Call 4 Health The Compassionate Call Center December 1, November 30, 2017

Transcription

1 Call 4 Health The Compassionate Call Center December 1, November 30, 2017 Maryland Benefit Highlights

2 WELCOME NEW OR NEWLY BENEFIT ELIGIBLE CALL 4 HEALTH EMPLOYEE! On behalf of the Employee Benefits Department, we welcome you to the Call 4 Health Team! If you work a full- me schedule (30 or more hours per week) you are eligible for our Benefits Package. It includes medical, dental, vision, and free life insurance. All policies are effec ve the 1 st day of the month following 60 days of full- me status. REQUIREMENT/DEADLINE TO ENROLL: It is MANDATORY that you complete the online benefits enrollment applica on within the first 31 days of your full- me status. IF you decide to WAIVE / DECLINE coverage offered you s ll MUST complete the online applica on during this me frame in order to be enrolled for the employer paid life insurance policy. Please note, the online benefits enrollment applica on can be found on FOCUS ON THE CALL (FOTC) under the Links tab labeled Employee Insurance Enrollment Applica on. Upon comple on, it is required you the applica on to the Human Resource Department at HR@call4health.com We look forward to your growth with us!

3 Table of Contents Directory 1 Group Insurance Eligibility 2 Sec on 125 & Qualifying Events 3 Frequently Asked Ques ons 4 Affordable Care Act 5 Medical Insurance 6 Terms to Know 9 Dental Insurance 10 Vision Insurance 11 Life Insurance 13 Employee Assistance Program (EAP) 14 HealthAdvocate 14 COBRA No ce 15 Employee Annual No ces 17 Payroll Deduc ons 19 Important Contact Informa on Contact Name Human Resources: Dahlia Tusa, Director of Human Resources Dus en Garman, Human Resource Specialist Juan Panta, Opera ons Manager Medical Insurance: Florida Blue Group Name: HCAS of Florida - Group #80972 Dental & Vision Plan: Humana Group Name: HCAS of Florida - Group# Life Insurance: Unum Group Name: HCAS of Florida EAP: CompPsych Guidance Resources Health Advocate General Insurance Inquiries: Agent: CBIZ Employee Services Organiza on Contact Informa on (561) Ext / dtusa@call4health.com (561) Ext / dgarman@call4health.com (410) Ext / jpanta@call4health.com (800) (800) (877) Company Web ID: EAPBusiness (866) Us at: HCAS@cbiz.com 1

4 Group Insurance Eligibility Eligibility Employees are eligible to par cipate in our insurance plans if they meet the following criteria: Full- me employees working a minimum of 30 hours per week: Coverage will be effec ve the 1 st of the month following 60 days a er your date of hire. Example: If you are hired on May 11 th, your coverage will be effec ve on August 1 st. Dependent Eligibility A dependent is defined as the employee's legal spouse and dependent child(ren). The term "child" includes any of the following: A natural child A child placed for adop on A legally adopted child A stepchild A foster child A dependent of dependents up to 18 months (FL) A child for whom legal guardianship has been awarded to the employee or spouse Termina on: For medical, dental, and vision, coverage terminates on the last day of the month from the date of termina on. Dependent Child Eligibility Age Requirements Florida Over-Age Regula on (Statute ): Coverage may con nue past the age of 26 to the end of the calendar year in which the dependent reaches the age of 30 for medical plans if: The child is dependent upon the policyholder for support, AND The child is unmarried with no dependents, AND The child is a Florida resident residing with the policyholder or a full- me or a part- me student, AND The child is not enrolled in any other health coverage policy or plan, AND The child is not en tled to benefits under Medicare Title XVIII of the Social Security Act unless the child is handicapped. Disabled Dependents: Coverage for an unmarried dependent child may be con nued beyond age 26 if the dependent is: Physically or mentally disabled and incapable of self-sustaining employment by reason of mental or physical handicap, AND Coverage began prior to the age of 19, AND Dependent has been con nuously insured. Proof of eligibility is required upon request. Please contact Human Resources for addi onal informa on. 2

5 Sec on 125 & Qualifying Events Sec on 125 We par cipate in a Cafeteria Benefit Plan governed by the Internal Revenue Service (IRS) Code, Sec on 125. Premiums for medical, dental, and vision insurance plans are deducted pre-tax from your gross income and therefore you pay less tax. IRS regula ons require the coverage(s) you select MUST remain in effect for the en re plan year. This means that you and your dependents cannot arbitrarily: Change health plans Cancel coverage Add dependents Remove dependents Therefore, for enrolled members, changes to your coverage are only allowed during open enrollment and that would be effec ve December 1 st. Qualifying Events The IRS, Sec on 125, only allows changes to your group insurance elec ons during the plan year when an eligible change in status occurs which affects your, your spouse s and/or your dependent s coverage eligibility. You must request changes within 30 days of the qualifying event or wait un l the next annual open enrollment. You may be legally and financially responsible for any claim and/or expense incurred as a result of the employee or a dependent who con nues to be enrolled but no longer meets eligibility requirements. Approved changes will be effec ve on the first of the month following the date of the qualifying event, newborns on the date of birth. Any cancella ons will be processed at the end of the month following the date of the qualifying event or the day following a death. Proof of the qualifying event is required upon request. Examples of Qualifying Events The birth/adop on/legal custody of a child Eligibility gain due to increase in work hours A marriage Eligibility lost due to decrease in work hours A divorce A covered dependent is no longer eligible A child returns to eligible status A child loses or gains coverage with an ex-spouse A spouse obtains or loses employment and The death of a spouse or dependent child coverage Loss of eligibility for Medicaid or CHIP coverage or becoming eligible for a premium assistance subsidy under Medicaid or CHIP (60 day no fica on period) 3

6 Frequently Asked Ques ons Can I waive my coverage? You may choose to waive coverage under the Medical Plan, but before you do, keep in mind that the Affordable Care Act also known as Health Care Reform requires most individuals to pay a tax penalty unless they have health care coverage that sa sfies certain minimum standards. The penalty is effec ve as of January 1, Call 4 Health s medical plan op ons sa sfy the applicable minimum standards, individuals enrolled in the Medical Plan will not be subject to the penalty. Please see The Affordable Care Act on the next page for more informa on. What happens if I miss the enrollment deadline? If you are a newly eligible team member and you do not enroll within the deadline, you will not have Medical, Dental or Vision coverage for the rest of the plan year. Your next chance to enroll is during the Open Enrollment period (typically in November) for the December 1, 2017 plan year. When is Call 4 Health s plan year? Call 4 Health s plan year runs from December 1, November 30, Can I change my benefit elec ons? You can only change your coverage level within thirty (30) days of a Qualifying Life Event: Example: Marriage, Divorce, Birth or Adop on, Death of a Spouse, Death of a Dependent, Loss of Dependent Status, and Loss of Spouse s job where coverage is maintained through the spouse s plan. (see Qualifying Events on preceding page) All other changes will be deferred to Open Enrollment. 4

7 Affordable Care Act The Affordable Care Act is also commonly referred to as Health Care Reform. Beginning January 1, 2014, most individuals (adults and children) will be required to pay a shared responsibility penalty unless they have qualified health care coverage. The law requires you to maintain minimum essen al coverage, such as coverage under: An employer-sponsored group health plan; or Medicare, Medicaid, Florida KidCare, Tri-Care or other Veteran s health programs; or An individual health insurance policy offered Government sponsored plans in the individual market or through an exchange. There are poten al penal es that could be imposed by the IRS for failure to maintain minimum essen al coverage which are as follows: 2016 and beyond - Greater of $695 per adult and $ per child (up to $2,085 for a family) or 2.5% of family income Health Insurance Marketplace On October 1, 2013, the Federal government established the Health Insurance Marketplace. The Marketplace (also known as the health insurance exchange ) allows individuals to compare and purchase private health insurance plans. Some individuals may be eligible for a premium subsidy from the federal government to assist in paying for such plans. Because all of Call 4 Health s Medical Plan op ons exceed the federally required standards for minimum value and affordability, you may not be eligible for any federal premium subsidies or tax credits to assist you in paying for the cost of the Marketplace coverage. Please visit for more informa on and to apply. 5

8 Medical Insurance Florida Blue is our medical insurance carrier. You have the op on of elec ng from five (5) PPO Plans. The PPO plans provide In and Out-of-Network coverage. You may locate a physician by visi ng and select the specific network. For detailed coverages, exclusions, and s pula ons, please refer to Florida Blue's summary of coverage or contact Member Services. Benefits Descrip on ACA BlueOp ons PPO ACA BlueOp ons PPO ACA BlueOp ons PPO Op on 1 Op on 2 Op on 3 In Network Network Name BlueOp ons BlueOp ons BlueOp ons Deduc ble--individual/family $5,000 / $10,000 $500 / $1,500 $2,000 / N/A Coinsurance 30% 20% 50% Out of Pocket Max Individual/Family $6,350 / $12,700 $2,500 / $5,000 $6,350 / $12,700 Includes Deduc ble, Coinsurance, Deduc ble, Coinsurance, Deduc ble, Coinsurance, Copays, & RX Copays Copays, & RX Copays Copays, & RX Copays Office Visits Primary Care Physician (PCP) $30 $20 $30 PCP Selec on Required No No No Specialist $55 $40 $75 Referral Necessary No No No Hospital / Facility Services Inpa ent 30% a er deduc ble $1,000 copay $3,000 copay Outpa ent Hospital 30% a er deduc ble $300 copay $400 copay Ambulatory Surgical Center Services 30% a er deduc ble $100 copay 50% a er deduc ble Advanced Imaging (MRI, CT Scans) at Hospital Facility 30% a er deduc ble $300 copay $400 copay Physician Hospital including ER 30% a er deduc ble 20% a er deduc ble 50% a er deduc ble Other Services Emergency Room (waived if admi ed) $300 copay $100 copay 50% a er deduc ble Urgent Care $60 copay $45 copay 50% a er deduc ble Advanced Imaging (MRI, CT Scans) at Independent Facility 30% a er deduc ble $150 copay $200 copay Physician Other Facili es 30% a er deduc ble 20% a er deduc ble 50% a er deduc ble Prescrip on Drugs Retail, Tier 1 / 2 / 3 $10 Generic / $10 Generic / $10 /$50 /$80 20% (Limited RX) 20% (Limited RX) Mail Order (90 Day) 2.5x Retail of Generics ONLY 2.5x Retail 2.5x Retail of Generics ONLY Non Network (Balance Billing May Apply) Deduc ble--individual/family $10,000 / $30,000 $750 /$2,250 $6,000 / N/A Coinsurance 50% 40% 50% Out of Pocket Max-Individual/Family $20,000 / $40,000 $5,000 / $10,000 $30,000 / $30,000 Coverage Level ACA BlueOp ons PPO ACA BlueOp ons PPO ACA BlueOp ons PPO Cost per Paycheck Cost per Paycheck Cost per Paycheck Employee Only $63.75 $ $77.01 Employee + Spouse $ $ $ Employee + Child(ren) $ $ $ Family $ $ $ Note that Preven ve Services Covered at No Cost In-Network Based on Carrier Guidelines. No Life me Maximums on All Plans. Out-of-Network charges are subject to Usual, Customary and Reasonable (UCR) charge limita ons and Balance Billing. Deduc bles must be sa sfied before coinsurance applies. 6

9 Medical Insurance Benefits Descrip on ACA BlueOp ons PPO ACA BlueOp ons PPO Op on 4 Op on 5 In Network Network Name BlueOp ons BlueOp ons Deduc ble--individual/family $2,500 / $7,500 $1,500 / N/A Coinsurance 20% 50% Out of Pocket Maximum--Individual/Family $6,000 / $12,000 $6,350 / $12,700 Includes Deduc ble, Coinsurance, Copays, & Deduc ble, Coinsurance, Copays, & RX Copays RX Copays Office Visits Primary Care Physician (PCP) $35 $35 PCP Selec on Required No No Specialist $65 $50 Referral Necessary No No Hospital / Facility Services Inpa ent 20% a er deduc ble $2,500 copay Outpa ent Hospital 20% a er deduc ble $400 copay Ambulatory Surgical Center Services 20% a er deduc ble 50% a er deduc ble Advanced Imaging (MRI, CT Scans) at Hospital Facility 20% a er deduc ble $400 copay Physician Hospital including ER 20% a er deduc ble 50% a er deduc ble Other Services Emergency Room (waived if admi ed) 20% a er deduc ble 50% a er deduc ble Urgent Care $70 copay 50% a er deduc ble Advanced Imaging (MRI, CT Scans) at Independent Facility $450 copay $200 copay Physician Other Facili es 20% a er deduc ble 50% a er deduc ble Prescrip on Drugs Retail, Tier 1 / 2 / 3 $10 /$50 /$80 $10 /$50 /$80 a er $100 Brand Deduc ble Mail Order (90 Day) 2.5x Retail 2.5x Retail Non Network (Balance Billing May Apply) Deduc ble--individual/family $5,000 / $15,000 $4,500 / N/A Coinsurance 40% 50% Out of Pocket Maximum--Individual/Family $8,000 / $20,000 $20,000 / $20,000 Coverage Level ACA BlueOp ons PPO ACA BlueOp ons PPO Cost per Paycheck Cost per Paycheck Employee Only $ $ Employee + Spouse $ $ Employee + Child(ren) $ $ Family $ $ Note that Preven ve Services Covered at No Cost In-Network Based on Carrier Guidelines. No Life me Maximums on All Plans. Out-of-Network charges are subject to Usual, Customary and Reasonable (UCR) charge limita ons and Balance Billing. Deduc bles must be sa sfied before coinsurance applies. 7

10 Medical Insurance Programs Member Website: Florida Blue Log on to to register and receive 24-hour online access for you to review your benefits, order ID cards, view claim status, search for providers in your network, download forms, search FAQ's, and learn about discount programs. Verify personal informa on Request informa on Find a provider Review your coverage Download forms Learn about discount programs Search frequently asked ques ons View Rx Formulary View & print claims (EOBs) Provider Directory Online How to Find a Doctor The search tool allows you to receive up-to-date provider lists by going to Click Find a Doctor and scroll to the bo om of the page and click Doctors & Hospitals Na onally. This will take you to the Na onal network for your medical plan. The network name is BlueCard PPO/EPO. Board Cer fica on Office Hours Loca on & Direc ons Hospital Affilia on Language Spoken Plans Accepted Florida Blue Mobile Applica on Access health informa on and tools on the go Works on any Smartphone iphone, Android, and even the ipad Just type in FloridaBlue.com from your mobile browser and download the FREE app from your iphone or Android Save Time. Save Money. Stay Healthy Emergency Care vs. Urgent Care Florida Blue has a wide network of urgent care providers that can handle those less serious types of medical events that may occur. For minor medical emergencies such as ear aches, sore throat, colds, minor cuts requiring s tches, minor breaks, etc. you can u lize one of the many urgent care providers saving you both me and money. Emergency room visits should be limited to life or limb threatening medical situa ons such as heart a ack, stroke, major wounds, or breaks, etc. In addi on to Urgent Care centers, you can also visit a Convenience Care Clinic or walk-in medical clinic at CVS or Walgreens. These centers can help with minor illness such as common cold, sinus or ear infec ons, strep throat, minor dermatological condi ons, etc. These clinics typically have evening and weekend hours. Discount Program: Blue365 This is a FREE member discount program on products and services available to all members such as: Fitness Programs: Discounts on memberships, fees, services and supplies are offered at par cipa ng providers. Weight Management Programs: Discounts on memberships, services and supplies are available at par cipa ng providers. Hearing Products: Members receive discounts for hearing examina ons, hearing aids and supplies purchased at par cipa ng providers. Vision: Preferred pricing and discounts on frames, lenses, and contact lenses at par cipa ng providers. Laser Vision Correc on Services: Discounted rates through par cipa ng providers. Alterna ve Medicine: Discounts are available for Acupuncturists, Chiropractors, Massage Therapists and Die cians. Tobacco Cessa on: Discounts through par cipa ng providers. 8

11 Terms to Know Allowed Amount The maximum amount of which the medical plan bases payments for covered services. This may also be call eligible expense, payment allowance, or nego ated rate. When accessing services out-ofnetwork, if a provider charges more than the allowed amount you may have to pay the difference. Coinsurance The percentage of the charges you are responsible for paying when you get care (i.e. the plan pays 90% and you pay 10%) un l you meet your out-of-pocket maximum. Copay The fee you pay to the provider based on the care or service you receive. Deduc ble The amount you must pay for certain services each plan year before the plan begins to pay benefits. In-Network The doctors, hospitals, laboratories, pharmacies, etc. that are par cipa ng providers in your plan s network. Out-of-Network The doctors, hospitals, laboratories, pharmacies, etc. that are NOT par cipa ng providers in your plan s provider network. When the provider is outside the network, the plan pays a lower benefit. Out-of-Pocket Maximum The maximum amount you would pay for covered care during the calendar year, including copays, deduc bles, coinsurance and prescrip ons. Plan Year The period from December 1, 2016 through November 30, Preventa ve / Well-care Comprehensive care emphasizing priori es for preven on, early detec on and early treatment of condi ons, generally including rou ne physical examina on, immuniza on and well person care. The plan pays 100% of the cost of in-network preventa ve care. 9

12 Dental Insurance Humana is our PPO dental insurance carrier. The PPO dental plan provides In and Out-of-Network coverage. You may locate a provider by visi ng or call For detailed coverages, exclusions, and s pula ons, please refer to Humana s summary of coverage or contact Member Services. Plan Name PPO Tradi onal INFS Preferred 09 Network Access In-Network Out-of-Network Network Name / OON Schedule Tradi onal Preferred INFS Calendar Year Maximum $1,500 Deduc bles Individual $50 $50 Family $150 $150 Deduc ble Waived Preventa ve - Class 1 Dental Descrip on Analysis Office Visit 100% 100% Preven ve - Class I Rou ne Exams 100% 100% Teeth Cleaning 100% 100% Teeth Cleaning Frequency Two (2) regular cleanings and two (2) addi onal periodontal cleanings every calendar year Panoramic X-rays 100% 100% Basic - Class II Fillings 20% a er deduc ble 20% a er deduc ble Extrac on - Simple per Tooth 20% a er deduc ble 20% a er deduc ble Periodontal Scaling 20% a er deduc ble 20% a er deduc ble Endodon cs - Root Canals 20% a er deduc ble 20% a er deduc ble Major - Class III Crowns 50% a er deduc ble 50% a er deduc ble Par al Dentures 50% a er deduc ble 50% a er deduc ble Full Dentures 50% a er deduc ble 50% a er deduc ble Orthodon a Benefit 20% Discount Only 20% Discount Only Age Limit N/A N/A Life me Maximum N/A N/A Coverage Level Cost per Paycheck Coverage Level Cost per Paycheck Employee Only $15.18 Employee + Spouse $34.35 Employee + Child(ren) $29.22 Family $48.96 PPO: Note that Non-par cipa ng den sts can bill you for charges above the amount covered by your HumanaDental plan. To ensure you do not receive addi onal charges, visit a par cipa ng PPO Network den st. If a member sees an Out-of-Network den st, the coinsurance level will apply to the average nego ated In-Network Fee Schedule (INFS) in your area. 10

13 Vision Insurance Humana is our vision insurance carrier. The plan provides In and Out-of-Network coverage through the Humana VCP network. You will receive the maximum level of coverage when you use a preferred In-Network provider. You may locate a provider by visi ng or call For detailed coverages, exclusions and s pula ons, please refer to Humana's summary of benefits or contact Member Services. Plan Name Humana Vision Care Plan Voluntary Network Access In-Network Out-of-Network Network VCP N/A Exam Copay $10 Up to $35 Reimbursement Materials Copay $15 N/A Frequency Exam Lenses Contact lenses 12 Months 12 Months 12 Months Frames 24 Months Frames Frames - Private Prac ce $50 Wholesale Allowance $45 Retail Allowance Frames - Retail Establishment $50 Wholesale Allowance $45 Retail Allowance Addi onal Discount 20% Discount N/A Lenses Single Material Copay Up to $25Reimbursement Bifocal Material Copay Up to $40 Reimbursement Trifocal Material Copay Up to $60 Reimbursement Addi onal Lens Upgrade Op ons Polycarbonate (Children) No Charge N/A Scratch Resistant 20-30% Discount N/A Progressive - Standard 20-30% Discount N/A Addi onal Glasses 20-30% Discount N/A Contact lenses - In Lieu of Glasses Elec ve (conven onal and disposable) $150 Allowance $150 Allowance Contacts - Medically Necessary No Charge Up to $210 Reimbursement Contact Lens Evalua on & Fi ng Included in allowance Included in allowance Laser Correc on Discount Off Regular Price Set copays for TLC, LasikPlus or QualSight LASIK or 10% Discount at independent Lasik provider, no more than $1,800 per eye for Conven onal Lasik / $2,300 per eye Custom Lasik N/A Coverage Level Cost per Paycheck Employee Only $3.73 Employee + Spouse $7.45 Employee + Child(ren) $7.08 Family $

14 Humana Informa on 12

15 Employer Paid Life and AD&D Insurance Life Insurance Call 4 Health provides Basic Life Insurance and Accidental Death & Dismemberment (AD&D) coverage to all eligible employees at no cost through Unum in the amount of $20,000 for all full me employees. Accidental Death & Dismemberment Insurance (AD&D) This AD&D insurance plan provides financial protec on for your beneficiary(ies) by paying a benefit in the event of your death or for you in the event of any other covered loss. (i.e. life, sight, limb, etc.) See Group Term Life Policy for further details. Eligibility: All full- me employees working a minimum of 30 hours or more per week are eligible for coverage first of the month following successful comple on of new hire wai ng period. Reduc on in Benefit Amounts: A ained Age Amount of Benefit Reduc on Age 70 Reduced by 35% Age 75 Reduced by 50% Cost: 100% Employer paid 13

16 Employee Assistance Program Work-life balance Employee Assistance Program Work-life balance employee assistance program provides access to a comprehensive employee assistance and worklife program for the insured employee and their family, to help manage workplace stress and deal more effec vely with personal issues ranging from severe to everyday problems. As an addi onal feature your work-life balance employee assistance program - provided at no addi onal charge through your company s insurance benefit plan - can help you find solu ons for the everyday challenges of work and home as well as for more serious issues involving emo onal and physical well-being. Childcare/ or eldercare referrals Personal rela onship informa on Health informa on and online tools Legal consulta ons with licensed a orneys Financial planning assistance Stress Management Career development Health Advocate Health Advocate is a service provided at no cost to you. With Health Advocate you have confiden al, unlimited access to a Personal Health Advocate who can help you and your eligible family members resolve healthcare and insurancerelated Issues, as well as es mate costs for medical procedures all through a single toll-free number or How can they help: Find the right doctors, hospitals and other providers Schedule appointments, transfer medical records Explain condi ons and research latest treatments Resolve billing and insurance claims issues Secure second opinions Clarify benefits and get approvals for covered services Find op ons for non-covered services Es mate costs for medical procedures and nego ate payments Locate eldercare services 14

17 COBRA No ce COBRA Ini al No ce Con nua on Coverage Rights Under COBRA You are receiving this no ce because you have recently become covered under a group health plan (Call 4 Health). This no ce contains important informa on about your right to COBRA con nua on coverage, which is a temporary extension of coverage under the Plan. This no ce generally explains COBRA con nua on coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. The right to COBRA con nua on coverage was created by a federal law, the Consolidated Omnibus Budget Reconcilia on Act of 1985 (COBRA). COBRA con nua on coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. For addi onal informa on about your rights and obliga ons under the Plan and under federal law, you should review the Plan s Summary Plan Descrip on or contact the Plan Administrator. What is COBRA con nua on coverage? COBRA con nua on coverage is a con nua on of Plan coverage when coverage would otherwise end because of a life event known as a qualifying event. Specific qualifying events are listed later in this no ce. A er a qualifying event, COBRA con nua on coverage must be offered to each person who is a qualified beneficiary. You 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 con nua on coverage must pay for COBRA con nua on coverage. If you are a team member, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens: Your hours of employment are reduced, or Your employment ends for any reason other than your gross misconduct. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because any of the following qualifying events happens: 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 en tled 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 coverage available? The Plan will offer COBRA con nua on coverage to qualified beneficiaries only a er the Plan Administrator has been no fied that a qualifying event has occurred. When the qualifying event is the end of employment or reduc on of hours of employment, death of the employee, commencement of a proceeding in bankruptcy with respect to the employer, or the employee s becoming en tled to Medicare benefits (under Part A, Part B, or both), the employer must no fy the Plan Administrator of the qualifying event. You Must Give No ce of some Qualifying Events For the other qualifying events (divorce or legal separa on of the employee and spouse or a dependent child s losing eligibility for coverage as a dependent child), you must no fy the Plan Administrator within sixty (60) days a er the qualifying event occurs. 15

18 COBRA No ce How is COBRA coverage provided? Once the Plan Administrator receives no ce that a qualifying event has occurred, COBRA con nua on coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA con nua on coverage. Covered employees may elect COBRA con nua on coverage on behalf of their spouses, and parents may elect COBRA con nua on coverage on behalf of their children. COBRA con nua on coverage is a temporary con nua on of coverage. When the qualifying event is the death of the employee, the employee s becoming en tled to Medicare benefits (under Part A, Part B, or both), your divorce or legal separa on, or a dependent child s losing eligibility as a dependent child, COBRA con nua on coverage lasts for up to a total of thirty-six (36) months. When the qualifying event is the end of employment or reduc on of the employee s hours of employment, and the employee became en tled to Medicare benefits less than eighteen (18) months before the qualifying event, COBRA con nua on coverage for qualified beneficiaries other than the employee lasts un l thirty-six (36) months a er the date of Medicare en tlement. For example, if a covered employee becomes en tled to Medicare eight (8) months before the date on which his employment terminates, COBRA con nua on coverage for his spouse and children can last up to thirty-six (36) months a er the date of Medicare en tlement, which is equal to twenty-eight (28) months a er the date of the qualifying event (thirty-six (36) months minus eight (8) months). Otherwise, when the qualifying event is the end of employment or reduc on of the employee s hours of employment, COBRA con nua on coverage generally lasts for only up to a total of eighteen (18) months. There are two ways in which this eighteen (18) month period of COBRA con nua on coverage can be extended. Disability extension of eighteen (18) month period of con nua on coverage: If you or anyone in your family covered under the Plan is determined by the Social Security Administra on to be disabled and you no fy the Plan Administrator in a mely fashion, you and your en re family may be en tled to receive up to an addi onal eleven (11) months of COBRA con nua on coverage, for a total maximum of twenty-nine (29) months. The disability would have to have started at some me before the 60th day of COBRA con nua on coverage and must last at least un l the end of the eighteen (18) month period of con nua on coverage. Second qualifying event extension of eighteen (18) month period of con nua on coverage: If your family experiences another qualifying event while receiving eighteen (18) months of COBRA con nua on coverage, the spouse and dependent children in your family can get up to eighteen (18) addi onal months of COBRA con nua on coverage, for a maximum of thirty-six (36) months, if no ce of the second qualifying event is properly given to the Plan. This extension may be available to the spouse and any dependent children receiving con nua on coverage if the employee or former employee dies, becomes en tled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Ques ons Ques ons concerning your Plan or your COBRA con nua on coverage rights should be addressed to the contact or contacts iden fied below. For more informa on about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affec ng group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor s Employee Benefits Security Administra on (EBSA) in your area or visit the EBSA website at ebsa. Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA s website. Keep Your Plan Informed of Address Changes In order to protect your family s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any no ces you send to the Plan Administrator. Plan Contact Informa on Informa on about the plan and COBRA con nua on coverage can be obtained on request from your Plan Administrator. Date: Plan Year Name of En ty/sender: HCAS of Florida dba Call 4 Health Contact Posi on/office: Human Resources Address: 2855 S. Congress Avenue Suites A & B Delray Beach, FL Phone Number: ext

19 Annual Employee No ces COBRA Con nua on of Health Coverage Benefits Under the Consolidated Omnibus Budget Reconcilia on Act (COBRA), employees and/or dependents may be able to con nue their enrollment in health plans if such coverage is terminated or due to a qualifying event. Upon plan termina on you will receive all required COBRA documents to your home address. Summary of Benefits and Coverage (SBC) You have access to a Summary of Benefits and Coverage (SBC). This document includes key provisions, limita ons, costsharing and examples explaining how your health plan works. The SBC is available through can be found on FOTC or by contac ng the HR department. Health Insurance Portability & Accountability Act (HIPAA) HIPAA requires prior health insurers and/or group plans to provide a Cer fica on of Creditable Coverage which applies to any applicable pre-exis ng condi ons. If you are declining enrollment for yourself or your eligible dependents because of other health insurance coverage, Special Enrollment Rights may in the future allow you to enroll yourself or your dependents in this plan, provided that you request enrollment within 30 days a er your other coverage ends. In addi on, if you have a new dependent as a result of marriage, birth or adop on, or placement for adop on; you may be able to enroll yourself and your dependents, provided you request enrollment within 30 days of the event. No ce of Enrollment Rights In addi on, if you have a new dependent as a result of marriage, birth, adop on, or placement for adop on, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days of the event. If you are declining enrollment for yourself or your dependents 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 contribu ng toward your or your dependents other coverage). However, you must request enrollment within 30 days (or any longer period that applies under the plan) a er your or your dependents other coverage ends (or a er the employer stops contribu ng toward the other coverage). Health Informa on Privacy No ce The Employer/Plan Sponsor of a Group Health Plan must comply with applicable federal and state laws to maintain the privacy of your protected health informa on (PHI). We may not use or disclose PHI for purposes other than enrollment, treatment, payment, opera ons and disclosures required by HIPAA law without a valid authoriza on. Women s Health and Cancer Rights Act of 1998 Your Employer s health plans provide benefits for mastectomy-related services including all stages of reconstruc on and surgery to achieve symmetry between the breasts, prosthesis, and complica ons resul ng from a mastectomy, including lymph edema. Children s Health Insurance Program Reauthoriza on ACT (CHIPRA) of 2009 If you or a dependent is covered under a Medicaid or CHIP plan and coverage is terminated as a result of the loss of eligibility for Medicaid or CHIP coverage, you may be able to enroll yourself and/or your dependent(s). However, you must enroll within 60 days a er the date eligibility is lost. If you or a dependent becomes eligible for premium assistance under an applicable State Medicaid or CHIP plan to purchase coverage under the group health plan, you may be able to enroll yourself and/or your dependent(s). However, you must enroll within 60 days a er you or your dependent is determined to be eligible for state premium assistance. Please note that premium assistance is not available in all states. Mental Health Parity Act (MHPA) A plan may not impose limita ons in life me or annual dollar limits for mental health benefits which differs from those of the medical and surgical benefits of the plan. 17

20 Annual Employee No ces Michelle s Law Your Employer s health plans allows for con nued coverage for dependent children who are covered under our 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 a er December 1, If your child is no longer a student, as defined in your Cer ficate of Coverage, because he or she is on a medically necessary leave of absence, your child may con nue to be covered under the plan for up to one year from the beginning of the leave of absence. This con nued coverage applies if your child was (1) covered under the plan and (2) enrolled as a student at a post-secondary educa onal ins tu on (includes colleges, universi es, some trade schools and certain other post-secondary ins tu ons). Your Employer will require a wri en cer fica on 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. Newborns and Mothers Health Protec on Act Group health plans and insurers may not restrict benefits for hospital length of stay for mother or newborn child in connec on with vaginal childbirth to less than 48 hours or less than 96 hours following a cesarean sec on delivery. Medicare Part D Creditable Coverage Your Employer s Florida Blue prescrip on drug coverage provided for BlueCare HMO 62, BlueOp ons PPO 03559, BlueOp ons PPO 03900, and BlueOp ons PPO by are considered Creditable Coverage under Medicare Part D. The prescrip on drug coverage provided for BlueOp ons PPO and BlueOp ons PPO are NOT considered Creditable Coverage under Medicare Part D. If you or your dependents are or will be eligible for Medicare, you may obtain more informa on by reques ng a Medicare D Disclosure of Creditable Coverage No ce. 18

21 Payroll Deduc ons Bi-Weekly Payroll Deduc ons (26 Payroll Deduc ons) Medical Insurance - FloridaBlue Plan Name ACA BlueOp ons PPO ACA BlueOp ons PPO ACA BlueOp ons PPO Employee $63.75 $ $77.01 Employee + Spouse $ $ $ Employee + Child(ren) $ $ $ Family $ $ $ Plan Name ACA BlueOp ons PPO ACA BlueOp ons PPO Employee $ $ Employee + Spouse $ $ Employee + Child(ren) $ $ Family $ $ Voluntary Dental Insurance - Humana Plan Name PPO - INFS Trad Pref 09 Employee $15.18 Employee + Spouse $34.35 Employee + Child(ren) $29.22 Family $48.96 Voluntary Vision Insurance - Humana Plan Name Vision Employee $3.73 Employee + Spouse $7.45 Employee + Child(ren) $7.08 Family $

22 Notes 20

23 This summary has been prepared by: CBIZ Benefits and Insurance Services, Inc. The informa on in this guide is a summary of the benefits available to you and is not intended to take the place of the carrier s official Member Cer ficates or our plan s Summary Plan Descrip on (SPD). This guide contains a general descrip on of the benefits to which you and your eligible dependents may be en tled to as an eligible employee. This guide does not change or otherwise interpret the terms of the official plan documents. To the extent that any of the informa on contained in this guide is inconsistent with the official plan documents, the provisions of the official documents will govern in all cases and the plan documents and carrier cer ficates will prevail.