Headcount Group Healthcare Plan

Headcount Group Healthcare Plan Our options include a choice of three major medical health plans which meet or exceed the Affordable Care Act s ( ACA ) Affordability and Quality standards and a Minimum Essential Coverage plan (MEC). Enrollment in any of the major medical plans or the MEC plan allow you to avoid tax penalties prescribed by the ACA for failure to be enrolled in a health plan. If you enroll on one of the major medical plans a pre tax deductions of up to 9.56% of wages will be made from your paycheck to cover the employee share cost of the base plan (the Healthy Value 3500). If you desire one of the richer benefit plans you may pay the difference between the costs of the base plan and the cost of the enhanced plans as described on the accompanying charts. We realize, however, that not all employees will be able to shoulder the employee share cost of the major medical plans. Therefore, all full time employees who are not enrolled on valid health plan outside of Headcount and who do not enroll on one of the major medical plans offered will automatically be enrolled onto the MEC plan. This low cost option will also protect you from paying the individual tax penalty and offers you valuable benefits. The employee cost share is a pre tax deduction of $6.15 during every weekly payroll cycle. Please keep in mind that the cost would be $12.30 if the employee gets paid bi weekly. Affordable Care Act Summary The Affordable Care Act (ACA) requires that individuals be enrolled in a health insurance plan or pay a tax penalty. This is known as the individual mandate. If you do not participate in a company sponsored health plan, a government plan, such as Medicaid, Medicare, or Tri med or a privately purchased health plan you are subject to a tax penalty. The 2016 the penalty is the greater of 2.5% of your annual household income or $695 per adult and $347.50 per child under 18 to a maximum penalty of $2,085 per family. Please note that an individual whose employer offers health plans that meet the ACA s affordability and quality standards (as Headcount s plans do) is not eligible for a subsidy through the health exchange. However, you may still be eligible for Medicaid and your family s eligibility for subsidies via the health exchanges or Medicaid will not be affected. If you have any questions about the health plans please Headcount via email at support@headcountmgmt.com or by phone at 212 803 7103. Please cc our health consultant Matt Wade at mwade@gficap.com on the email as well.

Who is eligible? Full time hourly employees (those working an average of 30 hours or more per week): 1 st of the month 1 st day of the month following 60 days of service. If you are eligible for benefits, you also may enroll these members of your family: Your Spouse Your Domestic Partner. Your Domestic Partner s children. Biological children, adopted children and children legally placed for adoption through age 25. Your Stepchildren, including your Spouse s biological children, adopted children and children legally placed with him or her for adoption through age 25. Children in Legal Guardianship, including grandchildren, siblings, nieces or nephews for whom the court has granted you, your Spouse or Domestic Partner full and plenary Legal Guardianship for them and their estate through age 25. Children in Legal Guardianship, including grandchildren, siblings, nieces or nephews for whom the court has granted you, your Spouse or Domestic Partner full and plenary Legal Guardianship for them and their estate through age 25. Mentally or physically disabled children past the normal age limit provided they meet the federal requirements. Next Steps If you are eligible for benefits: 1. Select a plan on the Employee Election form or decline benefits by completing the form. 2. To enroll additional family members, select the plan rate to indicate enrollment. 3. Complete the health application.

Effective Date: Jan 01, 2015 Key Features: Provides coverage for the 64 preventive and wellness services needed to provide Minimum Essential Coverage. First dollar coverage no deductibles or co-insurance. No medical underwriting required. No pre-existing condition limitations. No waiting periods. 24/7/365 telephonic doctor consultation services at no cost. Access to additional discounted service options for lab, pharmacy, and other health related products and services. Prepared By: First National Administrator Proposal Date: Dec 17, 2014

An Essential Foundation Why HealthyEssentials? The Lifestyle Health HealthyEssentials plan is designed to be a minimal essential benefit plan. Minimum Essential Coverage Plans are designed to provide 100% coverage for the 64 preventive and wellness services as designated by Centers for Medicare and Medicaid Services (CMS). In addition, HealthyEssentials provides additional benefits to members including telephonic physician consultation services at no cost and access to discounts on other key healthcare services such as outpatient lab and pharmacy services.... Key Features of the HealthyEssentials Plan Provides coverage for the 64 preventive and wellness services needed to provide Minimum Essential Coverage. First dollar coverage no deductibles or co-insurance. No medical underwriting required. No pre-existing condition limitations. No waiting periods. 24/7/365 telemed consults included. 24/7/365 telephonic doctor consultation services at no cost to members. Access to additional discounted service options for lab, pharmacy, and other health related products and services. V101314b

HealthyEssentials COVERED BENEFIT SUMMARY HealthyEssentials offers the following covered benefits to provide the Minimum Essential Coverage critical for PPACA compliance for large employers. 15 COVERED PREVENTIVE SERVICES FOR ADULTS (AGES 18 AND OLDER) 1. Abdominal Aortic Aneurysm - one time screening for age 65-75 2. Alcohol Misuse screening and counseling 3. Aspirin use for men ages 45-79 and women ages 55-79 to prevent CVD when prescribed by a physician 4. Blood Pressure screening for all adults 5. Cholesterol screening for adults 6. Colorectal Cancer screening for adults starting at age 50 limited to one every 5 years 7. Depression screening for adults 8. Type 2 Diabetes screening for adults 9. Diet counseling for adults 10. HIV screening for adults 11. Immunizations vaccines for adults (Hepatitis A & B, Herpes Zoster, Human Papillomavirus, Influenza (flu shot), Measles, Mumps Rubella, Meningococcal, Pneumococcal, Tetanus, Diptheria, Pertussis) 12. Obesity screening and counseling for all adults 13. Sexually Transmitted Infection (STI) prevention counseling for adults 14. Tobacco Use screening for all adults and cessation interventions 15. Syphilis screening for all adults... 23 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 Chemoprevention counseling for women 6. Breastfeeding comprehensive support / counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women. Non-network services will be payable as network services. 7. Cervical Cancer screening 8. Chlamydia Infection screening 9. Contraception: FDA-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 12. Gestational diabetes screening 13. Gonorrhea screening for all women 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 60 18. Routine prenatal visits for pregnant women 19. Rh Incompatibility screening for all pregnant women and follow-up testing 20. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users 21. Sexually Transmitted Infections (STI) counseling 22. Syphilis screening 23. Well-woman visits to obtain recommended preventive services V101314b

HealthyEssentials COVERED BENEFIT SUMMARY (CONT.) HealthyEssentials offers the following covered benefits to provide the Minimum Essential Coverage critical for PPACA compliance for large employers. 26 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 17) 4. 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 Chemoprevention 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 Haemophilus influenzae type b Hepatitis A Hepatitis B Human Papillomavirus Inactivated Poliovirus Influenza (Flu Shot) Measles, Mumps, Rubella Meningococcal Pneumococcal Rotavirus Varicella 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 10 23. 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 5 V101314b

Integrated Benefits As a Lifestyle Health Plans product, all HealthyEssentials Plans include unique, industry-leading value added benefits that further differentiate our product among the growing number of MEC plans on the market today. LifestyleMD Telemed Consultations All HealthyEssentials plan participants have access to licensed physicians 24/7/365 via phone or e-mail and will enjoy knowledgeable, on-demand, access to telemedicine consultations at no additional cost. A value added feature that improves access while reducing costs due to unnecessary office, urgent care or emergency room visits. Available as an integrated benefit at $0 Copay for HealthyEssentials plan participants.... DirectHealth Mall Discount Program Integrated into our Lifestyle Health program is access to DirectHealth Mall, a unique employee discount program designed to save plan participants money. DirectHealth Mall is a unique consumerdirect website that offers discount savings in the categories of outpatient lab testing, diabetic supplies, medical supplies, prescription, elective medical services, vision, dental, diet and fitness, and more. HealthyEssentials plan participants have direct access to this discount portal as an integrated feature of the plan design!... PPO Network Discounts Through our PPO network partnerships, HealthyEssentials plan participants have access to network discounts on major medical services. Ask a Lifestyle Health Plans sales associate for more details. V101314b

Plan HealthyChoice 1500 Healthy 100 HealthyValue 3500 MEC Plus Network Magnacare Magnacare Magnacare Effective Date 1/1/2015 1/1/2015 1/1/2015 Deductible $1,500 Single / $3,000 Family $2,500 Single / $5,000 Family $3,500 Single / $7,000 Family Lifestyle Deductible $500 Single / $1,000 Family reduction of member deductible based on Healthy Reward $500 Single / $1,000 Family reduction of member deductible based on Healthy Reward $500 Single / $1,000 Family reduction of member deductible based on Healthy Reward Co-insurance 20% 0% 20% Co-insurance Maximum $2,500 single / $5,000 Family No Coinsurance Liability $2,500 single / $5,000 Family Preventive Services 100% 100% 100% Professional Office Visits $30 Copay Primary Care $50 Copay Specialist $30 Copay Primary Care $50 Copay Specialist $30 Copay Primary Care $50 Copay Specialist Telephonic Physician Consultations $0 Copay $0 Copay $0 Copay Outpatient Lab 100% if preferred vendor, otherwise Deductible 100% if preferred vendor, otherwise Deductible 100% if preferred vendor, otherwise Deductible (Lab Corp is the Preferred Vendor) / Co-insurance / Co-insurance / Co-insurance Medicaid Outpatient Radiology Medicare Diabetic Supplies 100% if preferred vendor, otherwise Deductible / Co-insurance 100% if preferred vendor, otherwise Deductible / Co-insurance 100% if preferred vendor, otherwise Deductible / Co-insurance A Veteran's Health Plan Allergy Treatment $25 Copay, then 100% to $100 per visit $25 Copay, then 100% to $100 per visit $25 Copay, then 100% to $100 per visit My spouse's plan Outpatient Rehab & Therapy *Chiropractic Services Professional Services My parent's plan (Services outside of an office setting) Emergency Services *Hospital ER (Facility Charge Only) $150 Copay, then 100% to $1,000 per visit, then $150 Copay, then 100% to $1,000 per visit, then $250 Copay, then 100% to $1,000 per visit, then $50 Copay, then 100% to $300 per visit, then $50 Copay, then 100% to $300 per visit, then $50 Copay, then 100% to $300 per visit, then *Urgent Care / ER Professional Services *Ambulance Name of carrier: Outpatient Surgical & Therapeutic Procedures *Medical Facility Services *Physician & Surgeon Fees Inpatient Hospitalization Your ID #: *Medical Facility Services *Anesthesiologist & Surgeon Fees Employees with insurance please supply the following: Home Health, Skilled Nursing & Hospice Care Name of policy holder: Mental Health & Substance Abuse Durable Medical Equipment Prescription Drug Benefits *Preferred Network (Excludes CVS & Walmart) $20 or less / $50 / $75 / 50% $20 or less / $50 / $75 / 50% $20 or less / $50 / $75 / 50% Effective Date: (month and year) *Standard National Network $25 / $60 / $85 / 50% $25 / $60 / $85 / 50% $25 / $60 / $85 / 50% Dental Preventative & Diagnostic Covered 100 % - 2 Cleanings per year. Covered 100 % - 2 Cleanings per year. Covered 100 % - 2 Cleanings per year. Minor Restorative 80% 80% 80% Major Work 50% 50% 50% Deductible / Annual Limit Max Per Year None / None $1,000 None / None $1,000 None / None $1,000 I am not covered by a major medical Vision Eye Exam - Annual $10.00 $10.00 $10.00 insurance plan and decline to enroll on one here. I understand that I will be Lenses / Contacts- Frequency limit 1 x 12 Months 1 x 12 Months 1 x 12 Months placed on the MEC plan. Frames - No frequency limits 1 x 24 Months 1 x 24 Months 1 x 24 Months Max Per Year $130 $130 $130 Pre-Tax Employee Contribution (Per week) Single 9.56% of wages up to $97.47 9.56% of wages up to $93.58 9.56% of wages up to $80.17 $6.15 Couples, Employee w child(ren), Family I elect: (Circle One) Employee Election Form Health Plan Options 2015 (Employees on Weekly Payroll Cycle) Rate for the employee as above. Dependent premiums are 100% employee paid. Please contact Matt Wade at mwade@gficap.com for dependent premium costs. Healthy Choice 1500 Healthy 100 Healthy Value 3500 See Attachment I waive coverage in the company sponsored health plan because I am enrolled in: (Please circle one) MEC Plan Print and Sign Your Name Print Name: X

Employee Election Form Health Plan Options 2015 (Employees on Bi-Weekly Payroll Cycle) Plan HealthyChoice 1500 Healthy 100 HealthyValue 3500 Waiver / MEC plus Network Magnacare Magnacare Magnacare Effective Date 4/1/2016 4/1/2016 4/1/2016 Deductible $1,500 Single / $3,000 Family $2,500 Single / $5,000 Family $3,500 Single / $7,000 Family Healthy Rewards Program $500 Single / $1,000 Family reduction of member $500 Single / $1,000 Family reduction of member $500 Single / $1,000 Family reduction of member Reduction of deductible deductible based on Healthy Reward points deductible based on Healthy Reward points deductible based on Healthy Reward points Co-insurance 20% 0% 20% Co-insurance Maximum $2,500 single / $5,000 Family No Coinsurance Liability $2,500 single / $5,000 Family Preventive Services 100% 100% 100% Medicaid $30 Copay Primary Care $30 Copay Primary Care $30 Copay Primary Care Professional Office Visits $50 Copay Specialist $50 Copay Specialist $50 Copay Specialist Medicare Telephonic Physician Consultations $0 Copay $0 Copay $0 Copay A Veteran's Health Plan Outpatient Lab 100% if preferred vendor, otherwise Deductible / 100% if preferred vendor, otherwise Deductible / 100% if preferred vendor, otherwise Deductible / (Lab Corp is the Preferred Vendor) Co-insurance Co-insurance Co-insurance My spouse's plan Outpatient Radiology My parent's plan 100% if preferred vendor, otherwise Deductible / 100% if preferred vendor, otherwise Deductible / 100% if preferred vendor, otherwise Deductible / Employees with insurance please supply Diabetic Supplies Co-insurance Co-insurance Co-insurance the following: Allergy Treatment $25 Copay, then 100% to $100 per visit $25 Copay, then 100% to $100 per visit $25 Copay, then 100% to $100 per visit Name of carrier: Outpatient Rehab & Therapy *Chiropractic Services Professional Services (Services outside of an office setting) Emergency Services Your ID #: $150 Copay, then 100% to $1,000 per visit, then $150 Copay, then 100% to $1,000 per visit, then $250 Copay, then 100% to $1,000 per visit, then *Hospital ER (Facility Charge Only) $50 Copay, then 100% to $300 per visit, then $50 Copay, then 100% to $300 per visit, then $50 Copay, then 100% to $300 per visit, then Name of policy holder: *Urgent Care / ER Professional Services *Ambulance Outpatient Surgical & Therapeutic Procedures *Medical Facility Services Effective Date: (month and year) *Physician & Surgeon Fees Inpatient Hospitalization *Medical Facility Services Mark one below and sign where *Anesthesiologist & Surgeon Fees indicated: Home Health, Skilled Nursing & Hospice Care Mental Health & Substance Abuse Durable Medical Equipment Prescription Drug Benefits *Preferred Network (Excludes CVS & Walmart) $20 or less / $50 / $75 / 50% $20 or less / $50 / $75 / 50% $20 or less / $50 / $75 / 50% *Standard National Network $25 / $60 / $85 / 50% $25 / $60 / $85 / 50% $25 / $60 / $85 / 50% Dental I waive coverage in the company sponsored health plan because I am enrolled in: (Please circle one) I am covered by a major medical plan as indicated above and elect to waive participation in the company plan. Preventative & Diagnostic Covered 100 % - 2 Cleanings per year. Covered 100 % - 2 Cleanings per year. Covered 100 % - 2 Cleanings per year. Minor Restorative 80% 80% 80% I am not covered by a major medical Major Work 50% 50% 50% insurance plan and decline to enroll on Deductible / Annual Limit None / None None / None None / None Max Per Year $1,000 $1,000 $1,000 one here. I understand that I will be Vision placed on the MEC plan. Eye Exam - Annual $10.00 $10.00 $10.00 Lenses / Contacts- Frequency limit 1 x 12 Months 1 x 12 Months 1 x 12 Months Frames - No frequency limits 1 x 24 Months 1 x 24 Months 1 x 24 Months See "Healthy Essentials" Attachment Max Per Year $130 $130 $130 Pre-Tax Employee Contribution (Bi Weekly) Single 9.50% of wages up to $194.94 9.50% of wages up to $187.16 9.50% of wages up to $160.34 $12.30 Couple - Add to Single Rate $204.36 $200.65 $170.55 Employee with child(ren) - Add to Single Rate $171.43 $168.73 $143.46 Family - Add to Single Rate $407.85 $398.26 $340.73 I elect: (Circle One) Healthy Choice 1500 Healthy 100 Healthy Value 3500 MEC Plan Print and Sign Your Name Print Name: X

Health Application Form Section 1: Employer Information Employer Name: Hire Date: Employer Address: City: State: Zip: Section 2: Employee Information Employee Name: Date of Birth: Last First M.I. Address: Job Title City State Zip Marital Status: Single Divorced Married Widowed Home Phone: ( ) Cell Phone: ( ) E-mail Address: Hours Worked per Week: Spouse s Employer: Spouse s Business Phone: ( ) Section 3: Other Insurance Coverage Are you or any dependent(s) disabled YES NO If YES, please indicate name(s): Do you or your spouse have other health insurance? YES NO If YES, name of Carrier: Policy Holder s Name: Policy #: Effective Date: Name of Covered Dependents: Section 4: Prior Coverage Information To eliminate or reduce pre-existing condition waiting periods; a copy of your Certificate of Creditable Coverage from your current carrier will be required when enrollment in the program is completed. Submission of your prior coverage information does not automatically waive any pre-existing condition limitations. Section 5: Subscriber / Dependents (Please complete for all participating dependents.) First Name MI Last Name Social Security # DOB Age M / F Tobacco Use YES / NO Section 6: Health Plan Enrollment Coverage Level Plan Selected Employee Only I elect to participate Employee / Spouse Options provided upon I decline participation Employee / Child(ren) underwriting approval Family Section 7: Health Information Please furnish us with the height and weight or you and your spouse: Self: Height feet inches; Weight Spouse: Height feet inches; Weight Ver.060614

Please answer the following questions regarding any medical treatment, conditions, or medical treatment for you and your family. If you answer Yes to any question please provide detail in space provided below. 1. Have you or any of your dependent(s) been diagnosed or treated for any of the following conditions in the past five (5) years? A. Cardiac Disorder Yes H. Aids / Immune System Disorder Yes B. Cancer (any form) Yes I. Alcohol / Drug Abuse Yes C. Diabetes Yes J. Mental / Nervous Disorder Yes D. Kidney Disorder Yes K. Neuromuscular Disorder Yes E. Respiratory Disorder Yes L. Stomach / Gastrointestinal Yes F. Liver Disorder Yes M. Arthritis, Back, Bone, Joint Disorder Yes G. High Blood Pressure Yes N. Seizures, convulsions, epilepsy Yes 2. Within the past 5 years, have you or any dependent ever had an application for insurance declined, postponed, rated, or otherwise modified?.. Yes 3. Have you or any of your dependent(s) had any medical conditions in the past 24 months requiring medical care, prescription management, or hospitalization in the amount of $5,000 or more?... Yes If Yes, please provide information on who and for what conditions in space provided below 4. Are you or any of your dependent(s) anticipating hospitalization or surgery, or had surgery or hospitalization recommended that has not been performed? If Yes please provide information below.. Yes 5. Are you or any dependent(s) currently pregnant or suspect you / they may be pregnant? If Yes, please provide due date and detail in space provided below. Yes Question Number Family Member Disease / Diagnosis / Treatment Date of Onset Month / Year Date Last Seen By Physician Remaining Symptoms or Problems 6. Prescriptions / Medications Please list any medications, prescriptions, or injections taken in the last 12 months. Family Member Medication / Rx / Injection Dosage Medical Condition Agreements The answers and statements on this Group Enrollment Form are true and complete. I agree that they shall form a part of the contract of insurance under which I am applying for coverage. I understand and agree that the insurance applied for shall not take effect until approved by the insurance carrier at its Home Office. I have read, or have had read to me, the completed application and I realize that any false statements or misrepresentation in the application may result in loss of coverage under the contract Medical Authorization I authorize any of the following to disclose any data it has on me, my health or on the health of my family. (1) any physician or other medical practitioner; (2) any hospital, clinic or other medical or medically related facility; (3) any insurance company; (4) The Medical Information Bureau; (5) any other organization, institution, or person that has any data on me or my health or on the health of my family. A copy of this shall be as valid as the original. Fraud Warning Any person who knowingly and with intent to defraud an insurer files an application or statement of claim containing false, incomplete or misleading information may be guilty of insurance fraud which is a crime. Section 8: Signature I hereby authorize my employer to deduct contributions towards my benefits. I hereby agree to abide by the terms and conditions of all benefit plan summary documents, which contain the benefits, limitations, and exclusions applicable to my health and other benefit coverage. I hereby authorize my healthcare providers to disclose information from my medical records to Medova Healthcare and their respective carriers to the extent necessary to for underwriting, benefit eligibility, and pre-existing condition determinations. Upon request, a customer service representative can explain my benefit coverage options. I have read and understand the above conditions and declarations. Employee Signature: Date: Ver.060614