Table of Contents. Introduction / Enrollment Instructions 4-6. Medical Plan - BCBS BlueChoice Plan 7-9. Medical Plan - BCBS BluePreferred Plan 11-13

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2 Table of Contents 3 Introduction / Enrollment Instructions 4-6 Medical Plan - BCBS BlueChoice Plan 7-9 Medical Plan - BCBS BluePreferred Plan Medical Plan - BCBS Health Savings Account Dental-Delta Dental of Oklahoma Voluntary Vision VSP Life Insurance-Prudential Long-term Disability Insurance-Prudential Flexible Spending Account with the Benny Card CABA Employee Assistance Services 36 Important Notice Information Special Notice: The Medicare Part D Notice can be found on pages 41-44

3 Helpful Phone Numbers & Websites Blue Cross Blue Shield Medical Customer Service Register on Blue Access for to view benefits, EOBs, the cost estimator and find participating providers. Delta Dental of Oklahoma - Dental Customer Service For Claims and General Questions Vision Service Plans - Vision Customer Service -For Claims and General Questions Prudential - Basic Life, Optional Term Life & Long Term Disability Customer Service Life Insurance For Claims and General Questions Disability Questions about Evidence of Insurability Benefit Resources, Inc. Flexible Spending Account Customer Service-general questions Claim Fax number Employee Assistance Program CABA Call for assistance: (405) Toll Free Number: Gallagher Benefit Services, Inc. (405) Senior Account Executive -Katrina Nash (405) Please call Gallagher if you have claim issues you cannot resolve with the carrier or if you have questions about your new plans. 3

4 To All Eligible Employees of OCCC NEW OCCC s Medical coverage will be with Blue Cross Blue Shield effective July 1, There are three plans to choose from and two networks of providers - BluePreferred and BlueChoice. NEW This year employees will have the opportunity to enroll in a voluntary vision plan provided by Vision Service Plan (VSP). The dental plan will renew with Delta Dental of Oklahoma. IMPORTANT What do you need to enroll? This is your annual open enrollment opportunity. following information to enroll via MineOnline: This booklet as a reference. You will need the The names, Social Security numbers, dates of birth and addresses of any/all dependents you may wish to enroll in one or more of the plans. Life Insurance beneficiary: The names, Social Security numbers, dates of birth and addresses for your beneficiary. Transfer of personal leave to sick leave form. Optional Declaration of Dental and Health Insurance Option form Who is Eligible for Benefits? Full-time Employee Eligibility Regular Full-time employees who normally work 30 or more hours per week. Dependent Eligibility you may also cover your eligible dependents, including; a) your legal spouse, b) your eligible children up to age 26. Open Enrollment The enrollment choices you make will be in effect July 1, 2015 and will remain in effect until June 30, 2016 unless you have a qualifying event. 4

5 Please Read Carefully The Following Information is Very Important If you have a qualifying event, you must submit a change form to your Human Resource Department within 30 days of the qualifying event. To add a Dependent after the open enrollment period: If you decline enrollment for yourself or your dependents because you are covered by another health insurance plan, or dental plan you are eligible to enroll in this plan if you lose the other insurance coverage. Your completed form must be turned into the insurance carrier within 30 days of the loss of coverage so please make sure you turn the form into the Human Resource Department immediately following the qualifying event so the enrollment can be sent to the carrier. If your Human Resource Department does not receive your form within 30 days, you will not be able to enroll until the open enrollment period for a July 1, 2016 effective date. If you have new dependent(s) as a result of marriage, birth, adoption, or placement for adoption, you can enroll your dependents, provided you submit an enrollment request within 30 days of the date of the marriage, birth, adoption, or placement for adoption. It is very important that you turn in the enrollment form to your Human Resource Department immediately following the qualifying event so they can send the enrollment to the insurance carrier. If the insurance carrier does not receive the form within 30 days of the qualifying event you will have to wait until next open enrollment. Policy Certificate Booklet: The Certificates will be placed on the OCCC intranet once they are available this first plan year with BCBS. You will receive notification via from the HR Department as soon as they are posted. IMPORTANT: This announcement letter is an outline of the coverages proposed by the carrier(s). It does not include all of the terms, coverages, exclusions, limitations, and conditions of the actual contract. The policy and contract documents must be read for complete details. Policy information will be made available upon request. Announcement Letter for plan year July 2015 through June 2016 Date Prepared: 03/26/2015 5

6 Things you should know Blue Cross Blue Shield will administer the OCCC medical plan effective July 1, Three plan options will be offered. 1. PPO Plan with the BlueChoice Network and a $500 deductible, $25 office visit copay 2. PPO Plan with the BluePreferred Network and a $500 deductible, $25 office visit copay 3. High Deductible Plan with a Health Savings Account $3000 deductible and then 100%. (BlueChoice Network) Please review the plan section for the eligibility rules. BlueChoice is the largest network offered by BlueCross. All of the major hospitals are in the BlueChoice network. If you choose this plan and are outside the state of Oklahoma you will have access to network providers with the Blue Connection Card. BluePreferred is the provider network offered by Blue Cross Blue Shield with the deepest discounts. This network has the greatest savings specifically in the metropolitan Oklahoma City area. There are three plan options offered so please check the provider listing for your Doctor before choosing a plan. If you are traveling outside of Oklahoma you will have access to network providers with the Blue Connection Card. All of the major hospitals are in the BluePreferred network with the exception of Norman Regional. Please check with Blue Cross Blue Shield before using a provider to confirm that they are participating in the network. The Blue Cross Blue Shield plans will begin July 1, 2015 so please give your new ID card to your healthcare providers. If you have dependents covered you will receive two ID cards both with the employee s name printed on the cards. When the provider confirms eligibility they will be able to confirm that your dependents are enrolled. 6

7 Medical Insurance - Transition ID Cards: When you seek medical services after July 1, 2015 please give your medical provider the Blue Cross Blue Shield ID card. Providers: Please be aware of the network associated with the plan you have chosen. Finding an in-network provider is easy when you log in to Blue Access for members. The cost estimator is also available to assist you in making decisions at the time of service. Emergencies: If your situation is life threatening, go to the nearest emergency room. If surgery or hospitalization is contemplated, contact BCBS within 24 hours or as soon as reasonably possible to determine whether pre-authorization is necessary. If your situation is not life threatening, call your doctor s office and they will help you determine the appropriate level of care. Prescription Drugs: If you have a maintenance prescription that needs to be filled at the end of June please fill it with Aetna before June 30, 2015 for an easier transition. The plan highlights for each plan are included in the following section. You will remain in the plan you choose now until next open enrollment unless you have a qualifying event. 7

8 ID Cards: When you seek medical services after July 1, 2015 please give your medical provider the Blue Cross Blue Shield ID card. Providers: Please be aware of the network associated with the plan you have chosen. Finding an in-network provider is easy when you log in to Blue Access for members. The cost estimator is also available to assist you in making decisions at the time of service. Emergencies: If your situation is life threatening, go to the nearest emergency room. If surgery or hospitalization is contemplated, contact BCBS within 24 hours or as soon as reasonably possible to determine whether pre-authorization is necessary. If your situation is not life threatening, call your doctor s office and they will help you determine the appropriate level of care.

9 Medical Insurance - Employee Monthly Premium BCBS BlueChoice Monthly Premium OCCC Pays *Employee Cost Monthly *Employee Cost Bi-Weekly Employee Only $ $ $0.00 $0.00 Employee+ Spouse $1, $ $ $ Employee + Child(ren) $1, $ $ $ Employee + Family $1, $ $ $ BCBS BluePreferred Monthly Premium OCCC Pays Employee Cost Monthly Employee Cost Bi-Weekly Employee Only $ $ $0.00 $0.00 Employee + Spouse $1, $ $ $ Employee + Child(ren) $1, $ $ $ Employee + Family $1, $ $ $ BCBS HSA Monthly Premium OCCC Pays Employee Cost Monthly Employee Cost Bi-Weekly Employee Only $ $ $0.00 $0.00 Employee + Spouse $ $ $ $ Employee + Child(ren) $ $ $ $ Employee + Family $ $ $ $ *This amount also reflects a $ credit for meeting the needed wellness criteria. The plan highlights for each plan are included in this section. You will remain in the plan you choose now until next open enrollment unless you have a qualifying event.

10 8 BCBS BlueChoice Medical Plan

11 ID Cards: When you seek medical services after July 1, 2015 please give your medical provider the Blue Cross Blue Shield ID card. Providers: Please be aware of the network associated with the plan you have chosen. Finding an in-network provider is easy when you log in to Blue Access for members. The cost estimator is also available to assist you in making decisions at the time of service. Emergencies: If your situation is life threatening, go to the nearest emergency room. If surgery or hospitalization is contemplated, contact BCBS within 24 hours or as soon as reasonably possible to determine whether pre-authorization is necessary. If your situation is not life threatening, call your doctor s office and they will help you determine the appropriate level of care.

12 IMPORTANT: This announcement letter is an outline of the coverages proposed by the carrier(s). It does not include all of the terms, coverages, exclusions, limitations, and conditions of the actual contract. The policy and contract documents must be read for complete details. Policy information will be made available upon request. 9

13 *Allowable charge for non-contracting providers for covered services will be the lesser of the provider s billed charges or the Plan s non-contracting allowable charge. The non-contracting allowable charge is developed from base Medicare reimbursements, excluding any Medicare adjustments using information on the claim, and adjusted by a predetermined factor established by the Plan. Such factor will not be less than 100% of the base Medicare reimbursement rate. Blue Care Connection (BCC) When members receive covered inpatient hospital services, coordinated home care, skilled nursing facility or private duty nursing from a participating provider in the state of Oklahoma, the member will be responsible for contacting the BCC pre-notification line. When using non-participating Oklahoma providers and out-of-state providers, members are required to contact the BCC pre-notification line 1 business day prior to any elective inpatient admission or within 2 business days after an emergency or maternity admission. Failure to pre-notify with the BCC when required will result in benefits being reduced by $500. To locate a Participating Provider: Visit our web site at and use our Provider Finder tool. The amount the plan pays for covered services provided by non-network providers is based on a maximum allowable amount for the specific service rendered. Although your plan stipulates an out-of-pocket maximum for out-of-network services, please note the maximum allowed amount for an eligible procedure may not be equal to the amount charged by your out-of-network provider. Your out-of-network provider may bill you for the difference between the amount charged and the maximum allowed amount. This is called balance billing and the amount billed to you can be substantial. The out-of-pocket maximum outlined in your policy will not include amounts in excess of the allowable charge and other non-covered expenses as defined by your plan. The maximum reimbursable amount for non-network providers can be based on a number of schedules such as a percentage of reasonable and customary or a percentage of Medicare. The plan document or carrier s master policy is the controlling document, and this Benefit Highlight does not include all of the terms, coverage, exclusions, limitations, and conditions of the actual plan language. Contact your claims payer or insurer for more information. 10

14 BCBS BluePreferred Medical Plan IMPORTANT: This announcement letter is an outline of the coverages proposed by the carrier(s). It does not include all of the terms, coverages, exclusions, limitations, and conditions of the actual contract. The policy and contract documents must be read for complete details. Policy information will be made available upon request. Announcement Letter for plan year July 2015 through June

15 IMPORTANT: This announcement letter is an outline of the coverages proposed by the carrier(s). It does not include all of the terms, coverages, exclusions, limitations, and conditions of the actual contract. The policy and contract documents must be read for complete details. Policy information will be made available upon request. 12

16 *Allowable charge for non-contracting providers for covered services will be the lesser of the provider s billed charges or the Plan s non-contracting allowable charge. The non-contracting allowable charge is developed from base Medicare reimbursements, excluding any Medicare adjustments using information on the claim, and adjusted by a predetermined factor established by the Plan. Such factor will not be less than 100% of the base Medicare reimbursement rate. Blue Care Connection (BCC) When members receive covered inpatient hospital services, coordinated home care, skilled nursing facility or private duty nursing from a participating provider in the state of Oklahoma, the member will be responsible for contacting the BCC pre-notification line. When using non-participating Oklahoma providers and out-of-state providers, members are required to contact the BCC prenotification line 1 business day prior to any elective inpatient admission or within 2 business days after an emergency or maternity admission. Failure to pre-notify with the BCC when required will result in benefits being reduced by $500. The amount the plan pays for covered services provided by non-network providers is based on a maximum allowable amount for the specific service rendered. Although your plan stipulates an out-of-pocket maximum for out-of-network services, please note the maximum allowed amount for an eligible procedure may not be equal to amount charged by your out-of-network provider. Your out-of-network provider may bill you for the difference between the amount charged and the maximum allowed amount. This is called balance billing and the amount billed to you can be substantial. The out-of-pocket maximum outlined in your policy will not include amounts in excess of the allowable charge and other non-covered expenses as defined by your plan. The maximum reimbursable amount for non-network providers can be based on a number of schedules such as a percentage of reasonable and customary or a percentage of Medicare. The plan document or carrier s master policy is the controlling document, and this Benefit Highlight does not include all of the terms, coverage, exclusions, limitations, and conditions of the actual plan language. Contact your claims payer or insurer for more information. 13

17 BCBS Health Savings Account Are you eligible for the Health Savings Account? If you have a qualified High Deductible Health Plan (HDHP) - either through your employer or one you ve purchased on your own-chances are you can open a Health Savings Account. Additionally: You must have a valid Social Security Number (SSN) and a primary residence in the U.S. You cannot be covered by any other non-h.s.a.-compatible health plan. You cannot be enrolled in Medicare Part A or Medicare Part B. You cannot be covered by TriCare. You cannot have accessed your VA medical benefits in the past 90 days (to contribute to an H.S.A.) You cannot be claimed as a dependent on another person s tax return (unless it is your spouse). You must be covered by the qualified HDHP on the first day of the month. Note: If a spouse s Flexible Spending Account (FSA) can pay for any medical expenses before the qualified plan deductible is met, you are not eligible to open the Health Savings Account. For you to participate in both an FSA and Health Savings Account at the same time, the FSA, whether provided by your or your spouse s employer, must typically be limited to reimbursing dental expenses, vision care expenses and/or medical expenses that exceed your HDHP deductible. 14

18 What is an HDHP? An HDHP, or high-deduc ble health plan, is a major-medical health insurance plan that has a lower premium than tradi onal health plans. Your HDHP: Is a major-medical health plan that is HSA-compa ble. That means it can be used with a health savings account from HSA Bank Has a higher annual deduc ble with lower monthly premiums, which means you ll have less taken out of your paycheck and more to add to your HSA Covers 100% of preven ve care, including annual physicals, immuniza ons, well-woman and well-child exams, and more all without having to meet your deduc ble. Provides coverage for health screenings, such as blood pressure, cholesterol, diabetes, vision, and more. An HSA, or health savings account, is a unique tax-advantaged account that you can use to pay for current or future IRS-qualified medical expenses. With an HSA, you ll have: A tax-advantaged savings account that you use to pay for IRS-qualified medical expenses as well as deduc bles, co-insurance, prescrip ons, vision and dental care. Unused funds that will roll over year to year. There s no use or lose it penalty. Poten al to build more savings through inves ng. You can choose from a variety of HSA self-directed investment op ons with no minimum balance required. Addi onal re rement savings. A er age 65, funds can be withdrawn for any purpose without penalty 2015 contribu on limits Individual = $3,350 Family = $6,650 (Includes all contribu ons) Catch Up contribu ons Accountholder age 55 or older and not enrolled in Medicare $1,000 annually Note: Investment accounts are not FDIC insured, may lose value and are not a deposit or other obliga on of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribu on limits of the Health Savings Account. How can you benefit from tax savings? An HSA provides triple tax savings by reducing your Federal, State* and FICA taxes. Here s how: Contribu ons to your HSA can be made with pre-tax dollars, which reduces your taxable income Any a er-tax contribu ons that you make to your HSA are tax deduc ble HSA funds earn interest tax free** and when used for IRS-qualified medical expenses are also free from tax *HSA contribu ons are taxed in AL, CA, NJ. HSA Bank does not provide tax advice. Consult your tax professional for tax-related ques ons. ** Interest earned is taxed in NJ. 15

19 The amount the plan pays for covered services provided by non-network providers is based on a maximum allowable amount for the specific service rendered. Although your plan stipulates an out-of-pocket maximum for out-of-network services, please note the maximum allowed amount for an eligible procedure may not be equal to amount charged by your out-of-network provider. Your out-of-network provider may bill you for the difference between the amount charged and the maximum allowed amount. This is called balance billing and the amount billed to you can be substantial. The out-of -pocket maximum outlined in your policy will not include amounts in excess of the allowable charge and other non-covered expenses as defined by your plan. The maximum reimbursable amount for non-network providers can be based on a number of schedules such as a percentage of reasonable and customary or a percentage of Medicare. The plan document or carrier s master policy is the controlling document, and this Benefit Highlight does not include all of the terms, coverage, exclusions, limitations, and conditions of the actual plan language. Contact your claims payer or insurer for more information. 16

20 *Allowable charge for non-contracting providers for covered services will be the lesser of the provider s billed charges or the Plan s non-contracting allowable charge. The non-contracting allowable charge is developed from base Medicare reimbursements, excluding any Medicare adjustments using information on the claim, and adjusted by a predetermined factor established by the Plan. Such factor will not be less than 100% of the base Medicare reimbursement rate. Blue Care Connection (BCC) When members receive covered inpatient hospital services, coordinated home care, skilled nursing facility or private duty nursing from a participating provider in the state of Oklahoma, the member will be responsible for contacting the BCC pre-notification line. When using non-participating Oklahoma providers and out-of-state providers, members are required to contact the BCC prenotification line 1 business day prior to any elective inpatient admission or within 2 business days after an emergency or maternity admission. Failure to pre-notify with the BCC when required will result in benefits being reduced by $500. To locate a Participating Provider: Visit our web site at and use our Provider Finder tool. The amount the plan pays for covered services provided by non-network providers is based on a maximum allowable amount for the specific service rendered. Although your plan stipulates an out-of-pocket maximum for out-of-network services, please note the maximum allowed amount for an eligible procedure may not be equal to amount charged by your out-of-network provider. Your outof-network provider may bill you for the difference between the amount charged and the maximum allowed amount. This is called balance billing and the amount billed to you can be substantial. The out-of-pocket maximum outlined in your policy will not include amounts in excess of the allowable charge and other non-covered expenses as defined by your plan. The maximum reimbursable amount for non-network providers can be based on a number of schedules such as a percentage of reasonable and customary or a percentage of Medicare. The plan document or carrier s master policy is the controlling document, and this Benefit Highlight does not include all of the terms, coverage, exclusions, limitations, and conditions of the actual plan language. Contact your claims payer or insurer for more information. 17

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23 Dental Plan Delta Dental of Oklahoma Delta Dental Group Number 7612 Individual Maximum $1,000 (per person per Calendar Year for all charges) for Class I, II, and III Services Calendar Year Deductible: Individual Deductible Waived for Class I Services, $50 Per Individual for Class II & III Services Family Deductible Waived for Class I Services, $150 Per Family for Class II & III Services Coverage: PPO Network Premier Network Out-Of Network Class I Services (Diagnostic & Preventive) 100% 100% 90% Class II Services (Basic) 90% 80% 70% Class III Services (Major) 60% 50% 40% Class IV Services (Orthodontics) Not A Benefit Not A Benefit Not A Benefit Class I Services: Oral Evaluations Routine prophylaxis, including cleaning and polishing Periodontal maintenance procedures (D4910) following active therapy Bite-wing and periapical x-rays Full mouth x-rays Space maintainers to replace prematurely lost teeth of eligible dependent children (not for orthodontic purposes) Topical application of fluoride for eligible dependent children Topical application of sealants (for eligible dependent children only, limited to permanent first and second molars free of caries and restorations on the occlusal surface Minor emergency (palliative ) treatment for relief of pain Note: Benefits paid by the Plan for covered oral evaluations and routine prophylaxis will not reduce your Benefit Year Maximum Payment for combined Class I, Class II, and Class III covered dental services. Class II Services: Amalgam and composite fillings Stainless steel crowns (for eligible dependent children only) when the natural teeth cannot be restored with another filing material Endodontics: includes pulpal therapy and root canal treatment Oral Surgery: procedures for extractions and other oral surgery, including pre and post-operative care Periodontics: procedures performed for the treatment of diseases of the gums and supporting structures of the teeth, excluding periodontal maintenance following active therapy (D4910) which is payable as a Class I service. Class III Services: Major Restorative: provides porcelain or cast restorations (other than stainless steel) when teeth cannot be restored with another filling material Prosthodontic: procedures for construction of fixed bridges, partial dentures, and complete dentures Implants: procedures for implant placement, implant supported prosthetics, and maintenance and repair of implants and implant-supported prosthetics provided under this plan 20

24 Dental Plan Delta Dental of Oklahoma You do not have to choose a Dentist during the enrollment process. You can go to any Dentist at the time of service however, Delta Dental network Dentist have agreed to discounted services. Coverage is effective on the date of employment. The benefits are calendar year. Delta Dental Monthly Premium OCCC Pays for Active Employee Active Employee cost per month Employee Only $33.22 $33.22 $0.00 Employee + 1 $66.40 $33.22 $33.18 Family $89.62 $33.22 $56.40 Active Employee BiWeekly Cost $0.00 $15.31 $26.03 The dental plan is independent of the health plan, so an individual may enroll in only the dental plan. All employees are required to enroll or sign a waiver. Dependent coverage may be added at the time of initial enrollment, during open enrollment or within 30 days of a qualifying event. A person who has completed five years of service with the College and who is eligible to retire through the Oklahoma Teachers Retirement system may continue dental coverage through the college. Premiums are the responsibility of the retirees. Delta Dental Monthly Premium Employee Only $33.22 $33.22 Employee + 1 $66.40 $66.40 Family $89.62 $89.62 Retiree pays monthly 21

25 Voluntary Vision New this year! You will like what you see with VSP. Value and Savings. Enjoy more value and the lowest out-of-pocket costs. High Quality Vision Care. You will get the best care from a VSP provider, including a WellVision Exam the most comprehensive exam designed to detect eye and health conditions. Plus, when you see a VSP provider, your satisfaction is guaranteed. Choice of providers. The decision is yours to make choose a VSP provider or any out-of-network provider. Great Eyewear. It is easy to find the perfect frame at a price that fits your budget. Using your VSP benefit is easy. Register at vsp.com. Once your plan is effective, review your benefit information. Find an eyecare provider who is right for you. Visit vsp.com or call At your appointment, tell them you have VSP. There s on ID card necessary. If you would like a card as a reference, you can print one on VSP.com That s it! No claim forms to complete when you see a VSP provider. 22

26 Voluntary Vision Benefit In Network Description Copay Frequency Well Vision Exam Focuses on your eyes and overall wellness $10 Every 12 months Prescription Glasses $25 See Frame and Lenses Frame $130 allowance for a wide selection of frames $150 allowance for featured frame brands 20% savings on the amount over your allowance Included in Prescription Glasses Every 24 Months Lenses Lens Enhancements Contacts Instead of Glasses Single vision, lined bifocal, and lined trifocal lenses Polycarbonate lenses for dependent children Progressive lenses Average savings of 20-25% on other lens enhancements. $130 allowance for contacts; copay does not apply Contact lens exam (fitting and evaluation) Glasses and Sunglasses Included in Prescription Glasses Every 12 Months $0 Every 12 Months Up to $60 Every 12 Months Extra Savings Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details. 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam. Laser Vision Correction Your coverage with Out-of-Network Providers Average 15% off the regular price or 5% off the promotional price, discounts only available from contracted facilities. Exam...up to $45 Frame..up to $70 Single Vision Lenses... up to $30 Lined Bifocal Lenses...up to $50 Lined Trifocal Lenses..up to $65 Progressive Lenses.up to $50 Contacts....up to $105 VSP guarantees coverage from VSP network providers only. Coverage information is subject to change. In the event of a conflict between this information and your organization s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. 23

27 Voluntary Vision Plan VSP You can go to any Eye Doctor at the time of service however, VSP network providers have agreed to discounted services. Coverage is effective on the date of employment. The benefits are plan year - July 1 to June 30 VSP Monthly Premium Employee cost per month Active Employee Bi-Weekly Cost Employee Only $10.02 $10.02 $4.62 Employee + 1 $16.03 $16.03 $7.40 Employee +child(ren) $16.36 $16.36 $7.55 Family $26.38 $26.38 $12.17 The vision plan is independent of the health plan, so an individual may enroll in only the vision plan. Dependent coverage may be added at the time of initial enrollment, during open enrollment or within 30 days of a qualifying event. A person who has completed five years of service with the College and who is eligible to retire through the Oklahoma Teachers Retirement system may continue vision coverage through the college. Premiums are the responsibility of the retirees. IMPORTANT: This announcement letter is an outline of the coverages proposed by the carrier(s). It does not include all of the terms, coverages, exclusions, limitations, and conditions of the actual contract. The policy and contract documents must be read for complete details. Policy information will be made available upon request. 24

28 Life Insurance Prudential Insurance Company of America 25

29 OCCC Fulltime Active Employees Employee Basic Term Life, Basic Accidental Death & Dismemberment Employee Basic Term Life Coverage Amount: 2 times Base Annual Earnings (BAE) to a maximum of $300,000 You are automatically enrolled in this employer paid coverage. Spouse: You may elect coverage for your spouse for $10,000. Child(ren): You may elect coverage for your dependent children for $5,000. The employee pays the premium for this coverage if elected. If you are terminally ill, you can get a partial payment of your group life insurance benefits. Payment of premium can be waived if you are totally disabled for 6 months, you are less than 60 years old when the disability begins, and you continue to be totally disabled. This waiver terminates at age 65. This provision may vary by state. The amount of insurance reduces by 50% at age 70. Coverage will end on your termination of employment or as specified in the plan booklet. You may convert your insurance to an individual life insurance policy insured by The Prudential Insurance Company of America. Payouts to your beneficiaries are deposited into a Prudential Alliance Account, a personalized, interest -bearing account, under the beneficiary s name. The payout earns interest from the date the account is opened and the beneficiary can transfer or withdraw funds at any time. Basic Accidental Death & Dismemberment Coverage Amount: 2 times Base Annual Earnings (BAE) to a maximum of $300,000. You are automatically enrolled for an amount equal to your employee Basic Term Life coverage. This coverage is provided by your employer. Basic AD&D pays you and your beneficiary a benefit for the loss of life or other injuries resulting from a covered accident 100% for loss of life and a lesser percentage for other injuries. Injuries covered may include loss of sight or speech, paralysis, and dismemberment of hands or feet. Basic A&D benefits are paid regardless of other coverages you may have. 26

30 Prudential Insurance Company of America 27

31 Prudential Insurance Company of America 28

32 Prudential Insurance Company of America 29

33 Prudential Optional Employee Life Insurance Optional Term Life Monthly Cost per Coverage Amount Employee cost Coverage is available in increments of $10,000 to $500,000, not to exceed 7 times your covered annual earnings. Refer to the Optional Term Life section for evidence of insurability details. Initial rates based on age as of effective date of your coverage. Rates will change based on the following age schedule. Age $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100k $110k $120k $130k <20 $0.70 $1.40 $2.10 $2.80 $3.50 $4.20 $4.90 $5.60 $6.30 $7.00 $7.70 $8.40 $ $0.70 $1.40 $2.10 $2.80 $3.50 $4.20 $4.90 $5.60 $6.30 $7.00 $7.70 $8.40 $ $0.70 $1.40 $2.10 $2.80 $3.50 $4.20 $4.90 $5.60 $6.30 $7.00 $7.70 $8.40 $ $0.90 $1.80 $2.70 $3.60 $4.50 $5.40 $6.30 $7.20 $8.10 $9.00 $9.90 $10.80 $ $1.00 $2.00 $3.00 $4.00 $5.00 $6.00 $7.00 $8.00 $9.00 $10.00 $11.00 $12.00 $ $1.10 $2.20 $3.30 $4.40 $5.50 $6.60 $7.70 $8.80 $9.90 $11.00 $12.10 $13.20 $ $1.70 $3.40 $5.10 $6.80 $8.50 $10.20 $11.90 $13.60 $15.30 $17.00 $18.70 $20.40 $ $2.50 $5.00 $7.50 $10.00 $12.50 $15.00 $17.50 $20.00 $22.50 $25.00 $27.50 $30.00 $ $4.70 $9.40 $14.10 $18.80 $23.50 $28.20 $32.90 $37.60 $42.30 $47.00 $51.70 $56.40 $ $7.30 $14.60 $21.90 $29.20 $36.50 $43.80 $51.10 $58.40 $65.70 $73.00 $80.30 $87.60 $ $14.00 $28.00 $42.00 $56.00 $70.00 $84.00 $98.00 $ $ $ $ $ $ $19.50 $39.00 $58.50 $78.00 $97.50 $ $ $ $ $ $ $ $ $19.50 $39.00 $58.50 $78.00 $97.50 $ $ $ $ $ $ $ $ $19.50 $39.00 $58.50 $78.00 $97.50 $ $ $ $ $ $ $ $ Age $140k $150k $160k $170k $180k $190k $200k $250k $300k $350 $400k $450k $500k <20 $9.80 $10.50 $11.20 $11.90 $12.60 $13.30 $14.00 $17.50 $21.00 $24.50 $28.00 $31.50 $ $9.80 $10.50 $11.20 $11.90 $12.60 $13.30 $14.00 $17.50 $21.00 $24.50 $28.00 $31.50 $ $9.80 $10.50 $11.20 $11.90 $12.60 $13.30 $14.00 $17.50 $21.00 $24.50 $28.00 $31.50 $ $12.60 $13.50 $14.40 $15.30 $16.20 $17.10 $18.00 $22.50 $27.00 $31.50 $36.00 $40.50 $ $14.00 $15.00 $16.00 $17.00 $18.00 $19.00 $20.00 $25.00 $30.00 $35.00 $40.00 $45.00 $ $15.40 $16.50 $17.60 $18.70 $19.80 $20.90 $22.00 $27.50 $33.00 $38.50 $44.00 $49.50 $ $23.80 $25.50 $27.20 $28.90 $30.60 $32.30 $34.00 $42.50 $51.00 $59.50 $68.00 $76.50 $ $35.00 $37.50 $40.00 $42.50 $45.00 $47.50 $50.00 $62.50 $75.00 $87.50 $ $ $ $65.80 $70.50 $75.20 $79.90 $84.60 $89.30 $94.00 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

34 Prudential Optional Dependent Life Dependent Spouse Term Life Monthly cost per coverage Amount Coverage is available for your spouse in increments of $10,000 to $250,000, not to exceed 50% of your Optional Term Life coverage amount. Initial rates based on age as of effective date of your coverage. Rates will change based on the following age schedule. $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90, k 110k 120k 130k Age <20 $0.70 $1.40 $2.10 $2.80 $3.50 $4.20 $4.90 $5.60 $6.30 $7.00 $7.70 $8.40 $ $0.70 $1.40 $2.10 $2.80 $3.50 $4.20 $4.90 $5.60 $6.30 $7.00 $7.70 $8.40 $ $0.70 $1.40 $2.10 $2.80 $3.50 $4.20 $4.90 $5.60 $6.30 $7.00 $7.70 $8.40 $ $0.90 $1.80 $2.70 $3.60 $4.50 $5.40 $6.30 $7.20 $8.10 $9.00 $9.90 $10.80 $ $1.00 $2.00 $3.00 $4.00 $5.00 $6.00 $7.00 $8.00 $9.00 $10.00 $11.00 $12.00 $ $1.10 $2.20 $3.30 $4.40 $5.50 $6.60 $7.70 $8.80 $9.90 $11.00 $12.10 $13.20 $ $1.70 $3.40 $5.10 $6.80 $8.50 $10.20 $11.90 $13.60 $15.30 $17.00 $18.70 $20.40 $ $2.50 $5.00 $7.50 $10.00 $12.50 $15.00 $17.50 $20.00 $22.50 $25.00 $27.50 $30.00 $ $4.70 $9.40 $14.10 $18.80 $23.50 $28.20 $32.90 $37.60 $42.30 $47.00 $51.70 $56.40 $ $7.30 $14.60 $21.90 $29.20 $36.50 $43.80 $51.10 $58.40 $65.70 $73.00 $80.30 $87.60 $ $14.00 $28.00 $42.00 $56.00 $70.00 $84.00 $98.00 $ $ $ $ $ $ $19.50 $39.00 $58.50 $78.00 $97.50 $ $ $ $ $ $ $ $ $19.50 $39.00 $58.50 $78.00 $97.50 $ $ $ $ $ $ $ $ $19.50 $39.00 $58.50 $78.00 $97.50 $ $ $ $ $ $ $ $ Spouse Guarantee Issue Amount is $20,000 if coverage is elected when first eligible. 140k 150k 160k 170k 180k 190k 200k 210k 220k 230k 240k 250k Age <20 $9.80 $10.50 $11.20 $11.90 $12.60 $13.30 $14.00 $17.50 $9.80 $10.50 $11.20 $ $9.80 $10.50 $11.20 $11.90 $12.60 $13.30 $14.00 $17.50 $9.80 $10.50 $11.20 $ $9.80 $10.50 $11.20 $11.90 $12.60 $13.30 $14.00 $17.50 $9.80 $10.50 $11.20 $ $12.60 $13.50 $14.40 $15.30 $16.20 $17.10 $18.00 $22.50 $12.60 $13.50 $14.40 $ $14.00 $15.00 $16.00 $17.00 $18.00 $19.00 $20.00 $25.00 $14.00 $15.00 $16.00 $ $15.40 $16.50 $17.60 $18.70 $19.80 $20.90 $22.00 $27.50 $15.40 $16.50 $17.60 $ $23.80 $25.50 $27.20 $28.90 $30.60 $32.30 $34.00 $42.50 $23.80 $25.50 $27.20 $ $35.00 $37.50 $40.00 $42.50 $45.00 $47.50 $50.00 $62.50 $35.00 $37.50 $40.00 $ $65.80 $70.50 $75.20 $79.90 $84.60 $89.30 $94.00 $ $65.80 $70.50 $75.20 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

35 Prudential Insurance Company of America Disability Insurance 32

36 Prudential - Disability Coverage Details Full-time, actively at work employees are eligible and automatically enrolled. The College pays the premium. The coverage is effective the first day of the month following employment unless employment begins on the first of the month, then coverage is effective on the employment date. Disability coverage is for a twelve month period. Those employees who are on less than a twelve month appointment will have coverage provided on a twelve month basis. See the summary for the disability definition. There is a 60 day elimination period beginning with the day the disability begins. Benefits provide 60% of the employee s basic annual salary. This does not include overload, overtime, adjunct appointments, special appointments or temporary appointments. Benefits may be coordinated with other disability benefits through Oklahoma Teachers Retirement System, Social Security, Workers Compensation or other group disability plans to equal 70% of salary. The minimum monthly benefit when coordinated shall be the greater of $100 or ten percent of gross salary. See the summary for duration of benefits detail. The College will continue to pay health and dental benefits for six (6) months from the date the disability benefits begin. The employee may apply for a waiver of life premium when disabled. The employee must be less than 60 years of age at the time of the disability to be eligible. Pre-existing conditions apply. Coverage terminates at time employment terminates or retirement begins. IMPORTANT: This announcement letter is an outline of the coverages proposed by the carrier(s). It does not include all of the terms, coverages, exclusions, limitations, and conditions of the actual contract. The policy and contract documents must be read for complete details. Policy information will be made available upon request. 33

37 FSA - Pay Healthcare Expenses Pre-tax Flexible Spending Account Administered by BRI The elections made for the pre-tax deductions cannot be changed during the plan year. The only exception is that you may change your election consistent with an IRS approved change of family status (e.g marriage, divorce, death of a spouse or child, birth or adoption of a child, change of employment status of a spouse) Please complete the Flexible Spending Account election information included in the online enrollment process. If the election is not completed for this plan year your elections from last year do not carry forward. If you are participating in either the Health Care or Dependent Care Flexible Spending Account Plan Year ending June 30, 2015, current claims will be filed with Aetna. Effective July 1, 2015, OCCC is changing FSA administrators. If you have funds remaining on June 30, 2015 you will submit claims for services incurred during the plan year AND additional services incurred during the grace period of July 1, 2015 through September 15, 2015 to: Benefit Resources, Inc E. 91st Street, Suite 100, Tulsa, OK NEW for plan year July 1, 2015 through June 30, 2016 Benefit Resources, Inc. will be the FSA administrator. Don t miss the information regarding the Benny card on the next page. Also, the plan will change to allow a roll over of $500 of an unused election to rollover into the next plan year Medical Flexible Spending Limits: $2, Dependent Care Flexible Spending Limits: $5,000 34

38 35

39 Employee Assistance Program Administered by CABA Problems are part of everyday life. The Oklahoma City Community College understands this, and they have provided an Employee Assistance Program (EAP) to help you address the everyday challenges of life that sometimes arise. You will be provided with six confidential sessions per issue, to speak with an EAP Representative about issues such as; Family Marital / Relationship Personal and Job Stress Grief Legal Anxiety Depression Substance Abuse & Addiction The right time to seek help for a problem is as early as possible, before the problem becomes critical. Your EAP is here to help. For assistance contact CABA at: IMPORTANT: This benefit guide is an outline of the coverages proposed by the carrier(s), based on information provided by your company. It does not include all of the terms, coverages, exclusions, limitations, and conditions of the actual contract language. The policies and contracts themselves must be read for those details. Policy forms for your reference will be made available upon request. 36

40 Important Notice Information 37

41 Oklahoma City Community College Initial Notice of Your HIPAA Special Enrollment Rights Our records show that you are eligible to participate in the OKLAHOMA CITY COMMUNITY COLLEGE, GROUP HEALTH PLAN (to actually participate, you must complete an enrollment form and pay part of the premium through payroll deduction). A federal law called HIPAA requires that we notify you about an important provision in the plan - your right to enroll in the plan under its special enrollment provision if you acquire a new dependent, or if you decline coverage under this plan for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons. Loss of Other Coverage (Excluding Medicaid or a State Children s Health Insurance Program). If you decline enrollment for yourself or for an eligible dependent (including your spouse) while other health insurance or group health plan coverage is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your 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). Loss of Coverage for Medicaid or a State Children s Health Insurance Program. 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. New Dependent by Marriage, Birth, Adoption, or Placement for Adoption. 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 new dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. Eligibility for 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. *If you decline enrollment for yourself or for an eligible dependent, you must submit a signed statement to decline coverage. You are required to state that coverage under another group health plan or other health insurance coverage (including Medicaid or a state children s health insurance program) is the reason for declining enrollment. If you do not complete the form, you and your dependents will not be entitled to special enrollment rights upon a loss of other coverage as described above. To request special enrollment or to obtain more information about the plan s special enrollment provisions, contact your HUMAN RESOURCES DEPARTMENT. 38

42 General Notice Of COBRA Continuation Coverage 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-ofpocket 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. 39

43 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). 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 the Human Resources Department. 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. 40

44 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 OKLAHOMA CITY COMMUNITY COLLEGE Dr. Angie Christopher / Vice President of Human Resources

45 Important Notice from OKLAHOMA CITY COMMUNITY COLLEGE 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 the Oklahoma City Community College 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. The Oklahoma City Community College has determined that the prescription drug coverage offered by the Oklahoma City Community College Group Blue Cross & Blue Shield Medical 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. 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. CMS Form CC Updated April 1, 2011 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C , Baltimore, Maryland

46 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 Oklahoma City Community College coverage will not be affected. You can keep this coverage if you elect Part D, but the group health plan will not coordinate with Part D coverage. If you do decide to join a Medicare drug plan and drop your current Oklahoma City Community College coverage, be aware that you and your dependents will be able to get this coverage back only during open enrollment or a special enrollment event. 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 the Oklahoma City Community College 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. CMS Form CC Updated April 1, 2011 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C , Baltimore, Maryland

47 For More Information About This Notice Or Your Current Prescription Drug Coverage Contact the person listed below for further information. 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 the Oklahoma City Community College changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage More detailed information about Medicare plans that offer prescription drug coverage is in the Medicare & You handbook. You ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit 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 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). CMS Form CC Updated April 1, 2011 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C , Baltimore, Maryland

48 Date: 4/8/2015 Name of Entity/Sender: Oklahoma City Community College Contact-Position/Office: Dr. Angie Christopher/Vice President of Human Resources Address: 7777 S. May Avenue / Oklahoma City, OK Phone: CMS Form CC Updated April 1, 2011 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C , Baltimore, Maryland

49 Important Notices WOMEN S HEALTH AND CANCER RIGHTS ACT (WHCRA) If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: All stages of reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; Prostheses; and Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more information on WHCRA benefits, call your Human Resources Department at NEWBORN S AND MOTHER S HEALTH PROTECTION ACT Federal law (Newborn s and Mother s Health Protection Act of 1996) prohibits the plan from limiting a mother s or newborn s length of stay to less than 48 hours for a normal delivery or 96 hours for a cesarean delivery or form requiring the provider to obtain pre-authorization for a stay of 48 hours or 96 hours, as appropriate. However, federal law generally does not prohibit the attending provider, after consultation with the mother, from discharging the mother or her newborn earlier than 48 hours for normal delivery or 96 hours for cesarean delivery. MENTAL HEALTH PARITY ACT According to the Mental Health Parity Act of 1996, the lifetime maximum and annual maximum dollar limits for mental health benefits under the OCCC Group Health Plan are equal to the lifetime maximum and annual maximum dollar limits for medical and surgical benefits under this plan. However, mental health benefits may be limited to a maximum number of treatment days per year or series per lifetime. 46

50 Important Notices HIPAA PRIVACY RIGHTS The Health Insurance Portability and Accountability Act (HIPAA) provides you certain rights to privacy concerning your health information. The regulations designate certain types of information as Protected Health Information (PHI). Health care providers (medical professionals) and health plans, including OCCC Group Health Plan representatives, are restricted in their use of PHI to purposes of treatment, payment and health care operations and as required by national public health activities. Written authorization is required to use or disclose your PHI pertaining to your medical, prescription drug, dental and vision coverage outside of these purposes. You may receive a form requesting your authorization to use your PHI for another purpose. Should you grant this authorization, your PHI is still protected from use and disclosure by any party other than the one(s) to whom you grant written authorization, and from use and disclosure by authorized parties for any purposes other than the one you specifically authorized. PROTECTED HEALTH INFORMATION (PHI) PHI includes information that could be used to identify you as an individual in electronic, printed or spoken forms that relates to (1) past, present or future health, physical or mental condition, (2) provision of health care, (3) past, present or future payment for health care. 47

51 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 employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren t already enrolled. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at 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 January 31, Contact your State for more information on eligibility Website: Phone: ALABAMA Medicaid ALASKA Medicaid Website: health.hss.state.ak.us/dpa/programs/medicaid/phone (Outside of Anchorage): Phone (Anchorage): COLORADO Medicaid Medicaid Website: Medicaid Customer Contact Center: FLORIDA Medicaid Website: Phone: GEORGIA Medicaid Website: - Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: INDIANA Medicaid Website: Phone: IOWA Medicaid Website: Phone: KANSAS Medicaid Website: Phone:

52 KENTUCKY Medicaid Website: Phone: LOUISIANA Medicaid Website: Phone: NEW HAMPSHIRE Medicaid Website:: Phone: NEW JERSEY Medicaid and CHIP Medicaid Website: Medicaid Phone: CHIP Website: CHIP Phone: MAINE Medicaid Website: index.html Phone: TTY MASSACHUSETTS Medicaid and CHIP Website: Phone: NEW YORK Medicaid Website: Phone: NORTH CAROLINA Medicaid Website: Phone: MINNESOTA Medicaid NORTH DAKOTA Medicaid Website: Health Care, then Medical Assistance Phone: Click on Website: Phone: MISSOURI Medicaid OKLAHOMA Medicaid and CHIP Website: hipp.htm Phone: Website: Phone: MONTANA Medicaid Website: Phone: NEBRASKA Medicaid Website: Phone: NEVADA Medicaid Medicaid Website: Medicaid Phone: OREGON Medicaid Website: Phone: PENNSYLVANIA Medicaid Website: Phone: Website: Phone: RHODE ISLAND Medicaid 49

53 SOUTH CAROLINA Medicaid VIRGINIA Medicaid and CHIP Website: Phone: Medicaid Website: programs_premium_assistance.cfm Medicaid Phone: Website: Phone: SOUTH DAKOTA - Medicaid TEXAS Medicaid CHIP Website: programs_premium_assistance.cfm CHIP Phone: WASHINGTON Medicaid Website: pages/ index.aspx Phone: ext WEST VIRGINIA Medicaid Website: Phone: UTAH Medicaid and CHIP Website: Phone: , HMS Third Party Liability WISCONSIN Medicaid and CHIP Website: Medicaid: CHIP: Phone: VERMONT Medicaid Website: Phone: WYOMING Medicaid Website: Phone: Website: Phone: To see if any other states have added a premium assistance program since January 31, 2015, or for more information on special enrollment rights, contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services EBSA (3272) , Menu Option 4, Ext OMB Control Number (expires 10/31/2016) 50

54 This booklet highlights the main features of many of the benefit plans sponsored by OCCC. Full details of these benefits are contained in the legal documents governing the plans. If there is any discrepancy or conflict between the plan documents and the information presented here, the plan documents will govern. In all cases, the plan documents are the exclusive source for determining rights and benefits under the plans. OCCC reserves the right to change or discontinue the plans at any time. Participation in the plans does not constitute an employment contract. OCCC reserves the right to modify, amend or terminate any benefit plan or practice described in this guide. Nothing in this guide guarantees that any new plan provisions will continue in effect for any period of time. 51