January 1, 2023 - December 31, 2023 - The City of Decatur Enrollment Guide
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January 1, 2023 –
December 31, 2023
The City of Decatur Enrollment Guide
Welcome to Open Enrollment for your 2023
Benefits!
Who is eligible?
If you are a full-time employee (working 30 or more hours per week)
you are eligible to enroll in the benefits described in this guide.
Employees may also enroll their qualified dependents (children up to
age 26). Benefits for eligible employees and enrolled dependents
become effective on the first day of the month following 30 days of
full-time employment. THE CITY NOW OFFERS COVERAGE TO
A SPOUSE/DOMESTIC PARTNER WHO IS MEDICARE
ELIGIBLE. YOU MAY ENROLL DURING OPEN ENROLLMENT.
How to Enroll
The first step is to review your current benefit elections. Verify your
personal information and make any changes if necessary. Make
your benefit elections. Once you have made your elections, you will
not be able to change them until the next open enrollment period
unless you have a qualified change in status.
When to Enroll – New Online
Enrollment
The open enrollment period runs from November 21 through
November 30. The benefits you elect during open enrollment will be
effective from January 1, 2023 through December 31, 2023.
Partipants may enroll at the Decatur Conference Center from 8:00
a.m. until 5:00 p.m. Monday November 21, 2022 through
Wednesday, November 30, 2022. Enrollment forms must be
completed by November 30th, 2022 by 5:00 PM.
.
How to Make Changes
Unless you have a qualified change in status, you cannot make
changes to the benefits you elect until the next open enrollment
period. Qualified changes in status include: marriage, divorce, legal
separation, domestic partnership status change, birth or adoption of a child, change in
child’s dependent status, death of spouse, child or other qualified dependent, change in
residence due to an employment transfer for you, your spouse or domestic partner,
commencement or termination of adoption proceedings, or change in spouse’s or domestic
partner’s benefits or employment status.
Design © 2008-2013 Zywave, Inc. All rights reserved.
What’s Renewing for 2023 Medical – renewing with Blue Cross Blue Shield of Texas Voluntary Dental – renewing with Blue Cross Blue Shield of Texas Voluntary Vision – renewing Dearborn/BCBSTX/EyeMed Long Term Disability – renewing with Dearborn/BCBSTX Employee and Dependent Voluntary Life/AD&D – renewing with Dearborn/BCBSTX New Benefits – Renewing with New Benefits HR Connection – online enrollment for employee elections Benefit Contact Information Page | 4
Your HR Connection User Login
User Name:
Password:
We will once a gain be using HRconnection for our enrollments. HRconnection is a one-stop shop for human
resources-related communications, including benefit communications, training opportunities, upcoming
events, company facts and other valuable information. Accessible from the internet, you can visit it anytime
from any computer.
How do I access HRconnection?
For your initial login you will be sent an email from HR Connect. In the email there will be a link that takes
you directly to the login page where you will set up your password.
After initial enrollment, simply go to www.hrconnection.com. Once you are on the HRconnection website, en-
ter your user name and password. To retrieve your credentials, click “Forgot your password” and enter your
email address.
How do I find the information for which I am looking? Isn’t it easier to just ask HR?
This tool was developed with you , the user, in mind. The HRconnection home page consists of your main
menu, which can direct you to all of the information that you need about the company, our benefits programs,
company policies, your benefits elections, personal information, time-off tracking and much more.
Plus, via your mobile or table device, you can access your employee directory, time-off tracking and benefit
plan information...anytime...anywhere!
What if I still have questions after I find my
Information? Where do I go? A Valuable New Tool for
Remember, HR is still here to help
Simplifying Your Search for
Answer your questions when you cannot find
Important Employee and
Answers on HRconnection. Our team’s
commitment to service has not changed. Now, Company Information!
You just have more ways to get the information
you need into your hands faster.
We encourage you to provide feedback on HRconnection. If you see areas that need improvement, or you
just want to let me know how helpful these tools are to you, please let me know.
Sincerely,
Human Resources Department
ONLINE ENROLLMENT Page | 6
Medical and Prescription Drugs-Blue Cross Blue Shield
The following chart compares benefits that will take effect January 1, 2023.
Find a Provider at www.bcbstx.com or call 1-800-445-2227.
Base Plan Basic Plan Buy-Up Plan
Services BCBSTX MTBCP014H BCBSTX MTBCB031 BCBSTX MTBCP039
PPO HSA* Basic PPO PPO
Annual Deductible --
$5,000 / $10,000 $3,500 / $10,500 $5,000 / $15,000
Single/Family
Out-of-Pocket Max
$7,900
- Individual $ 5,000 $8,150
$16,300
- Family $10,000 $16,300
Coinsurance
100% / 70% 80% / 50% 100% / 70%
In-Network Out of Network
$35 $35
Primary Care Copay 0% After Deductible
0% After Deductible
Specialist Copay $70 $70
No Charge In-Network No Charge In-Network No Charge In-
Preventative Care Deductible does Not Deductible does Not Network Deductible
apply apply does Not apply
0% After Deductible 20% After Deductible 0% After Deductible
In-Patient Hospital
0% After Deductible 20% After Deductible 0% After Deductible
Out-Patient Hospital
Emergemcy Room 0% After Deductible
$500 Copay + 0% $500 Copay + 0%
Copay
0% After Deductible
Urgent Care $75 $75
0% After Deductible 20% After Deductible Included at 100% with
Labs / X Rays office copay
0% After Deductible 0% After Deductible
High-Tech Imaging 20% After Deductible
Pharmacy Services
Preferred Generic 0% After Deductible $0 $0
Non-Preferred Generic 0% After Deductible $10 $10
PreferredNon-Preferred 0% After Deductible $50 $50
Brand
PreferredNon-Preferred 0% After Deductible $100/$150/$250 $100/$150/$250
Specialty
Your Medical Cost beginning January 1, 2023
The City of Decatur contributes 100% to the Employee-Only cost for the Base Plan. Employees are
eligible to enroll qualified Spouses and Dependent Children and the City will contribute $1500 single
or $3000 family for the HSA plan. ($375.00 per quarter single or $750 per quarter family) The
medical cost will be deducted via payroll deduction on a pre-tax basis. The City has a semi-monthly
payroll and deducts insurance premiums 2 pay periods per month. You must be actively enrolled in
the City of Decatur’s group HDHP HSA and complete the HSA Payroll Deductions form in order to
receive quarterly employer contribution in January, April, July and October. The form must be
turned in to Payroll at least two weeks before the pay period for these dates.
EMPLOYEE SEMI-MONTHLY DEDUCTIONS (24 PAY PERIODS) EFFECTIVE 1/1/2023
Employee
Employee & Spouse Employee & Children Employee & Family
Only
Base Plan
MTBCP014H $0.00 $58.94 $0.00 $213.23
PPO HSA
Basic Plan
$30.89 $216.37 $86.92 $472.40
MTBCP031 PPO
Buy-Up Plan
$65.07 $299.28 $153.47 $587.69
MTBC039 PPO
Page | 8
Health Savings Accounts (HSA) HSA If you participate in the high-deductible health plan, you can set aside money in a Health Savings Account (HSA) before taxes are deducted to pay for eligible medical, dental and vision expenses. An HSA is similar to a flexible spending account in that you are eligible to pay for health care expenses with pre-tax dollars. There are several advantages of an HSA. For instance, money in an HSA can be invested much like 401(k) funds are invested. Unused money in an HSA account is not forfeited at the end of the year and it is carried forward. Also, your HSA account is yours to keep which means that you can take it with you if you change jobs or retire. If you have any money remaining in your HSA after your retirement (age 65), you may withdraw the money as cash, subject to IRS guidelines. The maximum amount that you can contribute (including employer contribution) to an HSA is $3,850 in 2023 for individual coverage and $7,750 in 2023 for family coverage. Additionally, if you are age 55 or older, you may make an additional “catch-up” contribution of $1,000. *You may only participate in a limited purpose FSA, specifically for non- medical related expenses such as dental, vision and dependent care. Health Care and Dependent Care Flexible Spending Accounts (FSA) Employees and dependents that elect the HSA and elect to open an HSA are eligible to use remaining FSA funds for eligible expenses incurred in 2023. Current FSA payroll deductions will continue through December 31, 2023. You may continue Dependent Care if you select HSA. The City of Decatur provides you the opportunity to pay for out-of-pocket medical, dental, vision and dependent care expenses with pre-tax dollars through Flexible Spending Accounts. You must enroll/ re-enroll in the plan to participate for the plan year January 1, 2023 to December 31, 2023. You can save approximately 25 percent of each dollar spent on these expenses when you participate in a FSA. A health care FSA is used to reimburse out-of-pocket medical expenses incurred by you and your dependents. A dependent care FSA is used to reimburse expenses related to care of eligible dependents while you and your spouse work. Contributions to your FSA come out of your paycheck before any taxes are taken out. This means that you don’t pay federal income tax, Social Security taxes, or state and local income taxes on the portion of your paycheck you contribute to your FSA. You should contribute the amount of money you expect to pay out of pocket for eligible expenses for the plan period. If you do not use the money you contributed it will not be refunded to you or carried forward to a future plan year. This is the use-it-or- lose-it rule. 2023 maximum FSA contribution amount is $3,050.
The maximum that you can contribute to the Dependent Care Flexible Spending Account is $5,000 if
you are a single employee or married filing jointly, or $2,500 if you are married and filing separately.
The following example shows how you can save money with a flexible spending account.
Bob and Jane’s combined gross income is $30,000. They have two children and file their income taxes jointly. Since Bob and Jane expect to spend
$2,000 in adult orthodontia and $3,300 for day care next plan year, they decide to direct a total of $5,300 into their FSAs.
Without FSAs With FSAs
Gross income: $30,000 $30,000
FSA contributions: 0 -5,000
Gross income: 30,000 25,000
Estimated taxes:
Federal -2,550* -1,776*
State -900** -750**
FICA -2,295 -1,913
After-tax earnings: 24,255 20,314
Eligible out-of-pocket
Medical and dependent care expenses: -5,000 0
Remaining spendable income: $19,255 $20,561
Spendable income increase: $1,306
*Assumes standard deductions and four exemptions.** Varies, assume 3percent.
The example above is for illustrative purposes only. Every situation varies and we recommend that you consult a tax advisor for all tax advice.
Page | 10Voluntary Dental-Blue Cross Blue Shield
The City of Decatur offers eligible full-time employees a comprehensive Voluntary Dental plan.
Employees are responsible for 100% of all premiums.
Find a Provider at www.bcbstx.com or call 1-800-445-2227.
Services Amount You Pay
Preventive
Exams, cleanings, x-rays – Covered 100% (2 per benefit period)
Services
Deductible Applies to basic and major services only – $50/$150
Basic Services Fillings, simple extractions, periodontics, endodontics – Covered 80%
Major Services Restorative services, crowns –Covered 50%
Annual Maximum $2,000 Annual Maximum
Plan benefit 50%
Adult and Child
$2,000 Lifetime Maximum
Orthodontics
Waiting Period-None
Employee-Only: $18.36
Deductions-2
Employee & Spouse: $36.71
Paychecks Per
Employee & Child(ren): $44.63
Month
Family: $69.02
Voluntary Vision-BCBS EYEMED
As part of the comprehensive benefit program the City of Decatur offers eligible full-time employees a
Voluntary Vision plan. Employees are responsible for 100% of all premiums. Cost of the plan will be
made on pre-tax basis via payroll deduction.
Find a Provider at www.eyemedvisioncare.com/bcbstxvis or call 1-800-507-3800.
Services Amount You Pay
Eye Exam $10 Copay
Materials/Eyewear $25 Copay
Standard
Corrective Lenses
*Single Once each 12 months
*Lined Bifocal
*Lined Trifocal
Contact Lenses Once each 12 months
Frame Allowance $130 Allowance – once each 24 months
Contact Lens
$130 Allowance - once each 12 months
Allowance
Employee-Only: $3.80
Deductions-2
Employee & Spouse: $7.22
paychecks per
Employee & Child – $7.60
month
Family – $11.18
Page |
11Short Term Disability-Blue Cross Blue Shield
The City of Decatur provides full-time employees a benefit to secure your income while out of work from an
unexpected injury or illness.The benefit provides 60% of base salary to a maximum of $2,000 weekly.There is
an elimination period of 7-days from accident or sickness and the benefit duration is 12 weeks.The City pays
the full cost of this benefit. www.bcbstx.com or call 1-877-348-0487.
Short Term Disability
Benefits Begin 7 Day Elimination Period
Benefits Payable Up to $2,000 per week
Percentage of Income
60%
Replaced
Maximum Benefit Duration 12 Weeks
Long Term Disability-Blue Cross Blue Shield
The City of Decatur provides full-time employees a benefit to secure your income while out of work from an
unexpected injury or illness. The benefit provides 60% of base salary to a maximum of $6,000 monthly. There
is an elimination period of 90-days and the benefit continues until your Social Security Normal Retirement Age.
The City pays the full cost of this benefit. www.bcbstx.com or call 1-877-348-0487.
ENHANCED PRODUCT SERVICES INCLUDED WITH LONG TERM DISABILITY:
• 24 hour telephonic support for behavioral health issues provided by masters degree clinicians at no
charge. Provides caller with assessment, counseling and referral advice for face-to-face counseling.
• Up to 3 face-to-face counseling sessions per year to address appropriate behavioral health issues.
Guidance Resources Online is a secure, password-protected interactive Web site that contains self-
assessments, search tools, extensive content on personal health and powerful tools to help with personal,
relational, legal, health and financial concerns. The service is free of charge to employees and their families
and is available 24 hours a day, 7 days a week.
Long Term Disability
Benefits Begin 90 Day Elimination Period
Benefits Payable Up to $6,000 per month
Percentage of Income
60%
Replaced
Maximum Benefit Duration SSNRABASIC LIFE / AD&D INSURANCE – BCBS The City of Decatur is proud to continue sponsoring the Basic Life/ADD pr ogram covering all full-time employees with a $25,000 group life and accidental death and dismember ment plan. The City of Decatur pays for the full cost of this benefit – meaning you are not responsible for paying any monthly prem iums. Basic Lif e/ADD insurance can provide for your loved ones if something were to happen to you. Please m ake sur e to update your beneficiar y information. Voluntary/Supplemental Life Insurance-BCBS Full-Time Employees are eligible to purchase supplemental gr oup life insurance. When you enroll yourself and/ or your dependents in this benefit, you pay the full cost through semi- monthly payroll deductions. Employee Guaranteed Issue (GI) $100,000. Benefits in increments of $10,000 to a maximum of $500,000. Spouse Guaranteed Issue (GI) $30,000. Benefits in increments of $5,000 to a maximum of $250,000, not to exceed 50% of the Employee voluntary life/ADD amount. Child(ren) Guaranteed Issue (GI) $10,000. Birth to 14 days: $250.00. Ages 15 days to 26 years: $10,000 During Open Enrollment period, Employees who previously waived coverage January 2022, for coverages for Employees, Dependents Spouses and Dependent Children, you may enroll in coverage for January 2023 with Evidence of Insurability (EOI). Those employees currently enrolled may request $10,000 additional coverage up to the Guarantee Issue without EOI. If the requested increase takes you over the GI, EOI is required. New Hires can enroll up to the GI without EOI. Page | 13
EMPLOYEE Voluntary/Supplemental Life & AD&D – BCBS Page | 14
SPOUSE Voluntary/Supplemental Life and AD&D - BCBS Page | 15
DEPENDENT Life (Children) – BCBS $10,000 Page | 16
Page | 17
ALL EMPLOYEES
20 ways the EAP can help
There are many ways to get help today - all completely confidential.
Your Employee Assistance Program (EAP) provides you with immediate
and confidential help for any work, health or life concern. Let us help
with stress, anxiety, parenting advice, family needs and much more.
Caring professionals can help you to:
1 Assess your personal problems or concerns so that you can understand them more clearly.
2 Address short-term problems and concerns for depression, anxiety, anger, relationships, and family matters.
3 Effectively cope and manage any issues or symptoms causing you stress.
4 Recognize and target risky behaviors related to drinking or drug use, gambling and/or other addictions.
5 Access support to help you stay motivated and involved in self-help or recovery.
6 Sort through complex decisions that may have long-term consequences for you, your family, or others (e.g., divorce,
retirement, or life change).
7 Make positive and lasting lifestyle changes with online tools, articles, videos, and self-assessments.
8 Help you decide what type of mental health professional will work best for you, based on your communication style
and goals.
9 Build a greater capacity to identify and remove barriers to personal growth and change.
10 Access grief support and learn coping strategies to help you deal with the loss of a loved one.
11 Find an attorney to assist matters such as separation/divorce, custody, child support, and estate planning.
© 2019 Morneau Shepell Ltd
Apple and the Apple logo are trademarks of Apple Inc., registered in the US and other countries. App Store is a service mark of Apple
Inc., registered in the US, and other countries. Google Play and the Google Play logo are trademarks of Google Inc.12 Better manage your finances by referring you for assistance with budgeting, savings, or debt management.
13 Locate childcare providers and arrange for back-up childcare in case your regular support system falls through.
14 Find referral resources and information for adoption and education (K-12 and college/trade schools).
15 Access resources to help manage and improve relationships with spouses, partners, or other significant people.
16 Find eldercare resources such as nursing/retirement homes and meal delivery services.
17 Learn positive communication skills to help improve communication and morale among your work team.
18 Learn how to work effectively with your employees and to improve their productivity.
19 Access crisis relief services following a critical incident involving death, injury, or post-traumatic stress.
20 (For supervisors) Learn effective ways to recommend EAP support, when employees’ personal issues are
interfering with performance.
Visit us online: Call us, toll-free, 24/7:
www.login.lifeworks.com (888) 456-1324
Get the “LifeWorks” app!
User ID: Password:
Your work e-mail You'll create at login
© 2019 Morneau Shepell Ltd
Apple and the Apple logo are trademarks of Apple Inc., registered in the US and other countries. App Store is a service mark of Apple
Inc., registered in the US, and other countries. Google Play and the Google Play logo are trademarks of Google Inc.Responder
Program Feature Health
A truly confidential crisis hotline answered by current and retired first responders
available 24/7/365*
Referrals to vetted Counselors that specialize in treating first responders*
Referrals to vetted Inpatient facilities and treatment centers that specialize in
treating first responders*
Post Treatment Care Services such as*:
• Family Support Services
• Ongoing Counseling & Treatment
• Tools/Resources to stay mentally healthy
Annual Training on topics such as:
• Peer Support formation and sustainment
• Emotional Body Armor
• PTSD, Trauma and Stress
• Relationship and Marital support and strengthening
Dedicated App with customized content to help First Responders with their
unique needs
Access to Ancillary Services such as:
• Gun Shot Benefits
• Cancer Genetic Testing and treatment assistance
• Pharmacogenetic Testing
*Services are provided by our national strategic partners that have been serving First Responders since 2009
While many individual programs exist today, Responder Health is the ONLY one that
combines the best solutions and makes implementation easy.BENEFIT CONTACT INFORMATION
COVERAGE TYPE CARRIER CONTACT INFORMATION
Blue Cross Blue Shield 800-445-2227
Medical/ Prescription Drug Plan
Texas www.bcbstx.com
Blue Cross Blue Shield 800-445-2227
Dental
Texas www.bcbstx.com
Blue Cross Blue Shield 855-556-8796
Vision
Texas/EYEMED www.eyemedvisioncare.com/bcbstxvis
Blue Cross Blue Shield 877-348-0487
Life & AD&D Coverage
Texas www.bcbstx.com
888-456-1324
Employee Assistance Plan LifeWorks
www.login.lifeworks.com
800-800-7616
Telemedicine / Discount Plan New Benefits
www.mymemberportal.com
Employee Benefits Portal HR Connect www.hrconnection.com
800-532-3327
H.S.A. & FSA Admin Flores
Lisa Dixon
Broker HUB International 940-294-0319
lisa.dixon@hubinternational.com
The information in this Enrollment Guide is presented for illustrative purposes and is based on information provided
by the employer. The text contained in this guide was taken from various summary plan descriptions and benefit
information. While every effort was taken to accurately report your benefits, discrepancies or errors are always
possible. In case of discrepancy between the guide and actual plan documents, the actual plan documents will
prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If
you have any questions about the guide, please contact HR.ANNUAL NOTICES
Notice of Special Enrollment Rights
If you are declining enrollment for yourself or your dependents (including your spouse) because of other
health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in
this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops
contributing toward your or your dependents’ other coverage). However, you must request enrollment
within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing
toward the other coverage).
If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be
able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the
marriage, birth, adoption, or placement for adoption.
If you or your dependent(s) lose coverage under a state Children’s Health Insurance Program (CHIP) or
Medicaid, you may be able to enroll yourself and your dependents. However, you must request enrollment
within 60 days after the loss of CHIP or Medicaid coverage.
If you or your dependent(s) become eligible to receive premium assistance under a state CHIP or Medicaid,
you may be able to enroll yourself and your dependents. However, you must request enrollment within 60
days of the determination of eligibility for premium assistance from state CHIP or Medicaid.
To request special enrollment or obtain more information, contact your HR Representative or Plan
Administrator.
1General Notice of COBRA Rights
(For use by single-employer group health plans)
Continuation Coverage Rights Under COBRA
Introduction
You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This
notice has important information about your right to COBRA continuation coverage, which is a temporary
extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may
become available to you and your family, and what you need to do to protect your right to get it. When
you become eligible for COBRA, you may also become eligible for other coverage options that may cost less
than COBRA continuation coverage.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other
members of your family when group health coverage would otherwise end. For more information about
your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan
Description or contact the Plan Administrator.
You may have other options available to you when you lose group health coverage. For example, you may
be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage
through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-
pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health
plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late
enrollees.
What is COBRA continuation coverage?
COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a
life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice.
After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified
beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if
coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who
elect COBRA continuation coverage must pay for COBRA continuation coverage.
If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because
of the following qualifying events:
Your hours of employment are reduced, or
Your employment ends for any reason other than your gross misconduct.
If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under
the Plan because of the following qualifying events:
Your spouse dies;
Your spouse’s hours of employment are reduced;
Your spouse’s employment ends for any reason other than his or her gross misconduct;
Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or
1 You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of
the following qualifying events:
The parent-employee dies;
The parent-employee’s hours of employment are reduced;
The parent-employee’s employment ends for any reason other than his or her gross misconduct;
The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
The parents become divorced or legally separated; or
The child stops being eligible for coverage under the Plan as a “dependent child.”
When is COBRA continuation coverage available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator
has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of
the following qualifying events:
The end of employment or reduction of hours of employment;
Death of the employee;
The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).
For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent
child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within
30 Days days after the qualifying event occurs. You must provide this notice to:
Your HR Representative or Plan Administrator
How is COBRA continuation coverage provided?
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation
coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an
independent right to elect COBRA continuation coverage. Covered employees may elect COBRA
continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on
behalf of their children.
COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due
to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying
event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of
coverage.
There are also ways in which this 18-month period of COBRA continuation coverage can be extended:
2Disability extension of 18-month period of COBRA continuation coverage
If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and
you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to
an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would
have to have started at some time before the 60th day of COBRA continuation coverage and must last at
least until the end of the 18-month period of COBRA continuation coverage.
Second qualifying event extension of 18-month period of continuation coverage
If your family experiences another qualifying event during the 18 months of COBRA continuation coverage,
the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation
coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event.
This extension may be available to the spouse and any dependent children getting COBRA continuation
coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A,
Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the
Plan as a dependent child. This extension is only available if the second qualifying event would have caused
the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.
Are there other coverage options besides COBRA Continuation Coverage?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and
your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage
options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these
options may cost less than COBRA continuation coverage. You can learn more about many of these options
at www.healthcare.gov.
If you have questions
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the
contact or contacts identified below. For more information about your rights under the Employee
Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act,
and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S.
Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit
www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available
through EBSA’s website.) For more information about the Marketplace, visit www.healthcare.gov.
Keep your Plan informed of address changes
To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family
members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.
Plan contact information
2022-2023 Plan Year
3General FMLA Notice
EMPLOYEE RIGHTS
UNDER THE FAMILY AND
MEDICAL LEAVE ACT
The United States Department of Labor Wage and Hour Division
Leave Entitlements
Eligible employees who work for a covered employer can take up to 12 weeks of unpaid, job-protected leave in a
12-month period for the following reasons:
The birth of a child or placement of a child for adoption or foster care;
To bond with a child (leave must be taken within 1 year of the child’s birth or placement);
To care for the employee’s spouse, child, or parent who has a qualifying serious health condition;
For the employee’s own qualifying serious health condition that makes the employee unable to perform the
employee’s job;
For qualifying exigencies related to the foreign deployment of a military member who is the
employee’s spouse, child, or parent.
An eligible employee who is a covered servicemember’s spouse, child, parent, or next of kin may also take up
to 26 weeks of FMLA leave in a single 12-month period to care for the servicemember with a serious injury or
illness.
An employee does not need to use leave in one block. When it is medically necessary or otherwise permitted,
employees may take leave intermittently or on a reduced schedule.
Employees may choose, or an employer may require, use of accrued paid leave while taking FMLA leave. If an
employee substitutes accrued paid leave for FMLA leave, the employee must comply with the employer’s
normal paid leave policies.
Benefits & Protections
While employees are on FMLA leave, employers must continue health insurance coverage as if the
employees were not on leave.
Upon return from FMLA leave, most employees must be restored to the same job or one nearly identical to it
with equivalent pay, benefits, and other employment terms and conditions.
An employer may not interfere with an individual’s FMLA rights or retaliate against someone for using or
trying to use FMLA leave, opposing any practice made unlawful by the FMLA, or being involved in any
proceeding under or related to the FMLA.
1Eligibility Requirements
An employee who works for a covered employer must meet three criteria in order to be eligible for FMLA
leave. The employee must:
Have worked for the employer for at least 12 months;
Have at least 1,250 hours of service in the 12 months before taking leave;* and
Work at a location where the employer has at least 50 employees within 75 miles of the employee’s
worksite.
*Special “hours of service” requirements apply to airline flight crew employees.
Requesting Leave
Generally, employees must give 30-days’ advance notice of the need for FMLA leave. If it is not possible to
give 30-days’ notice, an employee must notify the employer as soon as possible and, generally, follow the
employer’s usual procedures.
Employees do not have to share a medical diagnosis, but must provide enough information to the employer
so it can determine if the leave qualifies for FMLA protection. Sufficient information could include informing
an employer that the employee is or will be unable to perform his or her job functions, that a family member
cannot perform daily activities, or that hospitalization or continuing medical treatment is necessary.
Employees must inform the employer if the need for leave is for a reason for which FMLA leave was
previously taken or certified.
Employers can require a certification or periodic recertification supporting the need for leave. If the employer
determines that the certification is incomplete, it must provide a written notice indicating what additional
information is required.
Employer Responsibilities
Once an employer becomes aware that an employee’s need for leave is for a reason that may qualify under
the FMLA, the employer must notify the employee if he or she is eligible for FMLA leave and, if eligible, must
also provide a notice of rights and responsibilities under the FMLA. If the employee is not eligible, the
employer must provide a reason for ineligibility.
Employers must notify its employees if leave will be designated as FMLA leave, and if so, how much leave will
be designated as FMLA leave.
Enforcement
Employees may file a complaint with the U.S. Department of Labor, Wage and Hour Division, or may bring a
private lawsuit against an employer.
The FMLA does not affect any federal or state law prohibiting discrimination or supersede any state or local
law or collective bargaining agreement that provides greater family or medical leave rights.
For additional information or to file a complaint:
1-866-4-USWAGE
(1-866-487-9243) TTY: 1-877-889-5627
www.dol.gov/whd
U.S. Department of Labor | Wage and Hour Division
2Employer’s Children’s Health Insurance Program (CHIP)
Notice
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 below,
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 dial
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).
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: Medicaid
Website: http://myakhipp.com/ www.medicaid.georgia.gov
Phone: 1-866-251-4861 - Click on Health Insurance Premium Payment (HIPP)
Email: CustomerService@MyAKHIPP.com Phone: 404-656-4507
Medicaid Eligibility:
http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
1ARKANSAS – Medicaid INDIANA – Medicaid
Website: http://myarhipp.com/ Healthy Indiana Plan for low-income adults 19-64
Phone: 1-855-MyARHIPP (855-692-7447) Website: http://www.in.gov/fssa/hip/
Phone: 1-877-438-4479
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: 1-785-296-3512
KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid
Website: https://chfs.ky.gov Website: https://www.dhhs.nh.gov/oii/hipp.htm
Phone: 1-800-635-2570 Phone: 603-271-5218
Toll-Free: 1-800-852-3345, ext 5218
LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP
Website: Medicaid Website:
http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 http://www.state.nj.us/humanservices/dmahs/clients/medicaid
Phone: 1-888-695-2447 /
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
MAINE – Medicaid NEW YORK – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public- Website: https://www.health.ny.gov/health_care/medicaid/
assistance/index.html Phone: 1-800-541-2831
Phone: 1-800-442-6003
TTY: Maine relay 711
MASSACHUSETTS – Medicaid and CHIP NORTH CAROLINA – Medicaid
Website: Website: https://dma.ncdhhs.gov/
http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 919-855-4100
Phone: 1-800-862-4840
MINNESOTA – Medicaid NORTH DAKOTA – Medicaid
Website: Website:
https://mn.gov/dhs/people-we-serve/seniors/health- http://www.nd.gov/dhs/services/medicalserv/medicaid/
care/health-care-programs/programs-and-services/other- Phone: 1-844-854-4825
insurance.jsp
Phone: 1-800-657-3739 or 651-431-2670
MISSOURI – Medicaid OKLAHOMA – Medicaid and CHIP
Website: Website: http://www.insureoklahoma.org
http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 1-888-365-3742
Phone: 573-751-2005
MONTANA – Medicaid OREGON – Medicaid
Website: Website:
http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP http://healthcare.oregon.gov/Pages/index.aspx
Phone: 1-800-694-3084 http://www.oregonhealthcare.gov/index-es.html
Phone: 1-800-699-9075
NEBRASKA – Medicaid PENNSYLVANIA – Medicaid
Website: http://www.ACCESSNebraska.ne.gov Website:
Phone: (855) 632-7633 http://www.dhs.pa.gov/provider/medicalassistance/healthinsur
Lincoln: (402) 473-7000 ancepremiumpaymenthippprogram/index.htm
Omaha: (402) 595-1178 Phone: 1-800-692-7462
2NEVADA – Medicaid RHODE ISLAND – Medicaid
Medicaid Website: http://dhcfp.nv.gov Website: http://www.eohhs.ri.gov/
Medicaid Phone: 1-800-992-0900 Phone: 855-697-4347
SOUTH CAROLINA – Medicaid VIRGINIA – Medicaid and CHIP
Website: https://www.scdhhs.gov Medicaid Website:
Phone: 1-888-549-0820 http://www.coverva.org/programs_premium_assistance.cfm
Medicaid Phone: 1-800-432-5924
CHIP Website:
http://www.coverva.org/programs_premium_assistance.cfm
CHIP Phone: 1-855-242-8282
SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid
Website: http://dss.sd.gov Website: http://www.hca.wa.gov/free-or-low-cost-health-
Phone: 1-888-828-0059 care/program-administration/premium-payment-program
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:
CHIP Website: http://health.utah.gov/chip https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf
Phone: 1-877-543-7669 Phone: 1-800-362-3002
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
3Genetic Information Nondiscrimination Act (GINA)
Disclosures
Genetic Information Nondiscrimination Act of 2008
The Genetic Information Nondiscrimination Act of 2008 (“GINA”) protects employees against discrimination
based on their genetic information. Unless otherwise permitted, your Employer may not request or require
any genetic information from you or your family members.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities
covered by GINA Title II from requesting or requiring genetic information of an individual or family member
of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you
not provide any genetic information when responding to this request for medical information. “Genetic
information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s
or family member’s genetic tests, the fact that an individual or an individual’s family member sought or
received genetic services, and genetic information of a fetus carried by an individual or an individual’s family
member or an embryo lawfully held by an individual or family member receiving assistive reproductive
services.
Mental Health Parity and Addiction Equity Act (MHPAEA)
Disclosure
The Mental Health Parity and Addiction Equity Act of 2008 generally requires group health plans and health
insurance issuers to ensure that financial requirements (such as co-pays and deductibles) and treatment
limitations (such as annual visit limits) applicable to mental health or substance use disorder benefits are no
more restrictive than the predominant requirements or limitations applied to substantially all
medical/surgical benefits. For information regarding the criteria for medical necessity determinations made
under the 2018-2019 Plan Year with respect to mental health or substance use disorder benefits, please
contact your plan administrator.
Newborns' and Mothers' Health Protection Act Notice
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for
any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48
hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law
generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother,
from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case,
plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or
the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
1Women's Health and Cancer Rights Act (WHCRA) Notices
Enrollment Notice
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the
Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related
benefits, coverage will be provided in a manner determined in consultation with the attending physician and
the patient, for:
All stages of reconstruction of the breast on which the mastectomy was performed;
Surgery and reconstruction of the other breast to produce a symmetrical appearance;
Prostheses; and
Treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical
and surgical benefits provided under this plan. Therefore, the following deductibles and coinsurance apply:
$5000 deductible (in-network) and 70% coinsurance (in-network) and $10000 deductible (out-of-network)
and 50% coinsurance (out-of-network). If you would like more information on WHCRA benefits, call your
plan administrator.
Annual Notice
Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides
benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve
symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including
lymphedema? Call your plan administrator for more information.
1Health Insurance Exchange Notice
For Employers Who Offer a Health Plan to Some or All Employees
New Health Insurance Marketplace Coverage Options and Your Health
Coverage
PART A: General Information
When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance:
The Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice
provides some basic information about the new Marketplace and employment-based health coverage
offered by your employer.
What is the Health Insurance Marketplace?
The Marketplace is designed to help you find health insurance that meets your needs and fits your budget.
The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may
also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment
for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early
as January 1, 2014.
Can I Save Money on my Health Insurance Premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if your employer does not offer
coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're
eligible for depends on your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be
eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan.
However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain
cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets
certain standards. If the cost of a plan from your employer that would cover you (and not any other members
of your family) is more than 9.5% of your household income for the year, or if the coverage your employer
provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for
a tax credit.1
Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by
your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also,
this employer contribution -as well as your employee contribution to employer-offered coverage- is often
excluded from income for Federal and State income tax purposes. Your payments for coverage through the
Marketplace are made on an after-tax basis.
How Can I Get More Information?
For more information about your coverage offered by your employer, please check your summary plan
description or contact:
1An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed
benefit costs covered by the plan is no less than 60 percent of such costs.
1Your HR Representative or Plan Administrator.
The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through
the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online
application for health insurance coverage and contact information for a Health Insurance Marketplace in your
area.
PART B: Information About Health Coverage Offered by Your Employer
This section contains information about any health coverage offered by your employer. If you decide to
complete an application for coverage in the Marketplace, you will be asked to provide this information. This
information is numbered to correspond to the Marketplace application.
3. Employer name 4. Employer Identification Number (EIN)
5. Employer address 6. Employer phone number
7. City 8. State 9. ZIP code
10. Who can we contact about employee health coverage at this job?
11. Phone number 12. Email address
Here is some basic information about health coverage offered by this employer:
As your employer, we offer a health plan to:
☑ Some employees. Eligible employees are: Full-Time Employees working 30 Hours or more per week
With respect to dependents:
☑ We do not offer coverage.
☑ If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is
intended to be affordable, based on employee wages.
Note: Even if your employer intends your coverage to be affordable, you may still be eligible for a premium
discount through the Marketplace. The Marketplace will use your household income, along with other
factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary
from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are
newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.
2USERRA Notice
Your Rights Under USERRA
A. The Uniformed Services Employment and Reemployment Rights Act
USERRA protects the job rights of individuals who voluntarily or involuntarily leave employment positions to
undertake military service or certain types of service in the National Disaster Medical System. USERRA also
prohibits employers from discriminating against past and present members of the uniformed services, and
applicants to the uniformed services.
B. Reemployment Rights
You have the right to be reemployed in your civilian job if you leave that job to perform service in the
uniformed service and:
You ensure that your employer receives advance written or verbal notice of your service;
You have five years or less of cumulative service in the uniformed services while with that particular
employer;
You return to work or apply for reemployment in a timely manner after conclusion of service; and
You have not been separated from service with a disqualifying discharge or under other than
honorable conditions.
If you are eligible to be reemployed, you must be restored to the job and benefits you would have attained if
you had not been absent due to military service or, in some cases, a comparable job.
C. Right to Be Free from Discrimination and Retaliation
If you:
Are a past or present member of the uniformed service;
Have applied for membership in the uniformed service; or
Are obligated to serve in the uniformed service; then an employer may not deny you
o Initial employment;
o Reemployment;
o Retention in employment;
o Promotion; or
o Any benefit of employment because of this status.
In addition, an employer may not retaliate against anyone assisting in the enforcement of USERRA rights,
including testifying or making a statement in connection with a proceeding under USERRA, even if that
person has no service connection.D. Health Insurance Protection
If you leave your job to perform military service, you have the right to elect to continue your existing
employer-based health plan coverage for you and your dependents for up to 24 months while in the
military.
Even if you do not elect to continue coverage during your military service, you have the right to be
reinstated in your employer's health plan when you are reemployed, generally without any waiting
periods or exclusions (e.g., pre-existing condition exclusions) except for service-connected illnesses
or injuries.
E. Enforcement
The U.S. Department of Labor, Veterans' Employment and Training Service (VETS) is authorized to
investigate and resolve complaints of USERRA violations.
For assistance in filing a complaint, or for any other information on USERRA, contact VETS at 1-866-4-USA-
DOL or visit its Web site at http://www.dol.gov/vets. An interactive online USERRA Advisor can be viewed at
http://www.dol.gov/elaws/userra.htm.
If you file a complaint with VETS and VETS is unable to resolve it, you may request that your case be
referred to the Department of Justice or the Office of Special Counsel, as applicable, for
representation.
You may also bypass the VETS process and bring a civil action against an employer for violations of
USERRA.
The rights listed here may vary depending on the circumstances. The text of this notice was prepared by
VETS, and may be viewed on the Internet at this address:
http://www.dol.gov/vets/programs/userra/poster.htm. Federal law requires employers to notify employees
of their rights under USERRA, and employers may meet this requirement by displaying the text of this notice
where they customarily place notices for employees. U.S. Department of Labor, Veterans' Employment and
Training Service, 1-866-487-2365.You can also read
