PART A: General Information

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1 New Health Insurance Marketplace Coverage Options and Your Health Coverage, o rm t p p ro v 2g f " o. -4-2N2- ( 3 e x p!r s xn9-n4242d PART A: General Information D n X y p Lrts o [ td D llw tlx 42- ( B td r w!ll z L n w w Ly to zu y D LltD!n s u ) td u LltD :n s u g LrX tp ll@. %o Ls s!s t y o u Ls y o u v Llu Lt o p t!o n s [o r y o u Ln y o u r [Lm!ly B td!s n o t!@ p ro v! s s o m zls!@!n [o rm Lt!o n Lzo u t td n w g LrX tp ll@ Ln m p lo y m n tnzls D v rl] o [[ r zy y o u r m p lo y r. What is the Health Insurance Marketplace? %D g LrX tp ll@!s s!] n to D lp y o u [!n D LltD!n s u tdlt m ts y o u r n s Ln [!ts y o u r zu ] t. %D g LrX tp ll@ o [[ rs oo n Ns to p s Do p p!n ] o to [!n m p Lr p r!v Lt D LltD!n s u o p t!o n s. 6o u m Ly Lls o z l!]!zl [o r L n w X!n o [ tdlt lo w rs y o u r m o n tdly p r m!u m r!] Dt Lw Ly. Yp n nr o llm n t [o r D LltD!n s v rl] tdro u ] D td g LrX tp ll@ z ]!n s!n Y@to z r 42-9 [o v rl] s tlrt!n ] Ls Lrly Ls HLn u Lry - B 42- (. Can I Save Money on my Health Insurance Premiums in the Marketplace? 6o u m Ly q u Ll![y to s Lv m o n y Ln lo w r y o u r m o n tdly p r m!u m B zu t o n ly![ y o u r m p lo y r o s n o t o [[ v rl] B o r o [[ v rl] tdlt o s n vt m rtl!n s tln Lr s. %D s Lv!n ] s o n y o u r p r m!u m tdlt y o u vr l!]!zl [o r p n s o n y o u r Do u s Do m. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? 6 s. :[ y o u DLv Ln o [[ r o [ D v rl] [ro m y o u r m p lo y r tdlt m rtl!n s tln Lr s B y o u w!ll n o t z l!]!zl [o r L tdro u ] D td g LrX tp ll@ Ln m Ly w!s D to nr o ll!n y o u r m p lo y rvs D LltD p lln. u o w v r B y o u m Ly z l!]!zl [o r L tdlt lo w rs y o u r m o n tdly p r m!u m B o r L r s tns DLr!n ]![ y o u r m p lo y r o s n o t o [[ v rl] to y o u Lt Lll or o s n o t o [[ v rl] tdlt m rtl!n s tln Lr s. :[ s t o [ L p lln [ro m y o u r m p lo y r tdlt w o u v r y o u eln n o t Ln y o td r m m z rs o [ y o u r [Lm!ly d!s m o r tdln 3.xA o [ y o u r Do u s Do m [o r td y LrB o r![ v rl] y o u r m p lo y r p ro v! s o s n o t m t td om!n!m u m v Llu o s tln Lr s t zy td t [[o r Lzl l Lr y o u m Ly z l!]!zl [o r L 1 Note: :[ y o u p u r@dls L D LltD p lln tdro u ] D td g LrX tp ll@!n s t L o [ L@@ p t!n ] D v rl] o [[ r zy y o u r m p lo y rb td n y o u m Ly lo s td m p lo y n tr!zu t!o n e![ Ln y d to td m p lo y rno [[ v rl]. t ls o B td!s m p lo y n tr!zu t!o n NLs w ll Ls y o u r m p lo n tr!zu t!o n to m p lo y rno [[ v rl] N!s o [t n [ro m [o r, rll Ln ' m tlx p u rp o s s. 6o u r p Ly m n ts [o v rl] tdro u ] D td g LrX tp ll@ Lr m L o n Ln L[t rtlx zls!s. How Can I Get More Information?, o r m o r!n [o rm Lt!o n Lzo u t y o u v rl] o [[ r zy y o u r m p lo y r B p y o u r s u m m Lry p lln t!o n o n tl@t Lisa Bublitz %D g LrX tp D lp y o u v Llu Lt y o u v rl] o p t!o n s ] y o u r l!]!z!l!ty [o v rl] tdro u ] D td g LrX tp ll@ s t. Ol Ls v!s!t HealthCare.gov [o r m o r!n [o rm Lt!o n ] Ln o n l!n Lp p l!@lt!o n [o r D LltD!n s v rl] n tl@t!n [o rm Lt!o n [o r L u LltD :n s u g LrX tp ll@!n y o u r Lr L. - t n m p lo y rns p o n s o r D LltD p lln m ts td om!n!m u m v Llu s tln Lr o![ td p lln vs s DLr o [ td to tll Lllo w z n s v r by td p lln!s n o l s s tdln i 2 p r@ n t o [ s ts.

2 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, Cedarburg School l;)istrict 5. Employer address W6a N611 Evergreen Blvd 7.City Cedarburg 10. who can we contact about employee health coveraqe at.thls job? 'Lisa Bublitz 4. Employer Identification Number (Eil':,I} Employer phone number !1. 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: [:] Some employees. Eligible employees are: Employed by the Cedarburg School District as a regular Full-Time or regular Part-Time basis (See your Summary Plan Description for a complete description) With respect to dependents: [li] We do offer coverage. Eligible dependents are: Employee's lawful spouse, Married or unmarried: natural born, blood related child; step-child; legally adopted child; child placed in employee's legal guardianship by court order; or employee has a legal obligation to provide full or partial support; and whose age is not beyond 26. (See your Summary Plan Description for a complete description) We do not offer coverage. Cl!l 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.

3 Premium Assistance Under Medicaid and the Children's Health Insurance Program (CHIP) Ifyou 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. Ifyou 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 Ifyou 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. Ifyou 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. Ifyou qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. Ifyou 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. Ifyou have questions about enrolling in your employer plan, contact the Department of Labor at or call EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, Contact your State for more information on eligibility - The AK Health Insurance Premium Payment Program Phone: CustomerService@MyAKHIPP.com Medicaid Eligibility: X ARKANSAS - Medicaid Phone: MyARHIPP ( ) COLORADO - Health First Colorado (Colorado's Medicaid Program) & Child Health Plan Plus (CHP+) Health First Colorado Health First Colorado Member Contact Center: / State Relay 711 CHP+: Colorado.gov /HCPF/Child-Health-Plan-Plus CHP+ Customer Service: / State Relay Click on Health Insurance Premium Payment (HIPP) Phone: INDIANA - Medicaid Healthy Indiana Plan for low-income adults Phone: All other Medicaid http :// Phone IOWA - Medicaid Phone:

4 KANSAS- Medicaid Phone: KENTUCKY - Medicaid Phone: LOUISIANA - Medicaid Phone: NEW IIAMPSIIIRE - Medicaid Phone: Hotline: NH Medicaid Service Center at NEW JERSEY - Medicaid and CHIP Medicaid http ://www. state.nj. us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: CHIP CHIP Phone: NEW YORK - Medicaid care/medicaid/ Phone: MAINE - Medicaid Phone: TTY: Maine relay 711 MASSAClllJSKITS - Medicaid and CHIP alth/ Phone: MINNESOTA- Medicaid other-insurance,j sp Phone: MISSOURI - Medicaid / /participants/pages /hipp. htm Phone: MONTANA- Medicaid pp Phone: NEBRASKA- Medicaid Phone: (855) Lincoln: (402) Omaha: (402) NEVADA - Medicaid Medicaid Medicaid Phone: NORTH CAROLINA - l\1edicaid Phone: NORTH l)akota - Medicaid dhs/services/medicalserv /medicaid L Phone: OKLAHOMA - Medicaid and CHIP http :// Phone: OREGON - Medicaid Phone: PENNSYLVANIA- Medicaid /medicalassistance /he althinsurancepremiumpaymenthippprogram/index.ht m Phone: RHODE ISLAND- Medicaid Phone: SOUTH CAROLINA - Medicaid Phone:

5 SOUTH DAKOTA - Medicaid Phone: TEXAS- Medicaid Phone: WASHINGTON - Medicaid Phone: ext WEST VIRC.INIA - Merlicairl Toll-free phone: MyWVHIPP ( ) UT AH - Medicaid and CHIP Medicaid CHIP Phone: WISCONSIN - Medicaid and CHIP df Phone: Medicaid premium assistance. cfm Medicaid Phone: CHIP premium assistance. cfm CHIP Phone: To see if any other states have added a premium assistance program since July 31, 2018, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services , Menu Option 4, Ext Paperwork Reduction Act Statement According to the Paperwork Reduction Act of1995 (Pub. L ) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (0MB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by 0MB under the PRA, and displays a currently valid 0MB control number, and the public is not required to respond to a collection of information unless it displays a currently valid 0MB control number. See 44 U.S.C Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid 0MB control number. See 44 U.S.C The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC or ebsa.opr@dol.gov and reference the 0MB Control Number MB Control Number 12rn-tn37 (expires 12/31/2019)

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