2020 Benefits Annual Enrollment Guide - Enrollment Period October 10th - October 23, 2020 - Avaya
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2020 Benefits Annual Enrollment Guide Enrollment Period October 10th – October 23, 2020
Active
Salaried
Employees
Annual Enrollment is your once-a-year opportunity to review your benefit options for the coming year and select
the coverages that will work best for you and your family. Use this brochure to learn what’s changing for 2020 and
what you need to do.
Click on a topic below
Annual Enrollment 2020 to go directly to the
October 10 – 23, 2019 information you need.
Benefits selected during this enrollment period
What's New for 2020
will be effective January 1, 2020.
Medical Plan Comparison
Please review this Guide in its entirety. It is your source of information for what’s changing in 2020. Consider all
of your benefit options and your financial and health care needs during Annual Enrollment. You will not need to
Important Reminders
actively enroll in most benefits for 2020 if you do not wish to make changes, with the exception of the following
elections that do not carry over from year to year:
Helpful Links & Tools
• Health Care or Limited Flexible Spending Account elections to Take Control of
• Dependent Care Flexible Spending Account elections Your Health
• Employee tax-favored Health Savings Account contributions
We listened to your feedback and are excited to highlight some Legal Reminders
If you (and/or your dependents)
of the enhancements to our plans for 2020. Details start on page 2.
• No Medical, Dental (PPO) or Vision Contribution Increases
have Medicare or will become Important Contacts
•N o Medical Deductible or Out-Of-Pocket Maximum Increases eligible for Medicare in the next 12
• Fidelity Investments® will be the new HSA recordkeeper months, a Federal law gives you
• Aetna Customer Care Management Unit – health advocate nurse
to assist with ongoing conditions or hospitalization
more choices about your
• PPO Dental Care Enhancement prescription drug coverage. Please
see page 22 for more details.
2 Next ▶What's New for 2020
Avaya knows how important health and insurance plans are for you The maximum visit for routine physical exams was changed to one per
and your family. The following pages include a summary of what’s calendar year (was one visit per 12 months).
changing for the year ahead. Additional details are available in later Vision and Dependent Life Change
sections of this Guide and at https://my.adp.com. If you have questions
or need assistance, contact the Avaya Health & Benefits Decision Center We have simplified the eligibility for your covered child(ren), so your child
at 1-800-526-8056 option 1 (TDD 1-800-952-0450) or via e-mail at can be covered up to December 31 of the year in which your child reaches
avayaservicecenter@adp.com. age 26 for Vision and Dependent Life. This is now consistent with Medical
and Dental coverage eligibility.
Attend a What’s New Webinar to learn about 2020 benefits
Health Savings Account Update
October 11 at 11 a.m. ET
On January 1, 2020, the Avaya Health Savings Account (HSA) vendor will
October 16 at 4 p.m. ET
be Fidelity.
See the Annual Enrollment email for details.
You will be able to see your 401(k) and HSA balance on the same website:
Benefits Genius Bar www.401k.com
Fidelity has no minimum for investing so any savings that is not needed
Call in with your annual enrollment benefit questions. Open daily
for current qualified expenses can be invested. You can pay for qualified
through Annual Enrollment from 3 – 4p.m. ET. See the Annual
medical expenses through a variety of options to access your funds,
Enrollment email for details.
including using an HSA checkbook, online bill paying service, or direct
Aetna Enhancements debit.
In 2020, there will be no increase in the individual and family deductibles The HSA is only available if you enroll in the Aetna Healthy Direction
and out-of-pocket (OOP) maximums! The Medical and Prescription Drug CDHP with HSA Medical Plan.
Plans have been enhanced: Here are the steps to take to open your new Fidelity HSA and transfer
The list of Preventive Medications where members pay zero cost has existing funds from your current HSA:
expanded and now includes preventive medication for asthma, Chronic From October 10, 2019 – October 23, 2019, make your new HSA election
Obstructive Pulmonary Disease, diabetes, heart disease and stroke and at https://my.adp.com and agree to Fidelity’s terms & conditions.
high blood pressure among other categories. See https://www.express-
In December, go to www.401k.com to activate your HSA with Fidelity.
scripts.com/avaya for the Preventive Medication List.
In December, after you activate your HSA with Fidelity, transfer any
If you are enrolled with Aetna through the Avaya Medical Plan (and are
existing HSA funds from PayFlex to Fidelity by clicking on the link on the
not enrolled in Medicare), you will have access to the Aetna Customer
www.401k.com website and approving the transfer. If you approve the
Care Management Unit (CCMU) – based on having an ongoing medical
funds to be transferred from PayFlex to Fidelity by January 10, 2020 there
condition or hospitalization, a dedicated nurse will contact you and your
will not be a fee to transfer the funds.
family to provide support and coordination of services.
If you do not authorize to have your HSA funds transferred from PayFlex to
Coverage of habilitative physical, occupational and speech therapy prescribed
Fidelity by January 10, 2020 PayFlex will charge you a fee to transfer funds
by a physician for other Developmental Delays in addition to Autism.
after this date and you will also be charged a monthly maintenance fee
Dermatology services are being added to Teladoc. starting in January 2020 if you have funds remaining in your PayFlex HSA.
Please review the Medical Comparison Chart for Active Salaried
Employees on page 8 of this Guide for more details.
3
▶ Back Next ▶What's New for 2020
Kaiser Plan Changes
2020 carrier-mandated changes:
Plan Benefit 2019 Plan Design 2020 Plan Design
Kaiser will cover and dispense Kaiser will cover and dispense
Kaiser MAS
Contraceptives prescription contraceptives once prescription contraceptives once every 12
(Maryland)
every 6 months months
Kaiser MAS Autism Spectrum Only covered for members aged 2
Coverage for all ages – no age limit
(Virginia) Disorder to 10
Kaiser CO Emergency Services $75 copay for ER visit $250 copay for ER visit
Allergy Evaluation and Primary Care: $15 copay
Kaiser CO $40 copay
Testing Specialty Care: $40 copay
Cost share will depend on where surgery
takes place; cost share will be lower at
Kaiser CO Outpatient Surgery 10% coinsurance
an ambulatory surgery center than at an
outpatient hospital department
TRICARE Changes for 2020
Due to low enrollment, the TRICARE Supplemental Plan will no longer be offered in 2020. If you would like to continue
your TRICARE Supplement Plan, please contact our third-party administrator, Selman & Co., at 1-855-637-1961.
HMSA Medical Plan Changes
Please visit https://www.avaya.com/benefits/salariedbenefits/ to review HMSA’s 2019/2020 carrier-mandated changes.
4 ▶ Back Next ▶What's New for 2020
Aetna Dental PPO Changes
After you obtain your preventive prophylaxis (cleaning), you will receive an additional $100 toward the annual benefit maximum in the following
calendar year. Preventive services will be excluded from the annual benefit maximum.
The following services were moved from a Major to a Basic Care benefit which means a lower cost for you: Endo/Perio(Osseous surgery, Partial Bony
Impactions and Full Bony Impactions) and General Anesthesia.
Annual Express Scripts (ESI) Prescription Drug Formulary Changes
The lists below describe some of the ESI carrier-mandated drug list and program changes, effective January 1, 2020. Personalized notifications, reminder
communications, and targeted alerts will go out to affected members before January 1. ESI’s formulary will continue to ensure that clinically sound, cost-
effective drugs are available to members and will drive greater savings. ESI's 2020 carrier-mandated drug exclusion list is available at
https://www.express-scripts.com/art/open_enrollment/DrugListExclusionsAndAlternatives.pdf. The 2020 formulary is available at https://my.adp.com
under the Forms & Plan Documents tile. Filter on “M” and click on the "MEDICAL BENEFITS - ESI RX PREFERRED DRUG GUIDE" link.
2020 Preferred-to-Non-Preferred Changes
ABSORICA ADAGEN AMITIZA
ARCAPTA NEOHALER ARZERRA ATROVENT HFA
BYVALSON FIRDAPSE FULPHILA
GRALISE HEXALEN LARTRUVO
MOXEZA RELENZA SANCUSO
TABLOID VARUBI VIAL XOFLUZA
ZONTIVITY
2020 HSA Contribution Maximums
Based on Internal Revenue Service rules, the maximum amount you can contribute to a Health Savings Account (HSA) in 2020 is $3,550 for self-only
CDHP medical plan coverage and $7,100 for all other coverage tiers. If you are turning age 55 in 2020 or are already over 55, you can contribute an
additional $1,000 in HSA catch-up contributions in 2020. These limits include: the contributions you make via payroll deductions, any contributions you
make to your HSA outside of payroll deductions, and the HSA dollars Avaya contributes to your HSA. Remember, the tax-favored HSA is only available if
you enroll in Avaya's Healthy Direction CDHP with HSA medical plan.
2020 Health Care or Limited FSA Contribution Maximum
The annual contribution maximum for Health Care or Limited Flexible Spending Account elections in 2020 has increased from $2,650 to $2,700. Please
make your new election at https://my.adp.com. 2019 elections will not carry over to 2020.
5
▶ Back Next ▶What's New for 2020
Employee Paycheck Contributions
Avaya reviews the benefit plans every year to ensure they remain comprehensive and competitive, keeping the costs for you and the company
manageable. Avaya will be picking up the plan cost increase for 2020. What does that mean for you? No medical, dental or vision plan
contribution changes for 2020! Below, please find the monthly employee contributions for the 2020 medical, dental and vision plans. These
contributions will apply in your first paycheck of 2020.
Monthly Employee Contributions
Benefit Type Benefit Plan Status Employee Only Employee + Spouse Employee + Child(ren) Family
Medical Aetna CDHP Alternative Salaried Non-Smoker $60.00 $144.00 $113.00 $200.00
Medical Aetna CDHP Alternative Salaried Smoker $80.00 $192.00 $151.00 $267.00
Medical Aetna CDHP w/HSA Salaried Non-Smoker $99.00 $246.00 $192.00 $339.00
Medical Aetna CDHP w/HSA Salaried Smoker $132.00 $328.00 $256.00 $452.00
Medical Aetna Point-of-Service (POS) Salaried Non-Smoker $172.00 $429.00 $335.00 $598.00
Medical Aetna Point-of-Service (POS) Salaried Smoker $229.00 $572.00 $447.00 $797.00
Kaiser (CA, CO, GA, MD
Medical Salaried Non-Smoker $191.00 $432.00 $377.00 $619.00
and NW only)
Kaiser (CA, CO, GA, MD
Medical Salaried Smoker $255.00 $576.00 $503.00 $825.00
and NW only)
Dental Aetna DMO $7.00 $13.00 $19.00 $30.00
Dental Aetna PPO $16.00 $41.00 $33.00 $59.00
Monthly Employee Contributions
Benefit Type Benefit Plan Status Employee Only Two-Person Family
Medical HMSA (HI residents only) Salaried Non-Smoker $99.00 $246.00 $339.00
Medical HMSA (HI residents only) Salaried Smoker $132.00 $328.00 $452.00
Vision EyeMed $8.01 $15.21 $22.33
6 ▶ Back Next ▶2020 POS and CDHP Medical and Prescription Drug Comparison Chart for Active Salaried Employees
Kaiser HMO information can be found online at https://my.adp.com under Forms & Plan Documents > Filter by the letter "S" for SBCs.
Aetna Salaried Point-of-Service (POS)1
Closed to new enrollees Aetna Healthy Direction CDHP with HSA1 Aetna CDHP Alternative1
Features
Annual HSA funding amount2:
Each time you need care, you choose: Each time you need care, you choose:
Up to $500/$1,000 (single/all other tiers)
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Any Aetna Choice POS II Any Aetna Choice POS II
Any Aetna Choice POS II
network provider, including network provider,
network provider, including
Teladoc physicians and including Teladoc
Teladoc physicians for 24/7
dermatologists for 24/7 phone physicians for 24/7 phone
phone or video physician visits
Choice of doctors or video physician and or video physician visits
Any eligible provider (available by downloading the Any eligible provider Any eligible provider
dermatology visits (available by (available by downloading
Teladoc app on your
downloading the Teladoc app the Teladoc app on your
smartphone or tablet or by
on your smartphone or tablet or smartphone or tablet or by
visiting https://www.teladoc.
by visiting https://www.teladoc. visiting https://www.
com/Aetna)
com/Aetna) teladoc.com/Aetna)
Preventive care (age and Covered at 100%; deductible You pay 35% after deductible, Covered at 100%; deductible You pay 35%, plus anything over Covered at 100%; You pay 40% after deductible,
frequency guidelines apply) does not apply plus anything over R&C does not apply R&C; deductible does not apply deductible does not apply plus anything over R&C
$1,000 for single tier coverage $2,000 for single tier coverage $2,000 for single tier coverage $3,375 for single tier coverage $3,400 for single tier $6,800 for single tier
Annual deductible3 and up to $3,000 maximum for and up to $6,000 maximum for coverage, $6,800 for all coverage, $13,600 for all
all other coverage tiers all other coverage tiers $4,000 for all other coverage tiers $6,750 for all other coverage tiers other coverage tiers other coverage tiers
Coinsurance (Plan pays)
Physician Office Visit You pay 20% after deductible You pay 35% after deductible, You pay 20% after deductible You pay 35% after deductible, You pay 20% after You pay 40% after deductible,
plus anything over R&C plus anything over R&C deductible plus anything over R&C
E mergency Room You pay 20% after deductible Paid as in-network if Aetna You pay 20% after deductible Paid as in-network if Aetna You pay 20% after Paid as in-network if Aetna
(For emergencies) Member Services is notified Member Services is notified deductible Member Services is notified
Urgent Care, Ambulance4 within 48 hours within 48 hours within 48 hours
In-Patient/Out-Patient You pay 20% after deductible You pay 35% after deductible, You pay 20% after deductible You pay 35% after deductible, You pay 20% after You pay 40% after
Services includes: Lab & plus anything over R&C plus anything over R&C deductible deductible, plus anything
X-ray, Surgery, Anesthesia, over R&C
Physician Hospital Visits/
Consultations, Room and
Board, Maternity, Radiation
Therapy, Chemotherapy
Are you responsible for Yes, unless you use a National Yes, unless you use a National Yes, unless you use a
charges in excess of the No Advantage Program (NAP) No Advantage Program (NAP) No National Advantage Program
Reasonable & Customary network provider network provider (NAP) network provider
Annual Out-of-Pocket $4,500 for single tier coverage $9,000 for single tier coverage $5,000 for single tier $10,000 for single tier
Maximum5 $3,500 for single tier coverage, $8,000 for single tier coverage
and up to $9,000 maximum for and up to $18,000 maximum coverage, $10,000 coverage, $20,000 for all
(Includes Deductible) $7,000 for all other coverage tiers $16,000 for all other coverage tiers
all other coverage tiers for all other coverage tiers (embedded at $7,150) 6 other coverage tiers
Precertification Your network provider You Your network provider You Your network provider You
responsibility
Yes, unless you use a National Yes, unless you use a National Yes, unless you use a
Are claim forms required? No Advantage Program (NAP) No Advantage Program (NAP) No National Advantage Program
network provider network provider (NAP) network provider
Notes: 1) R&C: Reasonable & Customary; (continued on next page)
2) Cells shaded in light red denote change from 2019 plan design.
7 ▶ Back Next ▶2020 POS and CDHP Medical and Prescription Drug Comparison Chart for Active Salaried Employees
Aetna Salaried Point-of-Service (POS)1 Aetna CDHP Alternative1
Closed to new enrollees. Aetna Healthy Direction CDHP with HSA1
(No HSA with this option)
Features
Prescription Drug Program coverage offered Prescription Drug Program coverage offered through Prescription Drug Program coverage offered through
through Express Scripts, Inc. (ESI) Express Scripts, Inc. (ESI) Express Scripts, Inc. (ESI)
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Not subject to a deductible. Not covered The full cost of the drug is applied to Not covered The full cost of the drug is applied to Not covered
the Medical deductible before the Medical deductible before
Retail Drugs benefits are considered for payment. benefits are considered for payment.
(up to a 30-day supply) After the deductible, you pay: After the deductible, you pay:
• Tier 1 (Generic)
$10 copay Retail Drugs Retail Drugs
• Tier 2 (Preferred Brand)
(up to a 30-day supply) (up to a 30-day supply)
30% Coinsurance, $30 min., • Tier 1 (Generic) $10 copay • Tier 1 (Generic) $10 copay
$80 max. • Tier 2 (Preferred Brand) • Tier 2 (Preferred Brand)
• Tier 3 (Non-preferred Brand) 25% Coinsurance, $30 min., 25% Coinsurance, $30 min.,
50% Coinsurance, $60 min., $70 max. $70 max.
Prescription Drug $120 max. • Tier 3 (Non-preferred Brand) • Tier 3 (Non-preferred Brand)
Benefits7 35% Coinsurance, $50 min., 35% Coinsurance, $50 min.,
ESI Mail Order, Walgreens $90 max. $90 max.
Retail, or CVS Retail Drugs
(up to a 90-day supply) ESI Mail Order, Walgreens Retail, ESI Mail Order, Walgreens Retail,
or CVS Retail Drugs or CVS Retail Drugs
• Tier 1 (Generic) $25 copay
(up to a 90-day supply) (up to a 90-day supply)
• Tier 2 (Preferred Brand)
• Tier 1 (Generic) $20 copay • Tier 1 (Generic) $20 copay
30% Coinsurance, $60 min.,
$200 max. • Tier 2 (Preferred Brand) • Tier 2 (Preferred Brand)
25% Coinsurance, $60 min., 25% Coinsurance, $60 min.,
• Tier 3 (Non-preferred Brand)
$175 max. $175 max.
50% Coinsurance, $120 min.,
$300 max. • Tier 3 (Non-preferred Brand) • Tier 3 (Non-preferred Brand)
35% Coinsurance, $100 min., 35% Coinsurance, $100 min.,
$225 max. $225 max.
$2,000 individual coverage tier Same as Medical Out-of-Pocket Same as Medical Out-of-Pocket
Pharmacy Out-of-Pocket Max N/A Maximum N/A Maximum N/A
$4,000 all other coverage tiers
The Prescription Drug Utilization Management Program requires prior authorization for certain types of prescription drugs, including but not limited to Nonsedating Antihistamines and Antifungals.
Prescription Drug Utilization Prior authorization means that requirements must be met before the Prescription Drug Program will cover the prescription. After three fills at the retail level, the member will pay 100% of the Express Scripts-
Management Program discounted cost for the medication for future retail fills not picked up at a Walgreens or CVS retail store. Out-of-pocket costs for long-term medications not ordered through ESI Home Delivery or CVS/Walgreens
retail do not apply to the member/family deductible or out-of-pocket maximum. If you purchase a brand name medication when a generic medication is available, you will pay the generic copay plus the difference
in cost between the brand name and the generic.
Notes: 1) R&C: Reasonable & Customary;
2) Cells shaded in light red denote change from 2019 plan design.
1 If you do not have access to in-network providers, upon approval from Aetna, you may receive benefits at the in-network level.
2 Company HSA contributions will be processed once annually for eligible employees according to the date your Health Savings Account with Fidelity is opened. Company HSA contributions will be deposited to
your Fidelity HSA within 10 business days of the paycheck in which it was processed. If you leave the company (voluntarily or involuntarily), or your coverage under the Aetna Healthy Direction CDHP with HSA
medical plan terminates for any reason before the normal payroll date the HSA funds would otherwise be processed for deposit, your Avaya group HSA will close and employer and employee HSA contributions
will not be deposited. Mid-year qualified status changes that result in a medical plan tier change will not result an adjustment to your company HSA contribution.
3 The medical deductible is separate from any deductible under the Prescription Drug Program for the POS. For the CDHP plans, the health care deductible must be met before plan benefits are paid, including
Prescription Drug Program benefits. Under the CDHP plans, for two-person or family coverage, the deductible is not satisfied for any family member until the two-person or family deductible is met.
4 Non-emergent Emergency Room or Ambulance services will be covered at the out-of-network level plus amounts over R&C.
5 Certain expenses (e.g., precertification penalties and any expenses in excess of the Reasonable & Customary charge) do not count toward the annual Out-of-Pocket Maximum. The annual Out-of-Pocket
Maximum for the POS Prescription Drug Program is separate from the annual Out-of-Pocket Maximum for the POS Medical plan.
6 Once one member of the family hits $7,150 in combined medical/Rx expenses, that individual will no longer incur expenses towards the family out-of-pocket maximum and most covered expenses would be
paid at 100% of the allowable amount for the rest of the calendar year for that family member; it would be up to the other covered members in the family to reach the remaining in-network out-of-pocket
maximum (before their covered expenses would be paid at 100% of the allowable amount for the remainder of the calendar year).
7 Mandatory home delivery through ESI or retail pick-up from either Walgreens or CVS applies to all long-term (maintenance) drugs.
8 ▶ Back Next ▶Important Reminders
Which Medical Plan is Right for You? Active employees are eligible for Avaya's HSA contribution based on the
date your HSA is opened, not the date you enroll in the Aetna Healthy
ALEX, Avaya's interactive Benefits Advisor, explains your medical plan
Direction CDHP with HSA medical plan. Company HSA contributions
options to determine which may be best for you, It is personalized, easy
will be deposited to your PayFlex HSA within 10 business days of the
to use and confidential. Try ALEX today by visiting https://www.myalex. paycheck in which it was processed. Mid-year qualified status changes
com/avaya/2020! ALEX is best viewed in Google Chrome. that result in a medical plan tier change will not result in an adjustment to
your company HSA contribution. It is your responsibility to ensure you do
Employer HSA Contribution Process
not exceed the annual maximum contribution.
Company HSA contributions will be processed once annually for eligible
employees, as follows: 2019 Employee HSA Contribution Elections Do Not Rollover to 2020
If you continue to be enrolled in the Aetna Healthy Direction CDHP with
On the first
For HSA's opened between You are eligible for this normal payroll HSA medical plan for 2020 and elected to defer tax-favored Health
these dates... much... date in this Savings Account contributions from your paycheck in 2019, you will need
month*... to log in to https://my.adp.com to continue those contributions, or elect
new contributions for 2020. HSA and HSA Catch-Up contributions can
$500/indiv or $1,000/
On/before 1/13/2020 family CDHP with HSA February be changed at any time throughout the year by selecting “DECLARE AN
election tier EVENT” under the Report a Qualifying Change tile on the home page.
$375/indiv or $750/ HSA contributions will be deposited to your personally-owned Health
1/14/2020 - 4/13/2020 family CDHP with HSA May Savings Account with Fidelity within 10 business days of the paycheck
election tier from which they are deducted and cannot be used until deposited. HSA
$250/indiv or $500/ contributions made by both you and Avaya will cease if you terminate
4/14/2020 - 7/13/2020 family CDHP with HSA August employment or leave the Healthy Direction CDHP with HSA medical
election tier plan. You must be actively employed and enrolled in the CDHP with
HSA medical plan on the normal payroll date your or the company HSA
$125/indiv or $250/
contributions would otherwise be processed to be eligible to receive
7/14/2020 - 10/13/2020 family CDHP with HSA November
them.
election tier
Funding will begin in Cutoff Date for Earning 2019 Raffle Tickets with SonicBoom
10/14/2020 or after
2021 The cutoff date for earning 2019 wellness raffle tickets is December 13,
* If you leave the company (voluntarily or involuntarily), or your coverage under the Aetna 2019.
Healthy Direction CDHP with HSA medical plan terminates for any reason before the
normal payroll date the HSA funds would otherwise be processed for deposit, your Avaya
group HSA will close and employer and employee HSA contributions will be forfeited and
will not be deposited.
9 ▶ Back Next ▶Important Reminders
HSA Customer Identification Process Requirement Account. You are not able to enroll in Avaya’s Limited Flexible Spending
Account unless you are enrolled in the Healthy Direction CDHP with HSA
If you are newly enrolling in the Healthy Direction CDHP with Health medical plan offered by Avaya.
Savings Account (HSA) medical plan and are opening an HSA with Fidelity
for the first time, Section 326 of the U.S. Patriot Act requires that you Spousal Surcharge
verify your identity through the Customer Identification Process before If you choose to cover your spouse/domestic partner under an Avaya
the HSA can be opened. If you do not complete and pass the Customer medical plan and your spouse/domestic partner has the opportunity
Identification Process, you will not be eligible to make HSA contributions to enroll in medical coverage through his/her employer, an additional
or receive Avaya’s HSA contributions. Go to www.401k.com and click on $100 per month will be added to your health insurance premium. This
Activate Health Savings Account to complete the opening of your account. surcharge is waived if your spouse or domestic partner works for an
employer who doesn't offer medical coverage, doesn’t qualify for their
2019 Flexible Spending Account Elections Do Not Rollover to 2020 employer’s coverage, or is eligible for Medicare.
If you wish to participate in the Health Care Flexible Spending Account Dependent Verification
(HCFSA), Limited Flexible Spending Account (LFSA), and/or the Dependent
Care Flexible Spending Account (DCFSA) in 2020, you must re-enroll during If you choose to enroll an eligible dependent(s) that is not currently
Annual Enrollment. Your 2019 elections do not carry over to 2020. covered under Avaya's health benefits, you will be required to
provide proof that they are your eligible dependent(s) per the Plan
Flexible Spending Account Balance Carryover guidelines. Dependent coverage will be pended until the appropriate
Avaya allows HCFSA and LFSA participants to carryover up to $500 documentation is received by ADP, our Dependent Verification vendor.
of unused funds into the following calendar year. If you have unused Upon completion of your enrollment, you will receive a verification letter
HCFSA or LFSA funds at the end of 2019, the rollover will happen for from ADP explaining how to verify dependent eligibility. Verification is
you automatically. Please factor this in to your 2020 elections to ensure due by the deadline on your request for verification form.
you don’t over-contribute in the upcoming year. 2020 Mid-Year Changes
Hyatt Legal Services Plan Once Annual Enrollment ends, you will not be able to make changes to
most benefits unless you have a qualified status change. Information on
Annual Enrollment is the one time of year you can enroll in (if not
qualified status changes is available in the Summary Plan Descriptions
already enrolled) or drop the Hyatt Legal benefit. To make changes
(SPDs) at https://www.avaya.com/benefitanswers.
to your legal services plan coverage, visit https://my.adp.com before
October 23, 2019.
Planning to Enroll in the CDHP Alternative Medical Plan in 2020?
If you enroll in the CDHP Alternative medical plan (which does not have
an HSA) and you intend to open a private HSA through your own bank,
you are strongly encouraged NOT to enroll in Avaya’s Health Care Flexible
Spending Account (HCFSA). Per IRS guidelines, if you are contributing
to or receiving contributions to an HSA, you may only be reimbursed
for eligible dental and vision expenses (no medical or prescription drug
expense reimbursement is allowed) from a Limited Flexible Spending
10
▶ Back Next ▶Important Reminders Prescription Drug Coverage Drugs are the fastest growing category of health spending. In cases where you select a brand name drug when a generic equivalent is available, you will be required to pay the generic copayment plus the difference in cost between the brand name drug and the generic drug. If you are prescribed a medication, ask your doctor or pharmacist if your condition could be treated effectively with a lower-cost or generic version of the drug. Remember, the Prescription Drug Program has a mandatory fill-provision for long-term (maintenance) medications. Aside from a limited number of exceptions, after the third fill of a long-term medication, you must begin obtaining your prescription through Express Scripts Pharmacy Mail Order service, or at either a CVS or Walgreens retail location, to avoid paying a penalty. Beneficiaries Maintaining beneficiary information is an important part of your financial planning. Annual Enrollment is a good time to review your life and AD&D insurance beneficiaries. You can update life and AD&D insurance beneficiary information online at any time at https://my.adp.com by selecting "MANAGE" under the Manage Information tile on the home page. If you do not have Internet access, you may contact the Avaya Health & Benefits Decision Center at 1-800-526-8056 (option 1), TDD 1-800-952-0450 or via e-mail at avayaservicecenter@adp.com to obtain a beneficiary form. Summary of Benefits Coverage (SBC) In compliance with health care reform, Avaya provides a SBC for each medical plan for which you are eligible to help you compare your coverage options. Please note that the SBC is not a full plan description like the Summary Plan Descriptions. SBCs are available at https://my.adp. com under the Forms & Plan Documents tile on the home page. Paper copies are also available, free of charge, by contacting the Avaya Health & Benefits Decision Center at 1-800-526-8056 (option 1), TDD 1-800-952- 0450, or via e-mail at avayaservicecenter@adp.com. 11 ▶ Back Next ▶
Helpful Links and Tools to Take Control of Your Health
Taking Control of Your Health Tool (click link) Description
• Enroll in or change your benefits Your one-stop-shop for all of your benefit needs.
• Update your HSA contribution Note: Need to update your HSA or HSA Catch-Up contribution mid-year or
https://my.adp.com
• Change a beneficiary outside of Annual Enrollment? From https://my.adp.com, select "DECLARE
• Find information on your medical carrier AN EVENT" under the Report a Qualifying Change tile on the home page.
• Understand your medical plan options and determine which option may
Choose the right medical plan for you and https://www.myalex.com/avaya/2020
be best for you
your family using ALEX, our interactive (Available to Kaiser and Aetna members)
• See how you may benefit from contributing to a Flexible Spending
Benefit Advisor ALEX is best viewed in Chrome
Account and/or Health Savings Account
www.aetna.com
(for Aetna medical members)
Get the best price on health care services Search for doctors and health care services based on cost, quality and
Login using your existing Navigator
without sacrificing quality convenience.
credentials or download the Aetna Health
app at the App Store® or Google Play™ store
Current Aetna members may log on to their Aetna’s online participating directory allows you to locate physicians
account at www.aetna.com and other health care providers such as dentists and hospitals. Try the
Aetna Mobile App for quick and convenient access to in-network providers.
Locate Aetna in-network physicians or Potential members may log on to
dentists where you need them www.aetna.com > Find a doctor > Under Participating physicians are also available 24/7 via phone or video chat
“Not a member yet?", select “Plan from an through Teladoc, Avaya's telemedicine vendor through Aetna. You may
employer"> When asked to Select a Plan, download the Teladoc app on your smartphone or tablet or visit
choose Aetna Choice POS II (Open Access) https://www.teladoc.com/Aetna for access.
Review the Medical Benefits - CDHP
Learn more about the Healthy Direction
Newsletter under the Forms & Plan
Consumer Directed Health Plan (CDHP) with A great way to set aside tax-favored dollars for future medical expenses.
Documents tile on the home page at
HSA medical plan
https://my.adp.com
Robust Annual Enrollment support including formulary lookup, pharmacy
Express Scripts (ESI) Annual Enrollment
www.express-scripts.com/avaya lookup, pricing medications, and ability to attach PDFs & full customer
website
service and web support
It’s important to find a doctor who's right for you. Choose or change
Locate Kaiser physicians in your region https://www.kp.org doctors at any time, browse online profiles by region, or call Member
Services in your area.
www.payflex.com (no longer the HSA A Health Savings Account (HSA) is designed to help pay for your current
• Review your HSA balance
vendor effective 1/1/2020) eligible health care costs and save for future health care expenses. Your
• Send a payment to a provider
www.401k.com (Fidelity will be the new contributions, earnings and withdrawals are all tax-favored. It’s a triple tax-
• Update your notification settings
vendor effective 1/1/2020) savings opportunity that can put more money in your pocket.
12 ▶ Back Next ▶Helpful Links and Tools to Take Control of Your Health
Taking Control of Your Health Tool (click link) Description
Wondering where to get your next EyeMed With 87,500 vision care providers nationwide, you’re sure to find one you
https://www.eyemedvisioncare.com
in-network eye exam? love in your area.
Take control of your wellbeing with
Avaya Wellness
All the confidential tools and information you need to take stock in
• Talk to a coach
https://avaya.app.sbwell.com your current health status and resources to work toward improving it
• Manage a chronic condition
every day.
• Take the Health Quality Assessment
• Participate in a group challenge
An FSA (not to be confused with an HSA) may be used for reimbursement
of eligible health care* expenses, and child or elder daycare expenses. The
amount you decide to contribute to the account for the year is deducted
Go to the Forms & Plan Documents tile on from your salary before income taxes. This reduces your taxable income,
What are Flexible Spending Accounts? the home page at https://my.adp.com. Filter saving you money on taxes.
on “F” for FSA forms and resources. *If contributing to or receiving contributions to an HSA, medical expenses
are not reimbursable under a general-purpose FSA. Let ALEX teach you
about this at https://www.myalex.com/avaya/2020! ALEX is best viewed
in Google Chrome.
Now it’s really easy to figure out how much you should contribute to your
Health Care and/or Dependent Care Flexible Spending Account with this
Determine the right amount to contribute https://dtg.adp.com/ExpenseViewer#/
intuitive online tool. ALEX, our interactive Benefit Advisor (https://www.
to your Flexible Spending Account home
myalex.com/avaya/2020) can also assist you with this decision! ALEX is
best viewed in Google Chrome.
Go to the Forms & Plan Documents tile on
• Saves you money on parking and transportation expenses to work
Save tax dollars on your commute to and the home page at https://my.adp.com.
• Lets you pay for certain commuting expenses with pre-tax dollars
from work every day! Filter on “C” for Commuter Benefit
• A great way to LOWER your taxable income
resources.
The Employee Assistance Program (EAP) is available 24/7 to help you
and your family successfully deal with life’s problems and challenges. The
Talk to someone about a personal issue https://www.magellanascend.com
EAP is a prepaid, confidential counseling and referral resource coordinated
through Magellan Behavioral Health.
The Family Resource Program provides services to busy parents
Looking for childcare and eldercare who are looking for help on issues such as adoption, senior care, and
https://www.magellanascend.com
resources? education resources. Additionally, the Family Resource Program offers
free tutoring through its Homework Connection program.
13
▶ Back Next ▶Legal Reminders Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed on the following pages, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or call 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). 14 ▶ Back Next ▶
Legal Reminders
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 January 31, 2019. Contact your State for more information on eligibility.
ALABAMA – Medicaid FLORIDA – Medicaid
Website: http://myalhipp.com/ Website: http://flmedicaidtplrecovery.com/hipp/
Phone: 1-855-692-5447 Phone: 1-877-357-3268
ALASKA – Medicaid GEORGIA – Medicaid
The AK Health Insurance Premium Payment Program
Website: http://myakhipp.com/ Website: www.medicaid.georgia.gov
Phone: 1-866-251-4861 (Click on Health Insurance Premium Payment (HIPP))
Email: CustomerService@MyAKHIPP.com Phone: 1-404-656-4507
Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
ARKANSAS – Medicaid INDIANA – Medicaid
Healthy Indiana Plan for low-income adults 19-64
Website: http://www.in.gov/fssa/hip/
Website: http://myarhipp.com/ Phone: 1-877-438-4479
Phone: 1-855-MyARHIPP (855-692-7447) All other Medicaid
Website: http://www.indianamedicaid.com
Phone: 1-800-403-0864
IOWA – Medicaid KANSAS – Medicaid
Website: http://dhs.iowa.gov/hawk-i Website: http://www.kdheks.gov/hcf/
Phone: 1-800-257-8563 Phone: 1-888-346-9562
KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid
Website: https://www.dhhs.nh.gov/oii/hipp.htm
Website: https://chfs.ky.gov
Phone: 1-603-271-5218
Phone: 1-800-635-2570
Toll-Free: 1-800-852-3345, ext 5218
LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP
Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/
Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Medicaid Phone: 1-609-631-2392
Phone: 1-888-695-2447 CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
15 ▶ Back Next ▶Legal Reminders
MAINE – Medicaid NEW YORK – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html
Website: https://www.health.ny.gov/health_care/medicaid/
Phone: 1-800-442-6003
Phone: 1-800-541-2831
TTY: Maine relay 711
MASSACHUSETTS – Medicaid and CHIP NORTH CAROLINA – Medicaid
Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Website: https://dma.ncdhhs.gov/
Phone: 1-800-862-4840 Phone: 919-855-4100
MINNESOTA – Medicaid NORTH DAKOTA – Medicaid
Website: https://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/
programs/programs-and-services/other-insurance.jsp
Phone: 1-844-854-4825
Phone: 1-800-657-3739 or 651-431-2670
MISSOURI – Medicaid OKLAHOMA – Medicaid and CHIP
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Website: http://www.insureoklahoma.org
Phone: 573-751-2005 Phone: 1-888-365-3742
MONTANA – Medicaid OREGON – Medicaid and CHIP
Website: http://healthcare.oregon.gov/Pages/index.aspx
Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
Website: http://www.oregonhealthcare.gov/index-es.html
Phone: 1-800-694-3084
Phone: 1-800-699-9075
NEBRASKA – Medicaid PENNSYLVANIA – Medicaid
Website: http://www.dhs.pa.gov/provider/medicalassistance/
Website: http://www.ACCESSNebraska.ne.gov
healthinsurancepremiumpaymenthippprogram/index.htm
Phone: (855) 632-7633; Lincoln: (402) 473-7000; Omaha: (402) 595-1178
Phone: 1-800-692-7462
NEVADA – Medicaid RHODE ISLAND – Medicaid
Website: http://dhcfp.nv.gov Website: http://www.eohhs.ri.gov/
Phone: 1-800-992-0900 Phone: 855-697-4347
SOUTH CAROLINA – Medicaid VIRGINIA – Medicaid and CHIP
Medicaid Website: https://www.scdhhs.gov Website: https://www.coverva.org/famis/
Medicaid Phone: 1-888-549-0820 Phone: 1-800-432-5924
16
▶ Back Next ▶Legal Reminders
SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid
Website: http://www.hca.wa.gov/free-or-low-cost-health-care/program-adminis-
Website: http://dss.sd.gov
tration/premium-payment-program
Phone: 1-888-828-0059
Phone: 1-800-562-3022 ext. 15473
TEXAS – Medicaid WEST VIRGINIA – Medicaid
Website: http://gethipptexas.com/ Website: http://mywvhipp.com/
Phone: 1-800-440-0493 Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP
Medicaid Website: https://medicaid.utah.gov/
Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf
CHIP Website: http://health.utah.gov/chip
Phone: 1-800-362-3002
Phone: 1-877-543-7669
VERMONT– Medicaid WYOMING – Medicaid
Website: http://www.greenmountaincare.org/ Website: https://health.wyo.gov/healthcarefin/medicaid/
Phone: 1-800-250-8427 Phone: 307-777-7531
To see if any other states have added a premium assistance program since January 31, 2019 or for more information on special enrollment rights,
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/agencies/ebsa www.cms.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such
collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor
a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions
of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently
valid OMB control number. See 44 U.S.C. 3512.
The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are
encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200
Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.
OMB Control Number 1210-0137 (expires 12/31/2020) 17
▶ Back Next ▶Legal Reminders
Notice of Availability: The Avaya Inc. Medical Expense Plan for a voluntary Health Quality Assessment or "HQA" that asks a series
Salaried Employees, a component of the Avaya Inc. Health & of questions about your health-related activities and behaviors and
Welfare Benefits Plan for Salaried Employees, Notice of Privacy whether you have or had certain medical conditions (e.g., cancer,
Practices diabetes, or heart disease). You may also be asked to complete
a voluntary biometric screening, which will include a blood test
THIS NOTICE DESCRIBES HOW YOU MAY OBTAIN A COPY OF THE for Glucose, HDL Cholesterol, Total Cholesterol, LDL Cholesterol,
PLAN’S NOTICE OF PRIVACY PRACTICES, WHICH DESCRIBES THE and Triglycerides. You are not required to complete the HQA or
WAYS THAT THE PLAN USES AND DISCLOSES YOUR PROTECTED participate in the blood test or other medical examinations.
HEALTH INFORMATION.
Employees who choose to participate in the wellness program will
The Avaya Inc. Medical Expense Plan for Salaried Employees, receive incentives in the form of raffle tickets for completing the
a component of the Avaya Inc. Health & Welfare Benefits Plan various activities listed on their SonicBoom Rewards page.
for Salaried Employees, (the “Plan”) provides health benefits to
eligible employees of Avaya Inc. (the “Company”) and their eligible Additional incentives may be available for employees who participate
dependents as described in the summary plan description(s) for the in certain health-related activities or achieve certain health outcomes.
Plan. The Plan creates, receives, uses, maintains and discloses health If you are unable to participate in any of the health-related activities
information about participating employees and dependents in the or achieve any of the health outcomes required to earn an incentive,
course of providing these health benefits. The Plan is required by you may be entitled to a reasonable accommodation or an alternative
law to provide notice to participants of the Plan’s duties and privacy standard. You may request a reasonable accommodation or an
practices with respect to covered individuals’ protected health alternative standard by contacting SonicBoom Wellness at
information, and has done so by providing to Plan participants a support@sbwell.com.
Notice of Privacy Practices, which describes the ways that the Plan The information from your HQA and the results from your biometric
uses and discloses protected health information. To receive a copy screening will be used to provide you with information to help you
of the Plan’s Notice of Privacy Practices you should contact Avaya’s understand your current health and potential risks, and may also be
Health Plan Administrator, who has been designated as the Plan’s used to offer you services through the wellness program, such as
contact person for all issues regarding the Plan’s privacy practices and health coaching, physical activity opportunities, and healthy-habit
covered individuals’ privacy rights. You can reach this contact person tracking tools. You also are encouraged to share your results or
at: 4655 Great America Parkway, Santa Clara, CA 95054, or via e-mail concerns with your own doctor.
at hwplanadmin@avaya.com.
Notice Regarding Wellness Program
Avaya’s Wellness program is a voluntary wellness program available
to all employees. The program is administered according to federal
rules permitting employer-sponsored wellness programs that seek
to improve employee health or prevent disease, including the
Americans with Disabilities Act of 1990, the Genetic Information
Nondiscrimination Act of 2008, and the Health Insurance Portability
and Accountability Act, as applicable, among others. If you choose
to participate in the wellness program you will be asked to complete
18 ▶ Back Next ▶Legal Reminders
Protections from Disclosure of Medical Information You may not be discriminated against in employment because of
We are required by law to maintain the privacy and security of your the medical information you provide as part of participating in the
personally identifiable health information. Although the wellness wellness program, nor may you be subjected to retaliation if you
program and Avaya may use aggregate information it collects to choose not to participate.
design a program based on identified health risks in the workplace, If you have questions or concerns regarding this notice, or about
SonicBoom Wellness will never disclose any of your personal protections against discrimination and retaliation, please contact
information either publicly or to the employer, except as necessary SonicBoom Wellness at support@sbwell.com.
to respond to a request from you for a reasonable accommodation
needed to participate in the wellness program, or as expressly HIPAA Special Enrollment Rights for Medical Plan Coverage
permitted by law. Medical information that personally identifies you
Loss of Eligibility for Other Health Coverage
that is provided in connection with the wellness program will not be
provided to your supervisors or managers and may never be used to If you are declining medical plan enrollment for yourself or your
make decisions regarding your employment. dependents (including your spouse) because of other health insurance
or group health plan coverage, you may be able to enroll yourself and
Your health information will not be sold, exchanged, transferred, or
your dependents in the medical plans under the Avaya Inc. Health &
otherwise disclosed except to the extent permitted by law to carry
Welfare Benefits Plan, the Avaya Inc. Health & Welfare Benefits Plan
out specific activities related to the wellness program, and you will
for Salaried Employees, or any other group health plan(s) that are
not be asked or required to waive the confidentiality of your health
applicable to your health status and may be maintained by Avaya
information as a condition of participating in the wellness program
from time to time (collectively and/or individually, as applicable, the
or receiving an incentive. Anyone who receives your information for
“Plan” or “Health Plan”), or switch health benefit options under the
purposes of providing you services as part of the wellness program
applicable plan, if you or your dependents lose eligibility for that other
will abide by the same confidentiality requirements.
coverage (or if the employer stops contributing toward your or your
The only individuals who will receive your personally identifiable dependents’ other non-COBRA coverage). However, you must request
health information are the account management team at SonicBoom enrollment within 31 days after the date your or your dependents’ other
and a SonicBoom health coach in order to provide you with services coverage ends (or after the employer stops contributing toward the
under the wellness program. other coverage) by contacting the Avaya Health & Benefits Decision
Center at 1-800-526-8056 (option 1). Loss of eligibility for coverage
In addition, all medical information obtained through the wellness includes:
program will be maintained separate from your personnel records,
information stored electronically will be encrypted, and no information
you provide as part of the wellness program will be used in making
any employment decision. Appropriate precautions will be taken to
avoid any data breach, and in the event a data breach occurs involving
information you provide in connection with the wellness program, we
will notify you immediately.
19 ▶ Back Next ▶Legal Reminders
•L
oss of eligibility as a result of legal separation, divorce, cessation if your spouse is not enrolled in the health plan, you may enroll him or
of dependent status (such as attaining the maximum age to be her and any other eligible dependents in the plan when you enroll a
eligible as a dependent child under the plan), death of an employee child due to birth, adoption or placement for adoption.
or partner, termination of employment, reduction in the number of
work hours of employment
When coverage begins. In the case of marriage, coverage will begin
•A
situation in which a plan no longer offers any benefits to the class on the day the election is made in the enrollment system as long as
of similarly situated individuals that includes the individual, and you notify the Company within 31 days of the event. In the case of
• In the case of an individual who has COBRA continuation coverage, birth, adoption or placement for adoption, coverage is retroactive to
at the time the COBRA continuation coverage is exhausted. the date of birth, adoption or placement for adoption.
However, loss of eligibility for other coverage does not include a loss Childrens’ Health Insurance Program Reauthorization Act (CHIPRA)
of coverage due to:
On April 1, 2009, The Children’s Health Insurance Program
•T
he failure of the employee or dependent to pay premiums on a Reauthorization Act of 2009 (CHIPRA) added two new HIPAA special
timely basis enrollment rights that will apply to Avaya’s medical and dental plans.
• Voluntary disenrollment from a plan, or If you or your dependent(s) are eligible, but not enrolled in medical or
•T
ermination of coverage for cause (such as making a fraudulent dental coverage, you will be entitled to a special enrollment period if:
claim or an intentional misrepresentation of a material fact in •Y
ou or your dependent decline enrollment because your dependent
connection with the plan). is covered under a Medicaid or State child health plan and your
dependent’s eligibility for the Medicaid or the State child health plan
When coverage begins. If you enroll yourself, your spouse/domestic ends, or
partner and/or your eligible dependent child(ren) in a group health
plan due to a loss of eligibility for coverage event described above, •Y
our dependent becomes eligible for state premium assistance
coverage under this plan will begin the date the election is made. from a Medicaid or State child health plan with respect to cover
under this Plan.
Gaining a New Dependent
You must request enrollment in the medical and dental plans within
If you have a new dependent as a result of marriage, birth, adoption, 60 days after the date your dependent(s) loses coverage under a
or placement for adoption, you may be able to enroll yourself and Medicaid or a State child health plan or the date your dependent
your dependents in a medical plan offered by Avaya. However, you becomes eligible for assistance under Medicaid or a State child health
must request enrollment within 31 days after the marriage, birth, plan where premiums are charged by the plans by contacting the
adoption, or placement for adoption. Avaya Health & Benefits Decision Center at 1-800-526-8056 (option 1).
In addition, if you are not enrolled in the Avaya Inc. Health & Welfare
Benefits Plan, the Avaya Inc. Health & Welfare Benefits Plan for
Salaried Employees, or any other group health plan(s) that are
applicable to your health status and maybe maintained by Avaya from
time to time (collectively and/or individually, as applicable, the “Plan”
or “Health Plan”), as an employee, you also must enroll in the plan
when you enroll any of these dependents by contacting the Avaya
Health & Benefits Decision Center at 1-800-526-8056 (option 1). And,
20 ▶ Back Next ▶You can also read
