians facilities (urgent care, emergency room) nurse practitioners specialists pharmacies t i p When possible, choose urgent care facilities over the emergency room to save time and money. When you see an in-network provider, you will: Have lower health care costs for medical services and prescription drugs. Not need to obtain pre-authorization before a procedure such as surgery, your innetwork provider will handle this on your behalf. Not have to worry about paying for balance-billed charges and charges above the usual, reasonable, and customary. Not have to fill out forms to send to the insurance carrier in order to receive reimbursement, your in-network provider will handle this on your behalf. How to find an in-network provider Visit Medica website at or Call Check the Medica mobile app 8

9 m e d i c a l benefit summary Medica Choice Passport % HSA Calendar Year Deductible - Individual - Family Out-of-Pocket Max - Individual - Family Coinsurance - Preventive Care - Primary Care (injury or illness) - Specialist Prescription Drug Coinsurance - Generic Drugs / Preventive - Preferred Brand Drugs / Preventive - Non-preferred Brand Drugs - Specialty Drugs Preferred / Non-Preferred Medica Choice Passport % HSA Calendar Year Deductible - Individual - Family Out-of-Pocket Max - Individual - Family Coinsurance - Preventive Care - Primary Care (injury or illness) - Specialist Prescription Drug Coinsurance - Generic Drugs / Preventive - Preferred Brand Drugs / Preventive - Non-preferred Brand Drugs - Specialty Drugs Preferred / Non-Preferred In Network $3,000 $6,000 $6,500 $13,000 No Charge 20% 20% 20% / No Charge 20% / No Charge 40% 20% / 40% In Network $6,350 $12,700 $6,350 $12,700 No Charge 0% 0% 0% / No Charge 0% / No Charge 0% 0% Out-of-Network $6,000 $12,000 $26,000 $52,000 50% 50% 50% 50% 50% 50% Not Covered Out-of-Network $12,700 $25,400 $25,400 $50,800 50% 50% 50% 50% 50% 50% Not Covered 9

10 d e n t a l dental insurance A confident smile starts with oral health. The dental plans offered to you by NHS through The Standard make it easy for your and your family to take care of your smiles. As with all other coverage, it s important to stay in-network. Before each appointment, verify your dentist is still in The Standard s network and be sure to present your ID Card to your dentist each visit. If your dentist recommends services other than a preventive cleaning, ensure you ask for and receive a pre-treatment estimate before the work is performed. This will avoid any misunderstanding of The Standard benefit payment amounts. t i p Be aware of your deductible and calendar year maximum if you have services performed and when these start over. Per Month Deductions Employee $9.22 Employee + Spouse $37.42 Employee + Child(ren) $52.57 Family $

11 d e n t a l benefit summary The Standard % Paid by Carrier Coverage Allowance Deductible Type 1 100% Type 2 80% Type 3* 50% Annual Maximum Routine Exams (2 in 12 months) Bitewing X-rays (1 in 12 months) Full Mouth/Panoramic X-rays (1 in 5 years) Periapical X-rays Cleaning (2 in 12 months) Sealants (age 13 and under) Space Maintainers Fluoride (age 13 and under, 2 in 12 months) Restorative Amalgams Restorative Composites Endodontics (surgical/nonsurgical) Periodontics (surgical/nonsurgical) Simple/Complex Extractions Anesthesia Onlays Crowns (1 in 5 years per tooth) Crown Repair Denture Repair Implants Prosthodontics (1 in 5 years) 90 th Usual and Customary** Waived for Type 1; Type 2 & 3: $50 ($150 per Family) per calendar year $1,000 per person per calendar year *12 month waiting period on Type 3 dental services for all new enrollees effective 4/1/2019. **Usual and Customary (U&C) describes dental charges that have been determined to be the usual and customary charge for a given dental procedure within a particular ZIP code. U&C amounts are reviewed and updated on an annual basis. About The Standard As a leading provider of employee benefits products and services, Standard Insurance Company is dedicated to meeting the unique insurance needs of each customer. More than 26,167 groups trust The Standard for group insurance products and services, and the company covers nearly 7 million employees. Founded in Portland, Oregon, in 1906, The Standard has built a national reputation for delivering quality insurance products, personalized service and strong financial performance. The Standard wrote its first group insurance policy in 1951, and it remains in force today as a testament to the company's commitment to building successful long-term relationships. 11

12 d e n t a l Customer Service Your local Standard Insurance Company Employee Benefits Sales and Service Office will provide most of the ongoing service for your plan and can be reached at during normal business hours. We will assign your company a service representative who will provide regular contact and address questions and concerns related to the plan or the services we provide. We also make it easy for covered employees and dentists to contact us to confirm eligibility or request claims information by calling Our customer service representatives are available Monday through Thursday from 5:00 a.m. until 10:00 p.m. Pacific Time and until 4:30 p.m. Pacific Time on Friday. For plan information any time, access our automated voice response system or go online to standard.com. Type 3 Waiting Period - new enrollees only The group of initial employees who enroll in this plan have no waiting period for Type 3 benefits. Anyone hired after the initial plan enrollment will have a 12-month waiting period, after they enroll in this dental plan, before they are eligible to receive Type 3 benefits. Dental Network Information Employees and dependents have access to an extensive nationwide network of member dentists. The cost-saving benefits of visiting a network member dentist are automatically available to all employees and dependents who are covered by any of The Standard's dental plans and who live in areas where the nationwide network is available. To find member dentists in your area, visit: and click on "Find a Dentist." Pretreatment While we don't require a pretreatment authorization form for any procedure, we recommend them for any dental work you consider expensive. As a smart consumer, it's best for you to know your share of the cost up front. Simply ask your dentist to submit the information for a pretreatment estimate to our customer relations department. We'll inform both you and your dentist of the exact amount your insurance will cover and the amount that you will be responsible for. That way, there won't be any surprises once the work has been completed. Open Enrollment If a member does not elect to participate when initially eligible, the member may elect to participate at the policyholder's next enrollment period. This enrollment period will be held each year and those who elect to participate in this policy at that time will have their insurance become effective on April 1. Late Entrant Provision We strongly encourage you to sign up for coverage when you are initially eligible. If you choose not to sign up during this initial enrollment period, you will become a late entrant. Late entrants will be eligible for only exams, cleanings, and fluoride applications for the first 12 months they are covered. Section 125 This plan is provided as part of the Policyholder's Section 125 Plan. Each employee has the option under the Section 125 Plan of participating or not participating in this plan. If an employee does not elect to participate when initially eligible, he/she may elect to participate at the Policyholder's next Annual Election Period. This form is a benefit highlight, not a certificate of insurance. This policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or terminated. Please contact The Standard [or your employer] for additional information, including costs and complete details of coverage. 12

13 v i s i o n vision insurance Eyesight is critical to your overall health. Did you know that a regular eye exam can detect highcholesterol or even a brain-tumor? NHS offers you vision insurance through The Standard. You can elect which ever plan is best for you and your family. Annual preventive eye exams are covered under each plan. Make sure to stay in network. When you schedule your appointment, verify your provider is in The Standard s network. If you have a contact lens exam, this is not covered at 100% and you are responsible for this additional cost. t i p Make sure you provider codes your eye exam as preventive so it is covered at 100%. Per Month Deductions Employee $5.43 Family $

14 v i s i o n benefit summary Vision Service Plan (VSP) Through The Standard Eye Exam Once Every 12 Months $10 Copay Prescription Glasses Frame Allowance Once Every 24 Months Lenses Once Every 12 Months Lens Enhancements Once Every 12 Months $0 Copay Up to $150 allowance VSP offers 20% off any amount above the retail allowance The Costco allowance will be the wholesale equivalent Single vision, lined bifocal, lined trifocal, lenticular lenses are covered in full Standard polycarbonate for dependent children are covered in full Standard progressive lenses : Up to provider contracted fee for lined bifocal Standard polycarbonate for adults: $33 Copay Solid Plastic Dye: $15 Copay (except pink I & II) Photochromatic Lenses: $31-$82 Copay Scratch Resistant Coating: $17-$33 Copay Anti-Reflective Coating: $43-$85 Copay Ultraviolet Coating: $16 Copay Contact Lenses Once Every 12 Months In lieu of frame and spectacle lenses Up to a $60 Copay ; Fitting and evaluation Elective: Up to $150 allowance Medically Necessary: Covered in full Laser Vision Correction Glasses & Sunglasses VSP offers an average discount of 15% off or 5% off a promotional offer for LASIK Custom LASIK and PRK. The maximum out-of-pocket per eye for participants is $1,800 for LASIK and $2,300 for custom LASIK using Wavefront technology, and $1,500 for PRK. In order to receive the benefit, a VSP provider must coordinate the procedure. 20% saving on additional glasses, sunglasses ; enhancements At your appointment, tell them you have VSP. There s no ID card necessary. VSP Call Center: Service representative hours: 5 a.m. to 7 p.m. PST Monday through Friday, 6 a.m. to 2:30 p.m. PST Saturday Interactive Voice Response available 24/7 14

15 h e a l t h s a v i n g s a c c o u n t hsa A Health Savings Account, or HSA, allows you to set aside money on a pretax basis to pay for qualified expenses, such as doctor visits, prescriptions, braces, or even Lasik eye surgery, with tax-free dollars. Our HSA Administrator is Medica ONESource. There is no use it or lose it rule with HSAs. Any remaining balance at the end of the year will roll over into the next plan year. HSAs are also portable. This means that if you were to change jobs or health plans, the money in your account stays with you. One of the best parts of the HSA is its triple-tax advantage: tax-free deductions when you contribute to your account, tax-free investment earnings, and tax-free withdrawals for qualified medical expenses. You will receive a card linked to your account to pay for qualified expenses. You may be penalized or taxed if you use your HSA funds to pay for ineligible expenses. Qualified expenses include prescriptions, contact lens fitting, orthodontia, acupuncture, artificial teeth, eye glasses, or other expenses that apply towards your deductible. A full list of qualified expenses can be found on the IRS website. ELIGIBILITY You are enrolled in NHS s High Deductible Health Plan (HDHP); You are not covered under another medical plan such as Medicare, Tricare or a spouse s medical plan (not an HDHP) which provides similar coverage; and You cannot be claimed as a dependent on another person s insurance policy or tax return IRS CALENDAR YEAR CONTRIBUTION LIMITS t i p Keep all receipts from HSA expenses and associated documentation to prove HSA funds were used for qualified medical expenses. Individual Family Age 55+ Catch Up NHS Contributions $3,500 $7,000 $1,000 NHS matches $1 for $1 up to $55/month 15

16 f l e x i b l e s p e n d i n g a c c o u n t fsa* A Flexible Spending Account, or FSA, is an account set-up by your employer that allows you to pay for medical and dependent care expenses on a pre-tax basis. Pretax means before federal, state, and social security taxes are deducted from your paycheck. Refer to the IRS website for a full list of qualified and unqualified expenses. Our FSA Administrator is Medica ONESource. HEALTH CARE FSA Access to entire amount of money you set aside for the plan year on the first day of the plan Use it or lose it Forfeit any money remaining in the account at the end of the plan year You will receive a debit card that can be used at your doctor s office or pharmacy for qualified expenses LIMITED PURPOSE FSA t i p Budget wisely. FSA accounts have a use it or lose it rule. Any money leftover in the account at the end of the plan year must be forfeited. For dental and vision expenses only Available if you have an HSA DEPENDENT CARE FSA Use pre-tax income for dependent care for children up to age 14 who are being cared for while you or your spouse are working or seeking employment Eligible dependents could also include a spouse or other IRS dependent who is mentally or physically disabled Qualified expenses include daycare and at-home care services. ELIGIBILITY Do not need to participate in medical, dental, or vision plans sponsored by NHS. *Contact Human Resources to complete election form, if eligible due to new hire status or qualifying life event IRS CALENDAR YEAR CONTRIBUTION LIMITS Health Care Dependent Care Limited Purpose $2,700 Married, filing separately $2,500 All other filing statuses $5,000 $2,700 16

17 s u r v i v o r b e n e f i t s life and accidental death & dismemberment coverage When the unthinkable happens, you want to know your family is covered. NHS provides full-time employees the opportunity to purchase life and accidental death and dismemberment (AD&D) insurance through The Standard. VOLUNTARY LIFE INSURANCE Employee: Voluntary life insurance is available to you. You can elect increments of $10,000 up to a max of $300,000. There is a guaranteed issue amount of $150,000 if you are a new enrollee or if this is a special enrollment period Spouse: Voluntary life insurance is available to you. You can elect increments of $5,000 up to a max of $150,000, but cannot exceed the employee amount. There is a guaranteed issue amount of $25,000. Children: Voluntary life insurance is available to you. You can elect increments of $2,000 up to a max of $10,000. t i p Make sure your beneficiary is clearly identified on all survivor benefit insurance documents. ACCIDENTAL DEATH & DISMEMBERMENT If you pass away as the direct result of an accident, your beneficiary will receive both the life and AD&D portion of the benefit. If you suffer a covered accidental injury such as loss of speech and hearing, quadriplegia, paraplegia, loss of limb, or thumb and index finger, you would be the beneficiary of a benefit (based on the type of loss). 17

18 s u r v i v o r b e n e f i t s life and accidental death & dismemberment rates Age Reduction Schedule Reduces to 65% at age 65 Reduces to 50% at age 70 Reduces to 35% at age 75 Employee Monthly Rate for Each $10,000 of Voluntary Life and AD&D Insurance Coverage Age < Rate/ Month $.70 $.80 $1.10 $1.80 $2.80 $4.80 $7.60 $10.30 $12.09 $20.50 $33.25 If you elect AD&D insurance with your life insurance, your monthly AD&D rate is $.02 per $1,000 of AD&D benefit added to the above rates. Base on Employee age. Spouse Monthly Rate for Each $5,000 of Voluntary Life and AD&D Insurance Coverage Age < Rate/ Month $.35 $.40 $.55 $.90 $1.40 $2.40 $3.80 $5.15 $6.05 $10.25 $16.63 If you elect AD&D insurance for your spouse, your spouse s monthly AD&D rate is $.02 per $1,000 of AD&D benefit added to the above rates. Based on spouse age. Child Coverage Life $2,000 $4,000 $6,000 $8,000 $10,000 $.36/month $.72/month $1.08/month $1.44/month $1.80/month Child Coverage AD&D $2,000 $4,000 $6,000 $8,000 $10,000 $.04/month $.08/month $.12/month $.16/month $.20/month 18

19 i n c o m e p r o t e c t i o n disability NHS provides full-time employees with two short-term disability income benefit options. Both STD coverages are provided through Allstate. In the event you become disabled from a non-work related injury or sickness, disability income benefits are provided as a source of income. You are not eligible to receive short-term disability benefits if you are receiving workers compensation benefits. SHORT TERM DISABILITY Short Term Disability provides you with a specified percentage of your pre-disability income. NHS has two options for Short Term Disability, 6-months or 12-months. Conditions that can trigger Short Term Disability are usually temporary in nature, such as pregnancy, broken bones, sprains, or minor surgery. The coverage can begin on the first day, or can have a short waiting period such as 7 or 14 days. Most people use accumulated sick time to cover the waiting period. Elimination Period Accident Elimination Period Sickness Duration of Benefit 7 days 7 days Short-term Disability (6-months) Maximum benefit period is 6 months Short-term Disability (12-months) 14 days 14 days Maximum benefit period is 12 months Monthly Benefit $5,000* $5,000* * The following process is used to calculate your monthly benefit: (1) Multiply monthly earnings by 60%. (2) Subtract deductible sources of income from 1. (3) Determine the lesser of item 2 and the maximum monthly benefit amount issued to you. (4) pay the greater of item 3 or $

20 a d d i t i o n a l b e n e f i t s additional voluntary benefits Voluntary Benefits are designed to fill the gaps that are left by traditional benefit packages. Voluntary benefits are designed to work with whatever benefits you already have in place. They work together with your employer-sponsored benefits to provide a financial safety net for you and your family. Voluntary insurance is not major medical insurance. It is different because it is portable, and pays cash directly to you. Even though they are payroll deducted, you own these policies. Because they re portable, you can take them with you if you change jobs or move. How does it work? Major medical insurance pays the doctors and hospitals. Voluntary insurance is different. It pays cash to you, regardless of what your major medical has paid. You can use the money as you see fit. When you or a family member is sick or injured, the bills start to pile up and can be overwhelming. The cash you receive may be used however you need it to pay everything from copays and deductibles, to living expenses like mortgage, rent, or car payments. It s totally up to you. 20

21 a d d i t i o n a l b e n e f i t s critical illness Critical Illness insurance pays a benefit upon the diagnosis and/or treatment of a named critical illness or certain category of major surgery. Plan options let you choose the amount of coverage you need. The reasoning behind a critical illness policy is that someone with employer provided health care coverage and disability coverage could still incur a large amount of costs in copayment, deductibles, coinsurance, and non-covered items in the event of a critical illness. Critical illness policies help to pay these expenses, and assist someone during their recovery by paying the insured a cash benefit. Depending on your carrier, you can choose $10,000-$20,000 of coverage. This money would be paid to you in cash for you to use as you see fit. Carrier How to Enroll Additional Information Allstate Two plans are available for you to select from You can elect coverage for employee only, your spouse, and/or your dependent children under the age of 26 Rates are dependent on tobacco usage or not 21

22 a d d i t i o n a l b e n e f i t s accident Accident coverage is one of the more common benefits people choose to elect. Any guesses why? It s because accidents are a leading cause of injury for people under forty, and because they occur more randomly than sickness. Accident insurance pays you with cash benefits for expenses that may not be fully covered by your comprehensive health insurance, including: Treatment for an injury, like emergency room cost for a broken bone Ambulance cost for transportation to a hospital X-ray or lab exams Hospital confinement This kind of benefit can have off the job coverage only, or both on and off the job coverage. Check with your carrier to see what is offered. t i p Do you have children who play sports or are just prone to accidents? This may be the Voluntary coverage for you! Carrier How to Enroll Additional Information Allstate Two plans are available for you to select from You can elect coverage for employee only, your spouse, and/or your dependent children under the age of 26 22

23 a d d i t i o n a l b e n e f i t s cancer Receiving a cancer diagnosis can be one of life s most frightening events. Unfortunately, statistics show you probably know someone who has been in this situation. With Cancer insurance, you can rest a little easier. Our coverage pays you a cash benefit to help with the costs associated with treatments, to pay for daily living expenses, and more importantly, to empower you to seek the care you need. You choose the coverage that s right for you and your family. Our Cancer insurance pays cash benefits for cancer and 29 specified diseases to help with the cost of treatments and expenses as they happen. Benefits are paid directly to you unless otherwise assigned. With the cash benefits you can receive from this coverage, you may not need to use the funds from your Health Savings Account (HSA) for cancer or specified disease treatments and expenses. Carrier How to Enroll Additional Information Allstate Two plans are available for you to select from You can elect coverage for employee only, your spouse, and/or your dependent children under the age of 26 23

24 a d d i t i o n a l b e n e f i t s LegalShield and IDShield LegalShield has made smart legal coverage simple, in the form of accessible, affordable, full-service coverage. They have a network of dedicated law firms made up of seasoned lawyers to help you with your legal issues. You know exactly what you are getting and how much you are paying for it. If your identity is stolen or compromised, IDShield and their team of licensed private investigators will do whatever it takes for as long as it takes to restore your identity to its pre-theft status. You have their $5 million service guarantee. Carrier How to Enroll Additional Information LegalShield IDShield If you elect LegalShield coverage, the employee, spouse/domestic partner, and child(ren) under age 26 are all covered for one fee You have two options for IDShield coverage: IDShield Family covers the employee, spouse and up to 8 dependents under 18 IDShield Individual covers only the employee. Rates vary depending on which option you choose 24

25 n o t i c e s Health Insurance Exchange Notice New Health Insurance Marketplace Coverage Options and Your Health Coverage For Employers Who Offer a Health Plan to Some or All Employees PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: The Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment-based health coverage offered by your employer. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. An employersponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs. Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact: Marti Jensen rd St S, Suite 305, Fargo, ND mjensen@nhshotels.com The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area. 25

26 n o t i c e s PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application. 3. Employer name National Hospitality Services 5. Employer address rd St S, Suite Employer Identification Number (EIN) Employer phone number City Fargo 8. State ND 9. ZIP code Who can we contact about employee health coverage at this job? Marti Jensen 11. Phone number address mjensen@nhshotels.com Here is some basic information about health coverage offered by this employer: As your employer, we offer a health plan to: Some employees. Eligible employees are: Employees working 30+ hours per week With respect to dependents: We do offer coverage. Eligible dependents are: Domestic Partners, Spouses and Dependent Children. Eligible dependents are covered to age 26. Note: Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed midyear, or if you have other income losses, you may still qualify for a premium discount. If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages. 26

27 n o t i c e s 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 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 KIDS NOW or 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 employersponsored 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 or call 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, Contact your State for more information on eligibility ALABAMA Medicaid Website: Phone: ALASKA Medicaid The AK Health Insurance Premium Payment Program Website: Phone: CustomerService@MyAKHIPP.com Medicaid Eligibility: ARKANSAS Medicaid Website: Phone: MyARHIPP ( ) FLORIDA Medicaid Website: Phone: GEORGIA Medicaid Website: - Click on Health Insurance Premium Payment (HIPP) Phone: INDIANA Medicaid Healthy Indiana Plan for low-income adults Website: Phone: All other Medicaid Website: Phone

28 n o t i c e s COLORADO Health First Colorado (Colorado s Medicaid Program) & Child Health Plan Plus (CHP+) Health First Colorado Website: Health First Colorado Member Contact Center: / State Relay 711 CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus CHP+ Customer Service: / State Relay 711 KANSAS Medicaid Website: Phone: Website: Phone: KENTUCKY Medicaid LOUISIANA Medicaid Website: Phone: MAINE Medicaid Website: Phone: TTY: Maine relay 711 MASSACHUSETTS Medicaid and CHIP Website: Phone: MINNESOTA Medicaid Website: Phone: MISSOURI Medicaid Website: Phone: MONTANA Medicaid Website: Phone: NEBRASKA Medicaid Website: Phone: (855) Lincoln: (402) Omaha: (402) IOWA Medicaid Website: Phone: NEW HAMPSHIRE Medicaid Website: Phone: Hotline: NH Medicaid Service Center at NEW JERSEY Medicaid and CHIP Medicaid Website: Medicaid Phone: CHIP Website: CHIP Phone: NEW YORK Medicaid Website: Phone: NORTH CAROLINA Medicaid Website: Phone: NORTH DAKOTA Medicaid Website: Phone: OKLAHOMA Medicaid and CHIP Website: Phone: OREGON Medicaid Website: Phone: PENNSYLVANIA Medicaid Website: epremiumpaymenthippprogram/index.htm Phone: RHODE ISLAND Medicaid Website: Phone:

29 n o t i c e s NEVADA Medicaid Medicaid Website: Medicaid Phone: Website: Phone: SOUTH DAKOTA Medicaid TEXAS Medicaid Website: Phone: UTAH Medicaid and CHIP Medicaid Website: CHIP Website: Phone: VERMONT Medicaid Website: Phone: VIRGINIA Medicaid and CHIP Medicaid Website: Medicaid Phone: CHIP Website: CHIP Phone: SOUTH CAROLINA Medicaid Website: Phone: WASHINGTON Medicaid Website: Phone: ext WEST VIRGINIA Medicaid Website: Toll-free phone: MyWVHIPP ( ) WISCONSIN Medicaid and CHIP Website: Phone: WYOMING Medicaid Website: Phone: To see if any other states have added a premium assistance program since July 31, 2018, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services , Option 4, Ext Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L ) (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 currently valid OMB control number. See 44 U.S.C 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 The public reporting 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 or ebsa.opr@dol.gov and reference the OMB Control Number

30 n o t i c e s Notice of Patient Protections Your plan generally allows 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 Marti Jensen rd St S, Suite 305, Fargo, ND mjensen@nhshotels.com For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from this plan or 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 Marti Jensen rd St S, Suite 305, Fargo, ND mjensen@nhshotels.com 30

31 n o t i c e s Notice of Special Enrollment Rights 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. If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children's health insurance program is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your dependents' coverage ends under Medicaid or a state children's health insurance program. If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children's health insurance program with respect to coverage under this plan, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days after your or your dependents' determination of eligibility for such assistance. To request special enrollment or obtain more information, contact Marti Jensen rd St S, Suite 305, Fargo, ND mjensen@nhshotels.com 31

32 n o t i c e s Women's Health and Cancer Rights Act Notices Enrollment Notice 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 mastectomyrelated 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 this plan. If you would like more information on WHCRA benefits, call your plan administrator at: Marti Jensen rd St S, Suite 305, Fargo, ND mjensen@nhshotels.com Annual Notice Do 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 plan administrator for more information. Marti Jensen rd St S, Suite 305, Fargo, ND mjensen@nhshotels.com 32

33 n o t i c e s Mental Health Parity and Addiction Equity Act Disclosure The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 generally requires group health plans and health insurance issuers to ensure that financial requirements (such as co-pays and deductibles) and treatment limitations (such as annual visit limits) applicable to mental health or substance use disorder benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits. For information regarding the criteria for medical necessity determinations made under the NHS Plan with respect to mental health or substance use disorder benefits, please contact your plan administrator at: Marti Jensen rd St S, Suite 305, Fargo, ND mjensen@nhshotels.com Newborns' and Mothers' Health Protection Act Notice 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). 33

34 n o t i c e s Medicare Part D Creditable Coverage Notice Important Notice 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 your company 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 company has determined that the prescription drug coverage offered by the Company 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. 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 Company coverage will not be affected. If you do decide to join a Medicare drug plan and drop your current Company coverage, be aware that you and your dependents will 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 your company 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. 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. 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. 34

35 n o t i c e s For More Information About This Notice or Your Current Prescription Drug Coverage Contact the person listed below for further information call your benefit administrator. 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 your company 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. 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 or call them at (TTY ). 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). Marti Jensen rd St S, Suite 305, Fargo, ND mjensen@nhshotels.com For more information about Medicare prescription drug coverage: Visit 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 MEDICARE ( ). TTY users should call

36 n o t i c e s Genetic Information Nondiscrimination Act (GINA) Disclosures Genetic Information Nondiscrimination Act of 2008 The Genetic Information Nondiscrimination Act of 2008 ( GINA ) protects employees against discrimination based on their genetic information. Unless otherwise permitted, your Employer may not request or require any genetic information from you or your family members. The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. Genetic information, as defined by GINA, includes an individual s family medical history, the results of an individual s or family member s genetic tests, the fact that an individual or an individual s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. 36

37 n o t i c e s General Notice of COBRA Rights Continuation Coverage Rights Under COBRA Introduction You re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse s plan), even if that plan generally doesn t accept late enrollees. What is COBRA continuation coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a qualifying event. Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a qualified beneficiary. You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you re an employee, you ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: Your hours of employment are reduced, or Your employment ends for any reason other than your gross misconduct. If you re the spouse of an employee, you ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: Your spouse dies; Your spouse s hours of employment are reduced; Your spouse s employment ends for any reason other than his or her gross misconduct; Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: The parent-employee dies; The parent-employee s hours of employment are reduced; The parent-employee s employment ends for any reason other than his or her gross misconduct; The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); The parents become divorced or legally separated; or The child stops being eligible for coverage under the Plan as a dependent child When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: The end of employment or reduction of hours of employment; Death of the employee; The employee s becoming entitled to Medicare benefits (under Part A, Part B, or both). 37

38 n o t i c e s For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: Marti Jensen rd St S, Suite 305, Fargo, ND mjensen@nhshotels.com How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18- month period of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse s plan) through what is called a special enrollment period. Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor s Employee Benefits Security Administration (EBSA) in your area or visit (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA s website.) For more information about the Marketplace, visit Keep your Plan informed of address changes To protect your family s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan contact information Marti Jensen rd St S, Suite 305, Fargo, ND mjensen@nhshotels.com 38

39 n o t i c e s General FMLA Notice Employee Rights Under the Family and Medical Leave Act The United States Department of Labor Wage and Hour Division Leave Entitlements Eligible employees who work for a covered employer can take up to 12 weeks of unpaid, jobprotected leave in a 12-month period for the following reasons: The birth of a child or placement of a child for adoption or foster care; To bond with a child (leave must be taken within 1 year of the child s birth or placement); To care for the employee s spouse, child, or parent who has a qualifying serious health condition; For the employee s own qualifying serious health condition that makes the employee unable to perform the employee s job; For qualifying exigencies related to the foreign deployment of a military member who is the employee s spouse, child, or parent. An eligible employee who is a covered service member s spouse, child, parent, or next of kin may also take up to 26 weeks of FMLA leave in a single 12-month period to care for the service member with a serious injury or illness. An employee does not need to use leave in one block. When it is medically necessary or otherwise permitted, employees may take leave intermittently or on a reduced schedule. Employees may choose, or an employer may require, use of accrued paid leave while taking FMLA leave. If an employee substitutes accrued paid leave for FMLA leave, the employee must comply with the employer s normal paid leave policies. Benefits & Protections While employees are on FMLA leave, employers must continue health insurance coverage as if the employees were not on leave. Upon return from FMLA leave, most employees must be restored to the same job or one nearly identical to it with equivalent pay, benefits, and other employment terms and conditions. An employer may not interfere with an individual s FMLA rights or retaliate against someone for using or trying to use FMLA leave, opposing any practice made unlawful by the FMLA, or being involved in any proceeding under or related to the FMLA. Eligibility Requirements An employee who works for a covered employer must meet three criteria in order to be eligible for FMLA leave. The employee must: Have worked for the employer for at least 12 months; Have at least 1,250 hours of service in the 12 months before taking leave;* and Work at a location where the employer has at least 50 employees within 75 miles of the employee s worksite. *Special hours of service requirements apply to airline flight crew employees. 39

40 n o t i c e s Requesting Leave Generally, employees must give 30-days advance notice of the need for FMLA leave. If it is not possible to give 30-days notice, an employee must notify the employer as soon as possible and, generally, follow the employer s usual procedures. Employees do not have to share a medical diagnosis, but must provide enough information to the employer so it can determine if the leave qualifies for FMLA protection. Sufficient information could include informing an employer that the employee is or will be unable to perform his or her job functions, that a family member cannot perform daily activities, or that hospitalization or continuing medical treatment is necessary. Employees must inform the employer if the need for leave is for a reason for which FMLA leave was previously taken or certified. Employers can require a certification or periodic recertification supporting the need for leave. If the employer determines that the certification is incomplete, it must provide a written notice indicating what additional information is required. Employer Responsibilities Once an employer becomes aware that an employee s need for leave is for a reason that may qualify under the FMLA, the employer must notify the employee if he or she is eligible for FMLA leave and, if eligible, must also provide a notice of rights and responsibilities under the FMLA. If the employee is not eligible, the employer must provide a reason for ineligibility. Employers must notify its employees if leave will be designated as FMLA leave, and if so, how much leave will be designated as FMLA leave. Enforcement Employees may file a complaint with the U.S. Department of Labor, Wage and Hour Division, or may bring a private lawsuit against an employer. The FMLA does not affect any federal or state law prohibiting discrimination or supersede any state or local law or collective bargaining agreement that provides greater family or medical leave rights. For additional information or to file a complaint: USWAGE ( ) TTY: U.S. Department of Labor Wage and Hour Division 40

41 n o t i c e s USERRA Notice Your Rights Under USERRA A. The Uniformed Services Employment and Reemployment Rights Act USERRA protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake military service or certain types of service in the National Disaster Medical System. USERRA also prohibits employers from discriminating against past and present members of the uniformed services, and applicants to the uniformed services. B. Reemployment Rights You have the right to be reemployed in your civilian job if you leave that job to perform service in the uniformed service and: You ensure that your employer receives advance written or verbal notice of your service; You have five years or less of cumulative service in the uniformed services while with that particular employer; You return to work or apply for reemployment in a timely manner after conclusion of service; and You have not been separated from service with a disqualifying discharge or under other than honorable conditions. If you are eligible to be reemployed, you must be restored to the job and benefits you would have attained if you had not been absent due to military service or, in some cases, a comparable job. C. Right To Be Free From Discrimination and Retaliation If you: Are a past or present member of the uniformed service; Have applied for membership in the uniformed service; or Are obligated to serve in the uniformed service; Then an employer may not deny you: Initial employment; Reemployment; Retention in employment; Promotion; or Any benefit of employment because of this status. In addition, an employer may not retaliate against anyone assisting in the enforcement of USERRA rights, including testifying or making a statement in connection with a proceeding under USERRA, even if that person has no service connection. D. Health Insurance Protection If you leave your job to perform military service, you have the right to elect to continue your existing employer-based health plan coverage for you and your dependents for up to 24 months while in the military. Even if you do not elect to continue coverage during your military service, you have the right to be reinstated in your employer's health plan when you are reemployed, generally without any waiting periods or exclusions (e.g., pre-existing condition exclusions) except for service-connected illnesses or injuries. E. Enforcement The U.S. Department of Labor, Veterans' Employment and Training Service (VETS) is authorized to investigate and resolve complaints of USERRA violations. For assistance in filing a complaint, or for any other information on USERRA, contact VETS at USA-DOL or visit its Web site at An interactive online USERRA Advisor can be viewed at If you file a complaint with VETS and VETS is unable to resolve it, you may request that your case be referred to the Department of Justice or the Office of Special Counsel, as applicable, for representation. You may also bypass the VETS process and bring a civil action against an employer for violations of USERRA. The rights listed here may vary depending on the circumstances. The text of this notice was prepared by VETS, and may be viewed on the Internet at this address: Federal law requires employers to notify employees of their rights under USERRA, and employers may meet this requirement by displaying the text of this notice where they customarily place notices for employees. U.S. Department of Labor, Veterans' Employment and Training Service,

42 This document is not intended to be taken as advice regarding any individual situation and should not be relied upon as such. Marsh & McLennan Agency LLC shall have no obligation to update this publication and shall have no liability to you or any other party arising out of this publication or any matter contained herein. Any statements concerning actuarial, tax, accounting or legal matters are based solely on our experience as consultants and are not to be relied upon as actuarial, accounting, tax or legal advice, for which you should consult your own professional advisors. Any modeling analytics or projections are subject to inherent uncertainty and the analysis could be materially affective if any underlying assumptions, conditions, information or factors are inaccurate or incomplete or should change. Copyright 2019 Marsh & McLennan Agency LLC. All rights reserved.

43 Medica Choice Passport ND % HSA Coverage Period: Beginning on or after 4/1/19 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to or by calling (Minneapolis/St. Paul Metro area) or For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at or or call Medica at the numbers above to request a copy. Important Questions Answers Why this Matters: What is the overall deductible? Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? What is not included in the out-of-pocket limit? Will you pay less if you use a network provider? Do you need a referral to see a specialist? $3,000 per person/ $6,000 per family in-network and $6,000 per person/ $12,000 per family for out-of-network services. Yes. Preventive care, preventive prescriptions or prenatal care from in-network providers. No $6,500 per person/ $13,000 per family in-network. $26,000 per person/ $52,000 per family for out-of-network services. Premiums, balance-billing charges, and health care this plan doesn t cover. Yes. See or call or or 711 (TTY users) for a list of Medica Choice with UnitedHealthcare network providers. No. You don t need a referral to see a specialist. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at You don t have to meet deductibles for specific services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Even though you pay these expenses, they don t count towards the out-of-pocket limit. This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. You can see the specialist you choose without a referral. COM National Hospitality Services, LLC ( ) (136069) 1 of 7

44 Medica Choice Passport ND % HSA Coverage Period: Beginning on or after 4/1/19 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family Plan Type: PPO All coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Services You May Need Primary care visit to treat an injury or illness What You Will Pay Network Provider Out-of-network (You will pay the least) (You will pay the most) Primary care: 20% coinsurance Chiropractic: 20% coinsurance Convenience: 20% coinsurance Primary care: 50% coinsurance Chiropractic: 50% coinsurance Convenience: 50% coinsurance Specialist visit 20% coinsurance 50% coinsurance ---none--- Preventive care/ screening/ immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs No charge. Deductible does not apply. Lab: 20% coinsurance X-ray: 20% coinsurance 50% coinsurance 50% coinsurance ---none--- 20% coinsurance 50% coinsurance ---none--- Retail: 20% coinsurance Mail order: 20% coinsurance Preventive: No charge. Deductible does not apply. Retail: 20% coinsurance Mail order: 20% coinsurance Preventive: No charge. Deductible does not apply. Retail: 40% coinsurance Mail order: 40% coinsurance Preventive: Benefit does not apply. Preferred: 20% coinsurance No more than $200 copay/ prescription. Non-Preferred: 40% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance Not covered Limitations, Exceptions & Other Important Information Limited to 15 visits per member, per year for out-of-network chiropractic care. You may have to pay for services that aren t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Routine physicals and eye exams are not covered out-of-network. Up to a 31-day supply/ retail or 93-day supply/ mail order prescription. Mail order drugs not covered out-of-network. Up to a 31-day supply per prescription received from a designated specialty pharmacy. 2 of 7

45 Medica Choice Passport ND % HSA Coverage Period: Beginning on or after 4/1/19 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family Plan Type: PPO Common Medical Event If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you need mental health, behavioral health, or substance abuse services If you are pregnant Services You May Need What You Will Pay Network Provider Out-of-network (You will pay the least) (You will pay the most) Facility fee (e.g., ambulatory surgery 20% coinsurance 50% coinsurance ---none--- center) Physician/surgeon fees 20% coinsurance 50% coinsurance ---none--- Emergency room care 20% coinsurance Covered as an in-network benefit. ---none--- Emergency medical transportation Urgent care 20% coinsurance 20% coinsurance Covered as an in-network benefit. ---none--- Covered as an in-network benefit. ---none--- Facility fee (e.g., hospital room) 20% coinsurance 50% coinsurance ---none--- Physician/surgeon fees 20% coinsurance 50% coinsurance ---none--- Outpatient services 20% coinsurance 50% coinsurance ---none--- Inpatient services 20% coinsurance 50% coinsurance ---none--- Office visits Childbirth/delivery professional services Childbirth/delivery facility services Prenatal care: No charge. Deductible does not apply. Postnatal care: 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance ---none--- 20% coinsurance 50% coinsurance ---none--- Limitations, Exceptions & Other Important Information Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.) 3 of 7

46 Medica Choice Passport ND % HSA Coverage Period: Beginning on or after 4/1/19 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family Plan Type: PPO Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need What You Will Pay Network Provider Out-of-network (You will pay the least) (You will pay the most) Limitations, Exceptions & Other Important Information Home health care 20% coinsurance 50% coinsurance 120 visits in-network and 60 visits out-of-network, per member per year. Rehabilitation services 20% coinsurance 50% coinsurance Physical and occupational therapy combined limited to 20 visits out-of-network per member per year. Out-of-network speech therapy is limited to 20 visits per member per year. Habilitation services 20% coinsurance 50% coinsurance Physical and occupational therapy combined limited to 20 visits out-of-network per member per year. Out-of-network speech therapy is limited to 20 visits per member per year. Skilled nursing care 20% coinsurance 50% coinsurance 120 day limit combined in and out-of-network per member per year. Durable medical equipment 20% coinsurance 50% coinsurance ---none--- Hospice services 20% coinsurance 50% coinsurance ---none--- Children s eye exam No charge. Deductible does not apply. Not covered ---none--- Children s glasses Not covered Not covered Glasses are not covered by the plan. Children s dental check-up Not covered Not covered Dental check-ups are not covered by the plan. 4 of 7

47 Medica Choice Passport ND % HSA Coverage Period: Beginning on or after 4/1/19 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family Plan Type: PPO Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of other excluded services.) Acupuncture exceeding 15 visits per member per year for in-network and out-of-network acupuncture services combined Chiropractic care exceeding 15 visits per member per year for out-of-network chiropractic care. Cosmetic Surgery Dental Care (Adult) Dental check-up Glasses Hearing aids except for members 18 years of age and younger for hearing loss due to functional congenital malformation of the ears that is not correctable by other covered procedures; coverage is limited to one hearing aid per ear every three years. Long Term Care Private-duty nursing Routine foot care except for specified conditions Weight Loss programs Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Bariatric Surgery Infertility treatment limited to $5,000 medical/ $3,000 pharmacy per year. Non-emergency care when traveling outside the U.S. Routine eye care (Adult) 5 of 7

48 Medica Choice Passport ND % HSA Coverage Period: Beginning on or after 4/1/19 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family Plan Type: PPO Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: for group health coverage subject to ERISA, Department of Labor s Employee Benefits Security Administration at EBSA (3272) or for all other group health coverage, Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at x61565 or Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: for group health coverage subject to ERISA, Department of Labor s Employee Benefits Security Administration at EBSA (3272) or for all other group health coverage you may also contact Medica at or the North Dakota Department of Insurance at (701) or Does this Plan Provide Minimum Essential Coverage? Yes If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this Plan Meet the Minimum Value Standard? Yes If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace To see examples of how this plan might cover costs for a sample medical situation, see the next section of 7

49 Medica Choice Passport ND % HSA Coverage Period: Beginning on or after 4/1/19 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family Plan Type: PPO About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) The plan s overall deductible: $3,000 Specialist coinsurance: 20% Hospital (facility) coinsurance: 20% Other coinsurance: 20% Managing Joe s type 2 Diabetes (a year of routine in-network care of a well-controlled condition) The plan s overall deductible: $3,000 Specialist coinsurance: 20% Hospital (facility) coinsurance: 20% Other coinsurance: 20% Mia s Simple fracture (in-network emergency room visit and follow up care) The plan s overall deductible: $3,000 Specialist coinsurance: 20% Hospital (facility) coinsurance: 20% Other coinsurance: 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,800 In this example, Peg would pay: Cost Sharing Deductibles $3,000 Copayments $0 Coinsurance $1,500 What isn t covered Limits or exclusions $60 The total Peg would pay is $4,560 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400 In this example, Joe would pay: Cost Sharing Deductibles $3,000 Copayments $0 Coinsurance $50 What isn t covered Limits or exclusions $0 The total Joe would pay is $3,050 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $1,900 In this example, Mia would pay: Cost Sharing Deductibles $1,900 Copayments $0 Coinsurance $0 What isn t covered Limits or exclusions $0 The total Mia would pay is $1,900 The plan would be responsible for the other costs of these EXAMPLE covered services. 7 of 7

50 Medica Choice Passport ND % HSA Coverage Period: Beginning on or after 4/1/19 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family Plan Type: PPO

51 Medica Choice Passport ND % HSA Coverage Period: Beginning on or after 4/1/19 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to or by calling (Minneapolis/St. Paul Metro area) or For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at or or call Medica at the numbers above to request a copy. Important Questions Answers Why this Matters: What is the overall deductible? Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? What is not included in the out-of-pocket limit? Will you pay less if you use a network provider? Do you need a referral to see a specialist? $6,350 per person/ $12,700 per family in-network and $12,700 per person/ $25,400 per family for out-of-network services. Yes. Preventive care, preventive prescriptions or prenatal care from in-network providers. No $6,350 per person/ $12,700 per family in-network. $25,400 per person/ $50,800 per family for out-of-network services. Premiums, balance-billing charges, and health care this plan doesn t cover. Yes. See or call or or 711 (TTY users) for a list of Medica Choice with UnitedHealthcare network providers. No. You don t need a referral to see a specialist. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at You don t have to meet deductibles for specific services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Even though you pay these expenses, they don t count towards the out-of-pocket limit. This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. You can see the specialist you choose without a referral. COM National Hospitality Services, LLC ( ) (136070) 1 of 7

52 Medica Choice Passport ND % HSA Coverage Period: Beginning on or after 4/1/19 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family Plan Type: PPO All coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Network Provider Out-of-network (You will pay the least) (You will pay the most) Limitations, Exceptions & Other Important Information If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Primary care visit to treat an injury or illness Primary care: 0% coinsurance Chiropractic: 0% coinsurance Convenience: 0% coinsurance Primary care: 50% coinsurance Chiropractic: 50% Limited to 15 visits per member, per year for out-of-network coinsurance chiropractic care. Convenience: 50% coinsurance Specialist visit 0% coinsurance 50% coinsurance ---none--- You may have to pay for services that aren t preventive. Ask Preventive care/ No charge. Deductible screening/ immunization does not apply. 50% coinsurance your provider if the services needed are preventive. Then check what your plan will pay for. Routine physicals and eye exams are not covered out-of-network. Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Lab: 0% coinsurance X-ray: 0% coinsurance 50% coinsurance ---none--- 0% coinsurance 50% coinsurance ---none--- Retail: 0% coinsurance Mail order: 0% coinsurance Preventive: No charge. Deductible does not apply. Retail: 0% coinsurance Mail order: 0% coinsurance Preventive: No charge. Deductible does not apply. Retail: 0% coinsurance Mail order: 0% coinsurance Preventive: Benefit does not apply. Preferred: 0% coinsurance Non-Preferred: 0% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance Not covered Up to a 31-day supply/ retail or 93-day supply/ mail order prescription. Mail order drugs not covered out-of-network. Up to a 31-day supply per prescription received from a designated specialty pharmacy. 2 of 7

53 Medica Choice Passport ND % HSA Coverage Period: Beginning on or after 4/1/19 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family Plan Type: PPO Common Medical Event Services You May Need What You Will Pay Network Provider Out-of-network (You will pay the least) (You will pay the most) Limitations, Exceptions & Other Important Information If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you need mental health, behavioral health, or substance abuse services If you are pregnant Facility fee (e.g., ambulatory surgery 0% coinsurance 50% coinsurance ---none--- center) Physician/surgeon fees 0% coinsurance 50% coinsurance ---none--- Emergency room care 0% coinsurance Covered as an in-network benefit. ---none--- Emergency medical transportation Urgent care 0% coinsurance 0% coinsurance Covered as an in-network benefit. ---none--- Covered as an in-network benefit. ---none--- Facility fee (e.g., hospital room) 0% coinsurance 50% coinsurance ---none--- Physician/surgeon fees 0% coinsurance 50% coinsurance ---none--- Outpatient services 0% coinsurance 50% coinsurance ---none--- Inpatient services 0% coinsurance 50% coinsurance ---none--- Office visits Childbirth/delivery professional services Childbirth/delivery facility services Prenatal care: No charge. Deductible does not apply. 50% coinsurance Postnatal care: 0% coinsurance 0% coinsurance 50% coinsurance ---none--- 0% coinsurance 50% coinsurance ---none--- Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.) 3 of 7

54 Medica Choice Passport ND % HSA Coverage Period: Beginning on or after 4/1/19 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family Plan Type: PPO Common Medical Event Services You May Need What You Will Pay Network Provider Out-of-network (You will pay the least) (You will pay the most) Limitations, Exceptions & Other Important Information If you need help recovering or have other special health needs If your child needs dental or eye care Home health care 0% coinsurance 50% coinsurance 120 visits in-network and 60 visits out-of-network, per member per year. Rehabilitation services 0% coinsurance 50% coinsurance Physical and occupational therapy combined limited to 20 visits out-of-network per member per year. Out-of-network speech therapy is limited to 20 visits per member per year. Habilitation services 0% coinsurance 50% coinsurance Physical and occupational therapy combined limited to 20 visits out-of-network per member per year. Out-of-network speech therapy is limited to 20 visits per member per year. Skilled nursing care 0% coinsurance 50% coinsurance 120 day limit combined in and out-of-network per member per year. Durable medical equipment 0% coinsurance 50% coinsurance ---none--- Hospice services 0% coinsurance 50% coinsurance ---none--- Children s eye exam No charge. Deductible does not apply. Not covered ---none--- Children s glasses Not covered Not covered Glasses are not covered by the plan. Children s dental check-up Not covered Not covered Dental check-ups are not covered by the plan. 4 of 7

55 Medica Choice Passport ND % HSA Coverage Period: Beginning on or after 4/1/19 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family Plan Type: PPO Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of other excluded services.) Acupuncture exceeding 15 visits per member per year for in-network and out-of-network acupuncture services combined Chiropractic care exceeding 15 visits per member per year for out-of-network chiropractic care. Cosmetic Surgery Dental Care (Adult) Dental check-up Glasses Hearing aids except for members 18 years of age and younger for hearing loss due to functional congenital malformation of the ears that is not correctable by other covered procedures; coverage is limited to one hearing aid per ear every three years. Long Term Care Private-duty nursing Routine foot care except for specified conditions Weight Loss programs Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Bariatric Surgery Infertility treatment limited to $5,000 medical/ $3,000 pharmacy per year. Non-emergency care when traveling outside the U.S. Routine eye care (Adult) 5 of 7

56 Medica Choice Passport ND % HSA Coverage Period: Beginning on or after 4/1/19 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family Plan Type: PPO Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: for group health coverage subject to ERISA, Department of Labor s Employee Benefits Security Administration at EBSA (3272) or for all other group health coverage, Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at x61565 or Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: for group health coverage subject to ERISA, Department of Labor s Employee Benefits Security Administration at EBSA (3272) or for all other group health coverage you may also contact Medica at or the North Dakota Department of Insurance at (701) or Does this Plan Provide Minimum Essential Coverage? Yes If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this Plan Meet the Minimum Value Standard? Yes If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace To see examples of how this plan might cover costs for a sample medical situation, see the next section of 7

57 Medica Choice Passport ND % HSA Coverage Period: Beginning on or after 4/1/19 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family Plan Type: PPO About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) The plan s overall deductible: $6,350 Specialist coinsurance: 0% Hospital (facility) coinsurance: 0% Other coinsurance: 0% Managing Joe s type 2 Diabetes (a year of routine in-network care of a well-controlled condition) The plan s overall deductible: $6,350 Specialist coinsurance: 0% Hospital (facility) coinsurance: 0% Other coinsurance: 0% Mia s Simple fracture (in-network emergency room visit and follow up care) The plan s overall deductible: $6,350 Specialist coinsurance: 0% Hospital (facility) coinsurance: 0% Other coinsurance: 0% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,800 In this example, Peg would pay: Cost Sharing Deductibles $6,350 Copayments $0 Coinsurance $0 What isn t covered Limits or exclusions $60 The total Peg would pay is $6,410 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400 In this example, Joe would pay: Cost Sharing Deductibles $3,000 Copayments $0 Coinsurance $0 What isn t covered Limits or exclusions $0 The total Joe would pay is $3,000 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $1,900 In this example, Mia would pay: Cost Sharing Deductibles $1,900 Copayments $0 Coinsurance $0 What isn t covered Limits or exclusions $0 The total Mia would pay is $1,900 The plan would be responsible for the other costs of these EXAMPLE covered services. 7 of 7

58 Medica Choice Passport ND % HSA Coverage Period: Beginning on or after 4/1/19 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage for: Individual/Family Plan Type: PPO