OPEN ENROLLMENT EVENTS PDF Free Download

Department of Personnel Services Employee Benefits Office Dave Comerchero, Employee Benefits Manager County of Sacramento September 2014 Dear Retiree: Open Enrollment begins September 29, 2014 and ends October 24, 2014. As a result of last year s changes in medical carriers, there are only very modest increases in the 2015 medical premiums, and a significant decrease in the Kaiser Senior Advantage Medicare plan premiums. The retiree dental plan has been improved with increases to the in network benefit percentages for preventive and basic services, and a significant increase in the maximum allowable amounts for non network services. A comparison of the changes in estimated dental payments between 2013 and 2014 has been enclosed. Even if you do not plan on making any changes for 2015, you are strongly encouraged to review the 2015 Retiree Summary of Benefits for a thorough understanding of your benefits. IMPORTANT INFORMATION FOR 2015 Medical carriers and plans are unchanged for 2015. Kaiser, Sutter Health Plus and Western Health Advantage will be available in both Traditional $15 HMO co-pay plans and High Deductible HMO plans. Kaiser and UnitedHealthcare will still offer Medicare Advantage plans. High Deductible participants or medical waivers may still elect Optional Vision coverage under VSP. You only need to complete forms if you are making changes. If you are satisfied with your current medical or dental coverage, you do not need to do anything and your coverage will continue into 2015. If you wish to change medical plans, or add or drop dependents, you will need to complete the enclosed Retiree Open Enrollment Form. Note: additional forms are required when making changes to Kaiser Senior Advantage plans and are available from our office, at Open Enrollment events, or on our website at http://www.personnel.saccounty.net/benefits. If you wish to add or drop dental or vision you will need to complete the enclosed Retiree Open Enrollment Form. OPEN ENROLLMENT EVENTS 2014 LOCATION DATE TIME ATTENDEES DHHS 7001-A East Parkway Monday September 29 9 AM - 12 PM County Employees Benefits Office Insurance Carriers* County Administration 700 H Street Lobby Thursday October 2 9 AM 12 PM County Employee Benefits Office Insurance Carriers* Foothill Community Center 5510 Diablo Drive Friday October 17 9 AM 12 PM County Employee Benefits Office Insurance Carriers* 700 H Street, Suite 4667, Sacramento, California 95814 Phone (916) 874-2020 Fax (916) 874-4621 California Relay Service 7-1-1 www.saccounty.net

*Insurance Carriers Kaiser Permanente Sutter Health Plus Western Health Advantage UnitedHealthcare Principal Vision Service Plan - VSP Fidelity ICMA-RC ALL PLANS (effective 1/1/2015) Enrollment forms for any changes you make are due by October 24, 2014 by 5:00 PM. If you are adding a dependent to coverage you must bring (or submit) required documentation (described in the Summary of Benefits) to the Employee Benefits Office by October 31, 2014 by 5:00PM. Your dependent(s) will not be enrolled without proper documentation. If you have any questions about the Open Enrollment process, or if you need assistance, we strongly encourage you to look on our website: http://www.personnel.saccounty.net/benefits first to find the answer to your questions, links to the carriers and any forms you may need. You also have the option to attend an Open Enrollment Event to get your questions answered. Should you still have questions, please contact the Employee Benefits Office at (916) 874-2020 or by email at MyBenefits@saccounty.net. Respectfully, Dave Comerchero Benefits Manager IMPORTANT NOTICE: Legal instruments under which the Sacramento County Retiree Medical and Dental Insurance Program is created to provide that the plan does not create any contractual, regulatory, or other vested right or entitlement to either present or future retirees, their spouses, domestic partners, or dependents to any particular level of subsidization cost, or subsidization at all. Whether health plan offerings continue is vested within the sole discretion of the Sacramento County Board of Supervisors. Whether or not subsidization continues, and if so, the level of the subsidy, or whether or not a participating employer continues participation in the County Retiree Medical and Dental Insurance Program is vested within the sole discretion of each eligible, participating employer through agreement with the County of Sacramento.

County of Sacramento, Employee Benefits Office 700 H Street, Room 4667, Sacramento, CA 95814 RETIREE OPEN ENROLLMENT FORM Return By October 24, 2014 CONTACT US: 916.874.2020 PHONE 916.874.4621 FAX MyBenefits@SacCounty.net EMAIL http://www.personnel.saccounty.net/benefits/pages/default.aspx WEB 1 RETIREE INFORMATION Retirement Date Last Name First Name M.I. SSN DOB Physical Address City State Zip Phone M F 2 MEDICAL ENROLLMENT Retiree Only Retiree +1Dep Retiree +2 +Deps Waive* Initial Acknowledgment on back NON-MEDICARE PLANS MEDICARE PLANS Retiree Medicare Information Spouse Medicare Information Kaiser Permanente HMO High Deductible Kaiser Permanente Silver Medicare Claim Number Medicare Claim Number Western Health Advantage HMO High Deductible Kaiser Permanente Gold - - - - Effective Date Effective Date Sutter Health Plus HMO High Deductible UHC Advantage HMO HOSPITAL (Part A) HOSPITAL (Part A) UHC Advantage NPPO MEDICAL (Part B) MEDICAL (Part B) 3 DENTAL COVERAGE Retiree Only Retiree +1Dep Retiree +2 +Deps Waive* Initial Acknowledgment on back 4 VISION COVERAGE Retiree Only Retiree +1Dep Retiree +2 +Deps Waive 5 ENROLLMENT INFORMATION List all family members who should have coverage Cover Drop Retiree SP / DP M F Ch1 M F Ch2 M F Ch3 M F Last Name: First Name: Last Name: First Name: Last Name: M.I. M.I. SSN: DOB: SSN: DOB: SSN: TURN OVER FOR AUTHORIZATION AND AGREEMENT, FORM NOT VALID UNLESS SIGNED BY RETIREE Dr: Group: Dr: Group: Dr: Provider ID Number Existing Patient? Y N Provider ID Number Existing Patient? Y N Provider ID Number First Name: M.I. Disabled? DOB: Group: Y N Existing Patient? Y N Last Name: SSN: Dr: Medical Dental First Name: M.I. Disabled? DOB: Group: Vision Y N Existing Patient? Y N Last Name: SSN: Dr: Provider ID Number Medical First Name: M.I. Disabled? Dental DOB: Group: Vision Y N Existing Patient? Y N Medical Dental Vision Medical Dental Vision HMO HDHP KP Silver Medical Dental Vision OVER UHC Advantage HMO UHC Advantage NPPO KP Gold

BINDING ARBITRATION-- By signing below, I acknowledge that I have read, understand and agree to the terms and arbitration agreement stated below. A reproduction of this form shall be valid as an original. WESTERN HEALTH ADVANTAGE A. On behalf of myself and my eligible Dependents, I hereby apply for health care services coverage offered by Western Health Advantage (WHA) through my Employer, and agree to be bound by the WHA Group Service Agreement, Evidence of Coverage and Disclosure Form, and this Enrollment/Change Form. B. Arbitration agreement: i agree and understand that any and all disputes between myself (including any heirs or assigns) and western health advantage, including claims of medical malpractice (that is as to whether any medical services rendered under the health plan were unnecessary or unauthorized or were improperly, negligently or incompetently rendered), except for small claims court cases and claims subject to ERISA, shall be determined by submission to binding arbitration. Any such dispute will not be resolved by a lawsuit or resort to court process, except as California law provides for judicial review of arbitration proceedings. The parties, including any heirs or assigns, to this arbitration agreement are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of binding arbitration. RETIREE SIGNATURE: Date: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ KAISER FOUNDATION HEALTH PLAN ARBITRATION AGREEMENT I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure, and, if I am enrolled in coverage that is subject to the ERISA claims procedure regulation, or any claims that cannot be subject to binding arbitration under governing law) any dispute between myself, my heirs, relatives, or other associated parties on the one hand and Kaiser Foundation Health Plan, Inc. (KFHP), any contracted health care providers, administrators, or other associated parties on the other hand, for alleged violation of any duty arising out of or related to membership in KFHP, including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial and accept the use of binding arbitration. I understand that the full arbitration provision is contained in the Evidence of Coverage. RETIREE SIGNATURE: Date: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ SUTTER HEALTH PLUS (SHP) handles and resolves Member disputes through grievance, appeal and Independent Medical Review processes. However, in the event that a dispute is not resolved in those processes, SHP uses binding arbitration as the final method for resolving all such disputes. As a condition of your membership in Sutter Health Plus, you agree that any and all disputes between yourself (including any heirs or assigns) and Sutter Health Plus, including claims of medical malpractice (that is as to whether any Medical Services rendered under the health plan were unnecessary or unauthorized or were improperly, negligently or incompetently rendered), except for Small Claims Court cases and claims subject to ERISA, shall be determined by binding arbitration. Any such dispute will not be resolved by a lawsuit or resort to court process, except as California law provides for judicial review of arbitration proceedings. You and Sutter Health Plus, including any heirs or assigns to this Agreement, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of binding arbitration. (Initial) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ AUTHORIZATION All information on this form is true and correct; I understand that it is the basis on which coverage may be issued under the plan(s). Any dependents listed are my lawful spouse/domestic partner/and children, and are eligible for enrollment as my dependents. Any misstatements or omissions may result in future claims being denied and/or the policy being rescinded. My signature indicates my acceptance of the terms and conditions of the evidence of coverage for the carrier I have selected including arbitration, benefit coverage, and all associated policies and procedures. If applicable, I authorize my employer to deduct from my wages the required premiums. RETIREE SIGNATURE OFFICE USE ONLY MEDICARE SPLIT? Y N Date Effective Date Of Change Group Number Accepted By--Benefits Staff Representative: Date

This chart shows the estimated changes in payments and costs between the old 2014 benefit schedule and the new 2015 benefit schedule for the Retiree dental program. You can maximize your savings by choosing Principal network providers. Sample Cost Scenarios For Services In Zip 95814 2015 EPO Allowable Your New 2015 Your Old 2014 Rate 2015 Reimbursement Charge 2014 Reimbursement Charge 80%-New 55%-Old Prevent Procedure Description D0120 PERIODIC ORAL EXAM $27.00 $21.60 $5.40 $14.85 $12.15 D0150 COMPREHENSIVE ORAL EXAMINATION $38.00 $30.40 $7.60 $20.90 $17.10 D0210 INTRAORAL FMS AND BITEWINGS $72.00 $57.60 $14.40 $39.60 $32.40 D0274 BITEWINGS - FOUR FILMS $30.00 $24.00 $6.00 $16.50 $13.50 D0330 PANORAMIC - SINGLE FILM $44.00 $35.20 $8.80 $24.20 $19.80 D1110 PROPHYLAXIS ADULTS $65.00 $52.00 $13.00 $35.75 $29.25 Basic Procedure 60% - New 55% - Old D2140 AMALGAM ONE SURFACE PERMANENT $68.00 $40.80 $27.20 $37.40 $30.60 D2150 AMALGAM TWO SURFACE PERMANENT $90.00 $54.00 $36.00 $49.50 $40.50 D2392 RESIN TWO SURF,POST-PRIM/PERM $135.00 $81.00 $54.00 $74.25 $60.75 Major Procedure 55% -Same 55% - Same D2750 CROWN PORCELAIN TO HIGH NOBLE $748.00 $411.40 $336.60 $411.40 $336.60 D3330 ROOT CANAL - MOLAR $868.00 $477.40 $390.60 $477.40 $390.60 D4260 OSSEOUS SURG,4 OR MORE TEETH $803.00 $441.65 $361.35 $441.65 $361.35 D4341 SCAL RT PLAN, 4 OR MORE TEETH $141.00 $77.55 $63.45 $77.55 $63.45 D7140 EXTRACTION TOOTH OR EXPOSED RT $79.00 $43.45 $35.55 $43.45 $35.55 D7240 REMOVAL OF IMPACTED TOOTH-COMP $411.00 $226.05 $184.95 $226.05 $184.95 PPO Sample Cost Scenarios For Services In Zip 95814 2015 PPO Allowable Rate 2015 Reimbursement Your New 2015 Charge 2014 Reimbursement Your Old 2014 Charge 80% -New 55% - Old Prevent Procedure Description D0120 PERIODIC ORAL EXAM $31.00 $24.80 $6.20 $17.05 $13.95 D0150 COMPREHENSIVE ORAL EXAMINATION $50.00 $40.00 $10.00 $27.50 $22.50 D0210 INTRAORAL FMS AND BITEWINGS $89.00 $71.20 $17.80 $48.95 $40.05 D0274 BITEWINGS - FOUR FILMS $39.00 $31.20 $7.80 $21.45 $17.55 D0330 PANORAMIC - SINGLE FILM $54.00 $43.20 $10.80 $29.70 $24.30 D1110 PROPHYLAXIS ADULTS $79.00 $63.20 $15.80 $43.45 $35.55 Basic Procedure 60% - New 55% - Old D2140 AMALGAM ONE SURFACE PERMANENT $85.00 $51.00 $34.00 $46.75 $38.25 D2150 AMALGAM TWO SURFACE PERMANENT $113.00 $67.80 $45.20 $62.15 $50.85 D2392 RESIN TWO SURF,POST-PRIM/PERM $167.00 $100.20 $66.80 $91.85 $75.15 Major Procedure 55% -Same 55% - Same D2750 CROWN PORCELAIN TO HIGH NOBLE $899.00 $494.45 $404.55 $494.45 $404.55 D3330 ROOT CANAL - MOLAR $1,021.00 $561.55 $459.45 $561.55 $459.45 D4260 OSSEOUS SURG,4 OR MORE TEETH $974.00 $535.70 $438.30 $535.70 $438.30 D4341 SCAL RT PLAN, 4 OR MORE TEETH $173.00 $95.15 $77.85 $95.15 $77.85 D7140 EXTRACTION TOOTH OR EXPOSED RT $97.00 $53.35 $43.65 $53.35 $43.65 D7240 REMOVAL OF IMPACTED TOOTH-COMP $509.00 $279.95 $229.05 $279.95 $229.05 Sample Cost Scenarios For Services In Zip 95814 Allowable at 80% UCR for Zip 95814 2015 Reimbursement New 60% Of 80th Percentile Your Charge + Any Balance Over Allowable 2014 Reimbursement Your Charge + Any Balance Over Allowable Old 55% of PPO rate Extra Cost Over EPO Dentist Extra Cost Over PPO Dentist Prevent Procedure Description Not Including Balance Billing D0120 PERIODIC ORAL EXAM $60.00 $36.00 $24.00 $17.05 $42.95 $18.60 $17.80 D0150 COMPREHENSIVE ORAL EXAMINATION $98.00 $58.80 $39.20 $27.50 $70.50 $31.60 $29.20 D0210 INTRAORAL FMS AND BITEWINGS $150.00 $90.00 $60.00 $48.95 $101.05 $45.60 $42.20 D0274 BITEWINGS - FOUR FILMS $74.00 $44.40 $29.60 $21.45 $52.55 $23.60 $21.80 D0330 PANORAMIC - SINGLE FILM $128.00 $76.80 $51.20 $29.70 $98.30 $42.40 $40.40 D1110 PROPHYLAXIS ADULTS $104.00 $62.40 $41.60 $43.45 $60.55 $28.60 $25.80 Basic Procedure New 60% Of 80th Percentile Old 55% of PPO Rate D2140 AMALGAM ONE SURFACE PERMANENT $170.00 $102.00 $68.00 $46.75 $123.25 $40.80 $34.00 D2150 AMALGAM TWO SURFACE PERMANENT $195.00 $117.00 $78.00 $62.15 $132.85 $42.00 $32.80 D2392 RESIN TWO SURF,POST-PRIM/PERM $260.00 $156.00 $104.00 $91.85 $168.15 $50.00 $37.20 Major Procedure New 50% of 80th Percentile Old 55% of PPO Rate D2750 CROWN PORCELAIN TO HIGH NOBLE $1,150.00 $575.00 $575.00 $494.45 $655.55 $238.40 $170.45 D3330 ROOT CANAL - MOLAR $1,285.00 $642.50 $642.50 $561.55 $723.45 $251.90 $183.05 D4260 OSSEOUS SURG,4 OR MORE TEETH $1,806.00 $642.50 $1,163.50 $561.55 $1,244.45 $802.15 $725.20 D4341 SCAL RT PLAN, 4 OR MORE TEETH $281.00 $140.50 $140.50 $95.15 $185.85 $77.05 $62.65 D7140 EXTRACTION TOOTH OR EXPOSED RT $187.00 $93.50 $93.50 $53.35 $133.65 $57.95 $49.85 D7240 REMOVAL OF IMPACTED TOOTH-COMP $515.00 $257.50 $257.50 $279.95 $235.05 $72.55 $28.45 EPO Out of Network Higher Costs Are Incurred When Using Non-Network Providers

Internal Services Agency Department of Personnel Services Employee Benefits Office Dave Comerchero, Manager County of Sacramento September 10, 2014 RE: NOTICE OF CREDITABLE/NON CREDITABLE COVERAGE; MEDICAID-CHIP OFFER OF NO OR LOW COST COVERAGE As an individual eligible to participate in the group medical insurance program sponsored by the County of Sacramento, we are required to send you the attached Creditable/Non Creditable Coverage notice in accordance with the Medicare Prescription Drug Improvement and Modernization Act of 2003. If either you or a covered dependent are eligible for Medicare Part A and/or enroll in Medicare Part B, this letter and the attached Creditable/Non Creditable Coverage document contain important information. Please read this information carefully to understand your options. In addition, if you are eligible for health coverage from your employer, but are unable to afford the premiums, some states have premium assistance programs that can help pay for coverage. The attached document contains important information regarding Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage. Please read this information carefully to understand your options. If you are currently enrolled in a Kaiser, Sutter Health Plus, Western Health Advantage or UnitedHealthcare medical plan through the County of Sacramento group medical insurance program, the prescription drug coverage under this program is as good as, or better than, the coverage provided under the new Medicare Part D prescription drug program. It is creditable coverage as defined by the Center for Medicare and Medicaid Services (CMS), the federal organization that runs the Medicare program. Having creditable coverage will allow you to avoid future penalties for not enrolling in Part D if you are currently eligible to do so. If you currently waived the County of Sacramento group medical insurance program, this is not creditable coverage as defined by the Center for Medicare and Medicaid Services (CMS). You must decide whether to purchase Medicare Part D coverage on your own, enroll in a plan, or possibly risk monetary penalties in the future. If you are enrolled in another group medical insurance plan, please contact the sponsor of your other coverage to determine if their plan qualifies as creditable coverage. Having other creditable coverage will allow you to avoid future penalties for not enrolling in Part D. 700 H Street, Suite 4667, Sacramento, California 95814 phone (916) 874-2020 fax (916) 874-4621 www.saccounty.net

If you do not have creditable coverage you must enroll in Medicare D or you will be subject to penalties. The penalty is at least 1% per month for every month that a Medicare eligible person does not have creditable coverage. That penalty is added to the Medicare Part D premium when you subsequently do enroll in Medicare Part D. For example, if you go nineteen months without coverage, your premium will always be at least 19% higher than it would have been had you purchased the coverage. Enclosed is the official notice required by CMS regarding creditable/non creditable coverage. If you have any questions about this notice, or Medicare Part D, you may review the Medicare and You 2015 brochure distributed by CMS, you may call CMS at (800) 633-4227. For information regarding the Medicaid or CHIP programs you can contact your State Medicaid or CHIP office or dial 1-877- KIDS NOW or contact the County of Sacramento Employee Benefits Office at (916) 874-2020. Respectfully, Employee Benefits Office

Important Notice from the County of Sacramento About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the County of Sacramento and about your options under Medicare s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are three important things you need to know about your current coverage and Medicare s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. The County of Sacramento has determined that the prescription drug coverage offered by Kaiser, Sutter Health Plus, Western Health Advantage and UnitedHealthcare is, 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. 3. You can continue to waive your medical coverage with the County of Sacramento. However, because you waived coverage, it is non-creditable, you have decisions to make about Medicare prescription drug coverage that may affect how much you pay for that coverage, dependent on if and when you join a drug plan. When you make your decision, you should compare your current coverage, including what drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. Read this notice carefully it explains your options. 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 through December 7 th. However, if you lose your current creditable prescription drug coverage, through no fault of you own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. If you did not have creditable coverage you may have to pay a higher premium (a penalty). 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 County of Sacramento coverage will be affected. For individuals who elect Part D coverage elsewhere, the County of Sacramento s medical plan will end for the individual and all covered dependents.

Your current coverage pays for other health expenses in addition to prescription drugs. If you enroll in a Medicare prescription drug plan, you and your eligible dependents will not be eligible to receive all of your current health and prescription drug benefits. If you drop your current prescription drug coverage and enroll in Medicare prescription drug coverage, you may enroll back into a County of Sacramento benefit plan during an open enrollment period under the County of Sacramento benefit plan. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with the County of Sacramento and don t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage.. Call the Employee Benefits Office at (916) 874-2020. NOTE: You ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the County of Sacramento 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 prescription drug plans. For more information about Medicare prescription drug plans: Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the Medicare & You handbook for their telephone number) for personalized help Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. 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 www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: September 10, 2014 Name of Entity/Sender: County of Sacramento Employee Benefits Office 700 H Street, Room 4667 Sacramento, CA 95814 Phone Number: (916) 874-2020

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 are eligible for health coverage from your employer, your State may have a premium assistance program that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for these programs, but also have access to health insurance through their employer. If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance programs. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can 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, you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must permit you to enroll in your employer plan if you are not 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, you can contact the Department of Labor electronically at www.askebsa.dol.gov or by calling toll-free 1-866-444- 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, 2013. You should contact your State for further information on eligibility ALABAMA Medicaid Website: http://www.medicaid.alabama.gov Phone: 1-855-692-5447 ALASKA Medicaid Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529 ARIZONA CHIP Website: http://www.azahcccs.gov/applicants Phone (Outside of Maricopa County): 1-877-764-5437 Phone (Maricopa County): 602-417-5437 COLORADO Medicaid Medicaid Website: http://www.colorado.gov/ Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943 FLORIDA Medicaid Website: https://www.flmedicaidtplrecovery.com/ Phone: 1-877-357-3268 GEORGIA Medicaid Website: http://dch.georgia.gov/ Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: 1-800-869-1150

IDAHO Medicaid and CHIP Medicaid Website: www.accesstohealthinsurance.idaho.gov Medicaid Phone: 1-800-926-2588 CHIP Website: www.medicaid.idaho.gov CHIP Phone: 1-800-926-2588 INDIANA Medicaid Website: http://www.in.gov/fssa Phone: 1-800-889-9949 IOWA Medicaid Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 KANSAS Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-800-792-4884 KENTUCKY Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570 LOUISIANA Medicaid Website: http://www.lahipp.dhh.louisiana.gov Phone: 1-888-695-2447 MAINE Medicaid Website: http://www.maine.gov/dhhs/ofi/publicassistance/index.html Phone: 1-800-977-6740 TTY 1-800-977-6741 MASSACHUSETTS Medicaid and CHIP Website: http://www.mass.gov/masshealth Phone: 1-800-462-1120 MINNESOTA Medicaid Website: http://www.dhs.state.mn.us/ Click on Health Care, then Medical Assistance Phone: 1-800-657-3629 MISSOURI Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005 MONTANA Medicaid Website: http://medicaidprovider.hhs.mt.gov/clientpages/ clientindex.shtml Phone: 1-800-694-3084 NEBRASKA Medicaid Website: www.accessnebraska.ne.gov Phone: 1-800-383-4278 NEVADA Medicaid Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900 NEW HAMPSHIRE Medicaid Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 NEW JERSEY Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 NEW YORK Medicaid Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA Medicaid Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100 NORTH DAKOTA Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-755-2604

OKLAHOMA Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 OREGON Medicaid and CHIP Website: http://www.oregonhealthykids.gov http://www.hijossaludablesoregon.gov Phone: 1-800-699-9075 PENNSYLVANIA Medicaid Website: http://www.dpw.state.pa.us/hipp Phone: 1-800-692-7462 RHODE ISLAND Medicaid Website: www.ohhs.ri.gov Phone: 401-462-5300 SOUTH CAROLINA Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 SOUTH DAKOTA - Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059 TEXAS Medicaid Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493 UTAH Medicaid and CHIP Website: http://health.utah.gov/upp Phone: 1-866-435-7414 VERMONT Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427 VIRGINIA Medicaid and CHIP Medicaid Website: http://www.dmas.virginia.gov/rcp- HIPP.htm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.famis.org/ CHIP Phone: 1-866-873-2647 WASHINGTON Medicaid Website: http://hrsa.dshs.wa.gov/premiumpymt/apply.shtm Phone: 1-800-562-3022 ext. 15473 WEST VIRGINIA Medicaid Website: www.dhhr.wv.gov/bms/ Phone: 1-877-598-5820, HMS Third Party Liability WISCONSIN Medicaid Website: http://www.badgercareplus.org/pubs/p-10095.htm Phone: 1-800-362-3002 WYOMING Medicaid Website: http://health.wyo.gov/healthcarefin/equalitycare Phone: 307-777-7531 To see if any more States have added a premium assistance program since July 31, 2013, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 OMB Control Number 1210-0137 (expires 09/30/2013)