Benefits Guide January 1, December 31, 2018

Transcription

1 Benefits Guide January 1, December 31, 2018 Welcome to Indian River Transport, the official sponsor of your benefits program!

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3 Table of Contents Refer to this list when you need to contact one of your benefit vendors. For general information contact Human Resources. BENEFIT RESOURCE CENTER (BRC): page 5 Provider Name Benefit Resource Center Provider Phone Number 855-USI-6699 Provider Address BRCEast@usi.biz MEDICAL: page 6-9 Provider Name UMR Provider Phone Number Provider Web Address MEC: page Provider Name Key Benefit Administrators Provider Phone Number Provider Web Address kba.keyfamily.com DENTAL: page 12 Provider Name Guardian Provider Phone Number Provider Web Address VOLUNTARY LIFE & ACCIDENTAL DEATH & DISMEMBERMENT: page Provider Name Guardian Provider Phone Number Provider Web Address DISCLOSURE NOTICES page The information in this Benefits Summary is presented for illustrative purposes and is based on information provided by the employer. The text contained in this Summary was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Benefits Summary and the actual plan documents, the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of If you have any questions about this summary, contact Human Resources. 3

4 Benefit Information Your Benefits Plan In the following pages, you ll learn more about the benefits Indian River Transport offers. You ll also see how choosing the right combination of benefits can help protect you and your family s health and finances and your family s future. When Can You Enroll? You can sign up for Benefits at any of the following times: After completing initial eligibility period; During the annual open enrollment period; Within 30 days of a qualified family-status change. If you do not enroll at the above times, you must wait for the next annual open enrollment period. Making Changes Generally, you can only change your benefit choices during the annual benefits enrollment period. However, you may be able to change your benefit choices at anytime if you have a change in status including: Your marriage Your divorce or legal separation Birth or adoption of an eligible child Death of your spouse or covered child Change in your spouse s work status that affects his or her benefits Change in your work status that affects your benefits Change in residence or work site that affects eligibility for coverage Change in your child s eligibility for benefits Receiving Qualified Medical Child Support Order (QMCSO) If you have a family status change, you must notify the Human Resources Department within 30 days of the change. The Human Resources Department will send you the necessary, manual forms to complete. If you do not notify Human Resources within 30 days of a family status change, you will have to wait until the next annual enrollment period to make benefit changes unless you have another family status change. Eligibility You are eligible to join the Benefit Plan on the 1 st day of the month following 60 days of continuous regular full-time employment and service. You may also enroll your dependents, when you enroll. Eligible dependents include: > Your spouse, unless you are legally separated or divorced; > A dependent who is 26 years of age or younger Under the plan, children include your natural children, stepchildren living with you, legally adopted children and any other children for whom you have legal guardianship. Keep in mind that under the new Patient Protection & Affordable Care Act, health benefits provided to an employee s child who has not attained age 27 in the taxable year (January 1 December 31) will not be included in the employee s gross income for federal tax purposes. This means that employees may use pre-tax dollars to pay their share of the premiums for coverage provided to these individuals and will avoid imputed income on any employer-provided coverage. Key Benefit Terms COBRA A Federal law that allows workers and dependents who lose their medical, dental, or vision coverage to continue any of these coverages for a specified length of time by electing and paying for continuation benefits. Coinsurance The percentage of the medical or dental charge that you pay after the deductible has been met. Copay A flat fee that you pay for medical services, regardless of the actual amount charged by your doctor or another provider. This generally applies to physicians office visits and prescription drugs. Deductible The amount you pay toward medical and dental expenses each calendar year before the plan begins paying benefits. Out of Pocket Maximum The maximum amount you will pay in coinsurance during the calendar year 4

5 Benefit Resource Center Services Toll-free benefit call center available to: Answer questions regarding your health and other benefit plans Network: Is my doctor on the plan? Plan Coverage: Does my plan cover this? Billing: I received a bill from my provider, do I need to pay? Help you understand how a carrier paid your claim Specialist support to help you with complex claims issues Medical appeals information and support Life event (family status) rules what changes can I make? Life Insurance Beneficiary form requirements How do I complete an Evidence of Insurability form and where do I send it? What happens if I have coverage under two different medical plans? 5

6 Medical Insurance Bronze Plan Gold Plan IN-NETWORK: Plan Year / Contract Year Basis Calendar Year Calendar Year Deductible (Individual / Family) $6,000/ $12,000 $1,500 / $3,000 Maximum Out-of-Pocket (Individual / Family) $6,250 / $12,500 $3,000 / $5,000 Out-of Pocket Max Includes Deductible and Coinsurance Deductible and Coinsurance Coinsurance 60% 70% ROUTINE PREVENTATIVE SERVICES: Wellness Immunizations Mammography/Colonoscopy CO-PAYS: PCP Required / Open Access Covered 100% OPEN ACCESS Covered 100% OPEN ACCESS Office Visits/Consultations for Illness/Injury $40 copay $35 copay Specialist Visits $80 copay $50 copay Inpatient Hospital $500 per Confinement ;covered 60% after Deductible Covered 70% after Deductible Outpatient Surgery Covered 60% after Deductible Covered 70% after Deductible Emergency Room $300 copay $100 copay Urgent Care $100 copay $50 copay OUTPATIENT DIAGNOSTIC SERVICES: Lab Services Covered 60% after Deductible Covered 100% X-Ray Services Covered 60% after Deductible Covered 100% Complex Diagnostic Covered 60% after Deductible Covered 70% after Deductible PRESCRIPTIONS: Retail (30 day supply) $15 / $35 / $45 $15 / $35 / $45 Mail Order (90 day supply) 2 x copay 2 x copay OUT-OF-NETWORK: Deductible (Individual / Family) Maximum Out-of-Pocket (Individual / Family) Lifetime Major Medical Maximum Coinsurance PAYROLL DEDUCTIONS: No Out of Network Benefits Weekly No Out of Network Benefits Weekly Employee Only $ $ Employee and Spouse $ $ Employee and Child(ren) $ $ Family $ $

7 Medical Insurance 7

8 Pharmacy Benefits with Optum Rx 8

9 Specialty Pharmacy Benefits with Optum Rx 9

10 MEC Plan Key Benefits MEC Heavy Plan IN-NETWORK: Plan Year / Contract Year Basis Calendar Year Deductible (Individual / Family) $0 / $0 Maximum Out-of-Pocket (Individual / Family) $0 / $0 Annual Plan Benefit Coinsurance Telemedicine Unlimited Calls Geo Fencing ER and Rx Unlimited Access ROUTINE PREVENTATIVE SERVICES: Wellness Immunizations Mammography/Colonoscopy CO-PAYS: PCP Required / Open Access Office Visits/Consultations for Illness/Injury Specialist Visits Inpatient Hospital Outpatient Surgery Emergency Room OUTPATIENT DIAGNOSTIC SERVICES: Lab Services X-Ray Services Complex Diagnostic PRESCRIPTIONS: Retail (30 day supply) Mail Order (90 day supply) OUT-OF-NETWORK: Deductible (Individual / Family) Maximum Out-of-Pocket (Individual / Family) Lifetime Major Medical Maximum Coinsurance No charge for services mandated by the Patient Protection Affordable Care Act. See Page 11 OPEN ACCESS Please see plan summary for detailed benefit information The MVP is not a major medical plan. Please see plan summary for detailed benefit information PAYROLL DEDUCTIONS: Weekly Employee Only $15.92 Employee and Spouse $25.10 Employee and Child(ren) $39.46 Family $

11 MEC Benefit Summary This list below summarizes some but not all services. Please reference the US Preventive Services Task Force website for the entire list. Covered Preventative Services for Adults 1. Abdominal Aortic Aneurysm one time screening for age Obesity screening and counseling 2. Alcohol Misuse screening and counseling 13. Sexually Transmitted Infection (STI) prevention counseling 3. Aspirin use for men ages and women ages to prevent CVD 14. Tobacco Use screening and cessation interventions when prescribed by a physician 15. Syphilis screening 4. Blood Pressure screening 16. Hepatitis B screening for non pregnant adolescents and 5. Cholesterol screening for adults adults. 6. Colorectal Cancer screening for adults starting at age 50 limited to one 17. Lung Cancer screening years old who smoke 30 packs a every 5 years year. 7. Depression screening 18. Fall Prevention Physical therapy and vitamin D for 65 and 8. Type 2 Diabetes screening older at risk for falling 9. Diet counseling 19. Hepatitis C screening for high risk individuals and a onetime 10. HIV screening screening for HCV infection if born between Immunizations vaccines (Hepatitis A & B, Herpes Zoster, Human 20. Skin Cancer behavioral counseling for adults to age 24 with Papillomavirus, Influenza (flu shot), Measles, Mumps, Rubella, fair skin. Meningococcal, Pneumococcal, Tetanus, Diphtheria, Pertussis, Varicella) Covered Preventive Services for Women, Including Pregnant Women 1. Anemia screening on a routine basis for pregnant women 2. Bacteriuria urinary tract or other infection screening for pregnant women 3. BRCA counseling and genetic testing for women at higher risk 4. Breast Cancer Mammography screenings every year for women age 40 and over 5. Breast Cancer Chemo Prevention counseling for women 6. Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women. 7. Cervical Cancer screening 8. Chlamydia Infection screening 9. Contraception: Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs 10. Domestic and interpersonal violence screening and counseling for all women 11. Folic Acid supplements for women who may become pregnant when prescribed by a physician Covered Services for Children 1. Alcohol and Drug Use assessments 2. Autism screening for children limited to two screenings up to 24 months 3. Behavioral assessments for children limited to 5 assessments up to age Blood Pressure screening 5. Cervical Dysplasia screening 6. Congenital Hypothyroidism screening for newborns 7. Depression screening for adolescents age 12 and older 8. Developmental screening for children under age 3, and surveillance throughout childhood 9. Dyslipidemia screening for children 10. Fluoride Chemo Prevention supplements for children without fluoride in their water source when prescribed by a physician 11. Gonorrhea preventive medication for the eyes of all newborns 12. Hearing screening for all newborns 13. Height, Weight and Body Mass Index measurements for children 14. Hematocrit or Hemoglobin screening for children 15. Hemoglobinopathies or sickle cell screening for newborns 16. HIV screening for adolescents 17. Immunization vaccines for children from birth to age 18; doses, recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis, Hepatitis A & B, Human Papillomavirus, Inactivated Poliovirus, Influenza (Flu Shot), Measles, Mumps, Rubella, Meningococcal, 11 Pneumococcal, Rotavirus, Varicella, Haemophilus influenzae type b 12. Gestational diabetes screening 13. Gonorrhea screening 14. Hepatitis B screening for pregnant women 15. Human Immunodeficiency Virus (HIV) screening and counseling 16. Human Papillomavirus (HPV) DNA Test: HPV DNA testing every three years for women with normal cytology results who are 30 or older 17. Osteoporosis screening over age Rh Incompatibility screening for all pregnant women and follow up testing 19. Tobacco Use screening and interventions and expanded counseling for pregnant tobacco users 20. Sexually Transmitted Infections (STI) counseling 21. Syphilis screening 22. Well woman visits to obtain recommended preventive services 23. Aspirin for Preeclampsia prevention 24. Routine prenatal visits for pregnant women 18. Iron supplements for children up to 12 months when prescribed by a physician 19. Lead screening for children 20. Medical History for all children throughout development ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years 21. Obesity screening and counseling 22. Oral Health risk assessment for young children up to age Phenylketonuria (PKU) screening in newborns 24. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents 25. Tuberculin testing for children 26. Vision screening for all children under the age of Skin Cancer Behavioral Counseling age for exposure to sun 28. Tobacco intervention and counseling for children 29. Fluoride varnish for primary teeth through age 5.

12 Dental Insurance About Your Dental Options Indian River Transport offers a PPO dental plan through Guardian. A PPO Plan allows members to utilize the Guardian PPO national network. If a member uses a network provider they will pay less out-of-pocket costs. Network providers will not charge more than Guardian s allowable fee, so members will not be balance billed for more than the local usual and customary costs. If members receive services by an out-of- network dentist, they will have to pay the difference between the dentist s charges and Guardian s reasonable and customary amount, in addition to the member s normal cost share. Guardian In-Network Out-of Network Deductible Individual $50 $50 Family $150 $150 Annual Maximum Individual $1,500 Per Member Per Calendar Year Diagnostic & Preventative Deductible Waived Exams Cleanings Fluoride X-Rays Sealants 100% 100% Regular Restorative Services Deductible Applies Amalgam Fillings Extractions - Single Tooth 80% 80% Major Services Endodontics (Root Canal) Periodontics (Gum Disease) Crowns Bridges Dentures Orthodontics Deductible Applies 50% 50% Payroll Deductions Employee Only Family Weekly $5.00 $14.00 Please refer to the complete Summary Plan Description for plan provisions, terms, conditions of coverage, exclusions, and limitations. 12

13 Life and AD&D Insurance Basic Term Life and AD&D Insurance Indian River Transport provides all active full-time employees with $10,000 group life and accidental death and dismemberment (AD&D) insurance. This is an age based product and age reduction does apply. The $10,000 will reduce as follows: To 65% at age 65 To 45% at age 70 To 30% at age 75 To 20% at age 80 Indian River Transport pays the full cost of this benefit. Please contact Human Resources to update your beneficiary information. Voluntary Term Life and AD&D Insurance Employees who want to supplement their group life and AD&D insurance benefits may purchase additional coverage. When you enroll yourself and/or your dependents in this benefit, you pay the full cost through payroll deductions. You may purchase coverage on yourself in $10,000 increments. Minimum coverage is $10,000 and maximum coverage is $500,000 for employees. You may purchase coverage on your spouse in $5,000 increments. Minimum coverage for spouses is $5,000 and maximum coverage is $250,000. You may purchase coverage on dependent children in the amount of $10,000. The guaranteed issue amount for employees is $100,000, $25,000 for spouses, and $10,000 for children. Age reduction applies to the voluntary life insurance as follows: To 65% at age 70 To 35% at age 75 Note: Please see Human Resources for a complete Benefit Summary and Beneficiary Designation Form. The only time you can enroll in guaranteed issue voluntary life and AD&D insurance, is at the date you first become eligible to enroll. If you do not enroll then and later decide that you would like to enroll, you will be required to complete a medical questionnaire and go through medical underwriting. The insurance carrier reserves the right to decline coverage based on medical information obtained on the medical questionnaire. 13

14 Voluntary Life and AD&D Insurance How Much Your Coverage Will Cost The weekly cost of insurance for you and your spouse will depend on your ages and the amount of insurance you wish to purchase. As shown in the following chart, the cost of insurance increases with the age of the insured. Note that at age 65, your benefits are reduced. Spousal coverage ceases at age 70. Example (Life coverage only): Employee (age 28) Spouse (age 24) 25 units x ($250,000) 20 units x ($100,000) $.29 per unit = $7.25 $.14 per unit = $2.80 Children 1 unit x $.37 per unit = $.37 ($10,000) Total Weekly Cost $10.42 To calculate your cost, complete this chart: Employee units x $. per unit = $. Spouse units x $. per unit = $. Children units x $. per unit = $._ When You Reach Age 65 Total Weekly Cost $. By the time you reach age 65, chances are that your children will be grown and your mortgage paid. At age 70, providing you are still employed, your coverage will decrease to 65% of the benefit amount. It will decrease to 35% at age 75. Premiums and coverage for your spouse will end at age 70; at that time your spouse may choose to convert this coverage to a permanent life insurance policy. Employee/ Spouse Age Employee Weekly Cost per $10,000 Unit Spouse Weekly Cost Per $5,000 Unit Under 25 $.29 $ to 29 $.29 $ to 34 $.29 $ to 39 $.35 $ to 44 $.53 $ to 49 $.85 $ to 54 $1.27 $ to 59 $2.12 $ to 64 $3.51 $ to 69 $5.42 $ & Over $ AD&D: Employee $.035 per $10,000 Spouse $.035 per $5,000 The weekly life insurance cost for children is $.37 per $10,000 of coverage. One premium will insure all eligible children, regardless the number of children you have. Maximum coverage: Employee - $500,000 Spouse - up to 50% of employee s coverage Max. $250,000 Children - $10,000 (under 6 months $500) Guaranteed Issue Amounts: Employee - $100,000 Spouse - $25,000 Children - $10,000 (under 6 months $500) 14

15 Required Annual Employee Disclosure Notices The Newborns and Mothers Health Protection Act of 1996 The Newborns and Mothers Health Protection Act of 1996 prohibits group and individual health insurance policies from restricting benefits for any hospital length of stay for the mother or newborn child in connection with childbirth; (1) following a normal vaginal delivery, to less than 48 hours, and (2) following a cesarean section, to less than 96 hours. Health insurance policies may not require that a provider obtain authorization from the health insurance plan or the issuer for prescribing any such length of stay. Regardless of these standards, an attending health care provider may, in consultation with the mother, discharge the mother or newborn child prior to the expiration of such minimum length of stay. Further, a health insurer or health maintenance organization may not: 1. Deny to the mother or newborn child eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely to avoid providing such length of stay coverage; 2. Provide monetary payments or rebates to mothers to encourage such mothers to accept less than the minimum coverage; 3. Provide monetary incentives to an attending medical provider to induce such provider to provide care inconsistent with such length of stay coverage; 4. Require a mother to give birth in a hospital; or 5. Restrict benefits for any portion of a period within a hospital length of stay described in this notice. These benefits are subject to the plan s regular deductible and co-pay. For further details, refer to your Summary Plan Description. Keep this notice for your records and call Human Resources for more information. Michelle s Law The law allows for continued coverage for dependent children who are covered under your group health plan as a student if they lose their student status because of a medically necessary leave of absence from school. This law applies to medically necessary leaves of absence that begin on or after January 1, Women s Health and Cancer Rights Act of 1998 The Women s Health and Cancer Rights Act of 1998 requires Superior Uniform Group to notify you, as a participant or beneficiary of the Superior Uniform Group Health and Welfare Plan, of your rights related to benefits provided through the plan in connection with a mastectomy. You, as a participant or beneficiary, have rights for coverage to be provided in a manner determined in consultation with your attending physician for: 1. All stages of reconstruction of the breast on which the mastectomy was performed; 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and 3. Prostheses and treatment of physical compilations of the mastectomy, including lymphedema. These benefits are subject to the plan s regular deductible and co-pay. For further details, refer to your Summary Plan Description. Keep this notice for your records and call Human Resources for more information. Patient Protection: UMR 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 UMR at For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from UMR 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 UMR at If your child is no longer a student, as defined in your Certificate of Coverage, because he or she is on a medically necessary leave of absence, your child may continue to be covered under the plan for up to one year from the beginning of the leave of absence. This continued coverage applies if your child was (1) covered under the plan and (2) enrolled as a student at a post-secondary educational institution (includes colleges, universities, some trade schools and certain other post-secondary institutions). Your employer will require a written certification from the child s physician that states that the child is suffering from a serious illness or injury and that the leave of absence is medically necessary. 15

16 Required Annual Employee Disclosure Notices - Continued Statement of ERISA Rights Enforce your Rights As a participant in the Plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 ( ERISA ). ERISA provides that all participants shall be entitled to: If your claim for a welfare benefit is denied in whole or in part, you must receive a written explanation of the reason for the denial. You have a right to have the Plan review and reconsider your claim. Receive Information about Your Plan and Benefits Examine, without charge, at the Plan Administrator s office and at other specified locations, the Plan and Plan documents, including the insurance contract and copies of all documents filed by the Plan with the U.S. Department of Labor, if any, such as annual reports and Plan descriptions. Obtain copies of the Plan documents and other Plan information upon written request to the Plan Administrator. The Plan Administrator may make a reasonable charge for the copies. Receive a summary of the Plan s annual financial report, if required to be furnished under ERISA. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report, if any. Continue Group Health Plan Coverage If applicable, you may continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You and your dependents may have to pay for such coverage. Review the summary plan description and the documents governing the Plan for the rules on COBRA continuation of coverage rights. Prudent Actions by Plan Fiduciaries In addition to creating rights for participants, ERISA imposes duties upon the people who are responsible for operation of the Plan. These people, called fiduciaries of the Plan, have a duty to operate the Plan prudently and in the interest of you and other Plan participants. Under ERISA, there are steps you can take to enforce these rights. For instance, if you request materials from the Plan Administrator and do not receive them within 30 days, you may file suit in federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent due to reasons beyond the control of the Plan Administrator. If you have a claim for benefits that is denied or ignored, in whole or in part, and you have exhausted the available claims procedures under the Plan, you may file suit in a state or federal court. If it should happen that Plan fiduciaries misuse the Plan s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose (for example, if the court finds your claim is frivolous) the court may order you to pay these costs and fees. Assistance with your Questions If you have any questions about your Plan, this statement, or your rights under ERISA, you should contact the nearest office of the Employee Benefits and Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits and Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C No one, including the Company or any other person, may fire you or discriminate against you in any way to prevent you from obtaining welfare benefits or exercising your rights under ERISA. Section 111 Effective January 1, 2009, group health plans are required by Federal government to comply with Section 111 of the Medicare, Medicaid, and SCHIP Extensions of 2007 s new Medicare Secondary Payer regulations. The mandate is designed to assist in establishing financial liability of claims assignments. In other words, it will help establish who pays first. The mandate requires group health plans to collect additional information, more specifically, Social Security numbers for all enrollees, including dependents 6 months of age or older. Please be prepared to provide this information on your benefits enrollment form when enrolling into benefits. 16

17 Required Annual Employee Disclosure Notices - Continued HIPAA Privacy Policy for Self-Funded Plans with Access to PHI The group health plan is a self-funded group health plan sponsored by the Plan Sponsor. The group health plan and the plan sponsor intend to comply with the requirements of 45 C.F.R (k). HIPAA privacy requirements are in place and a copy of the Privacy Policy is available from the Human Resource Department. 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. Further, if you decline enrollment for yourself or eligible dependents (including your spouse) while Medicaid coverage or coverage under a State CHIP program is in effect, you may be able to enroll yourself and your dependents in this plan if: coverage is lost under Medicaid or a State CHIP program; or you or your dependents become eligible for a premium assistance subsidy from the State. 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 on the following page, 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 s 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). In either case, you must request enrollment within 30 days from the loss of coverage or the date you become eligible for premium assistance. To request special enrollment or obtain more information, please contact the Human Resources Department.. 17

18 Required Annual Employee Disclosure Notices - Continued 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 August 10, 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 ( ) 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 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 IOWA Medicaid Website: Phone: KANSAS Medicaid Website: Phone: KENTUCKY Medicaid Website: Phone: 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) NEVADA Medicaid Medicaid Website: Medicaid Phone:

19 Required Annual Employee Disclosure Notices - Continued NEW HAMPSHIRE Medicaid Website: Phone: NEW JERSEY Medicaid and CHIP Medicaid Website: dmahs/clients/medicaid/ 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: miumpaymenthippprogram/index.htm Phone: RHODE ISLAND Medicaid Website: Phone: SOUTH CAROLINA Medicaid Website: Phone: SOUTH DAKOTA - Medicaid Website: Phone: 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: 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 August 10, 2017, 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 , Menu Option 4, Ext

20 Required Annual Employee Disclosure Notices - Continued Required Annual Employee Disclosure Notices - Continued Medicare Part D This notice applies to employees and covered dependents who are eligible for Medicare Part D. Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with United HealthCare and about your options under Medicare s prescription 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. 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare through Medicare prescription drug plans and Medicare Advantage Plan (like an HMO or PPO) that offer prescription drug coverage. All Medicare prescription 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. United HealthCare has determined that the prescription drug overage offered by the Welfare Plan for Employees of Superior Uniform Group under the United HealthCare option are, on average for all plan participants, expected to pay out as much as the 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. You should also know that if you drop or lose your coverage with United HealthCare and don t enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more (a penalty) to enroll in Medicare prescription drug coverage later. 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 15 th to December 7 th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What happens to your current coverage if you decide to join a Medicare Drug Plan? If you decide to join a Medicare drug plan, your current United HealthCare coverage will not be affected. You can keep this coverage if you elect part D and this plan will coordinate with Part D coverage. If you decide to join a Medicare drug plan and drop your current United HealthCare 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 United HealthCare 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 at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For more information about this notice or your current prescription drug coverage Contact our office for further information (see contact information below). 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 United HealthCare 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 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 notice. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage, you may be required to provide a copy of this notice when you join to show that you are not required to pay a higher premium amount. Date: January 1, 2018 Name of Entity/Sender: Indian River Transport Contact--Position/Office: Human Resources Address: 2580 Executive Road Winter Haven, FL Phone Number: (863)

21 Health Insurance Marketplace Required Annual Employee Disclosure Notices - Continued 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. 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 Human Resources. 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. 1 An employer sponsored 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. 21

22 Health Insurance Marketplace Required Annual Employee Disclosure Notices - Continued 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 Indian River Transport 5. Employer Address 2580 Executive Road 4. Employer Identification Number (EIN) Employer phone number (800) City Winter Haven 8. State FL 9. ZIP code Who can we contact about employee health coverage at this job? Human Resources 11. Phone number (if different from above) 12. address Here is some basic information about health coverage offered by this employer: As your employer, we offer a health plan to: All employees. Eligible employees are: Full time working at least 30 hours per week. With respect to dependents: We do offer coverage. Eligible dependents are: Spouse, unmarried and married children up to age 26. Under the plan, children include your natural children, step children living with you, legally adopted children and any other children for whom you have legal guardianship. 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. ** 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 mid year, or if you have other income losses, you may still qualify for a premium discount. If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums. 22

23 Notes Required Annual Employee Disclosure Notices - Continued 23

24 The information in this Benefits Summary is presented for illustrative purposes and is based on information provided by the employer. The text contained in this Summary was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Benefits Summary and the actual plan documents, the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of If you have any questions about this summary, contact Human Resources. Presented by: 24