Message PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 1 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Provided to you by: Psychiatric Medical Care 2025-2026 BENEFITS GUIDE
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 2 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Welcome We would like to welcome you to the 2025-2026 annual benefits summary package for Psychiatric Medical Care (PMC). This packet contains summaries of the benefits offered to you by Psychiatric Medical Care. We encourage you to take the time to educate yourself about your options and choose the best coverage for you and your family. This benefits guide provides an overview of benefit plans, including eligibility, election periods and costs. In addition, the guide offers descriptions and explanations of each coverage plan option. We urge you to carefully consider all aspects of these programs, including their premiums, accessibility to health care services, flexibility, and restrictions. Table of Contents Welcome .................................................................................................................................................................................................................................................................... 2 Carrier Contacts ....................................................................................................................................................................................................................................................... 3 Enrolling and Eligibility............................................................................................................................................................................................................................................ 5 Who is Eligible? ..................................................................................................................................................................................................................................................... 5 Enrolling for Coverage......................................................................................................................................................................................................................................... 5 Eligibility and Enrolling............................................................................................................................................................................................................................................ 6 Passive Enrollment ............................................................................................................................................................................................................................................... 6 Changing Your Coverage During the Year...................................................................................................................................................................................................... 6 When Dependent Children Age Out ................................................................................................................................................................................................................ 6 Medical & Prescription Drug Benefits ................................................................................................................................................................................................................. 7 Medical Key Reminders ...................................................................................................................................................................................................................................... 8 Prescription Drug Coverage............................................................................................................................................................................................................................... 8 Where To Seek Care................................................................................................................................................................................................................................................ 9 Health Savings Account (HSA) ........................................................................................................................................................................................................................... 10 Understanding Health Savings Account (HSA) ............................................................................................................................................................................................... 11 Flexible Spending Accounts (FSA) ..................................................................................................................................................................................................................... 12 Dental Benefits ...................................................................................................................................................................................................................................................... 13 Voluntary Vision Benefits ................................................................................................................................................................................................................................... 14 Life and Accidental Death & Dismemberment (AD&D) Insurance ............................................................................................................................................................ 15 Group Life and AD&D ....................................................................................................................................................................................................................................... 15 Life and Accidental Death & Dismemberment (AD&D) Insurance ............................................................................................................................................................ 16 Voluntary Life and AD&D................................................................................................................................................................................................................................. 16 Disability Income Benefits .................................................................................................................................................................................................................................. 17 Voluntary Benefits ................................................................................................................................................................................................................................................ 18 Added Value Programs ........................................................................................................................................................................................................................................ 20 Important Notices ................................................................................................................................................................................................................................................. 21 Info on the Go! Scan with your Smartphone to access your 2025-2026 Benefits Guide and enrollment materials online ANYTIME.
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 3 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Carrier Contacts Your Carriers Contact Name Contact Information Medical Aetna Phone: 1 (800) 240-2386 Website: www.aetna.com Health Savings Account (HSA) Bank of America Phone: 1 (800) 992-3200 Option 1 Website: https://healthaccounts.bankofamerica.com/ Dental Delta Dental Phone: 1 (800) 223-3104 Website: www.deltadentaltn.com Vision Delta Dental Phone: 1 (800) 877-7195 Website: www.deltadentaltn.com Flexible Spending Accounts (FSAs) Bank of America Phone: 1 (800) 992-3200 Option 1 Website: https://healthaccounts.bankofamerica.com/ Life and AD&D Guardian Phone: 1 (800) 525-4542 Website: www.guardianlife.com
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 4 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Short-Term Disability Long-Term Disability Guardian Phone: 1 (800) 268-2525 Phone: 1 (800) 538-4583 Website: www.guardianlife.com Voluntary Benefits (Accident, Critical Illness & Hospital Indemnity) Aetna Phone: 1 (888) 772-9682 Website: www.myaetnasupplemental.com Employee Assistance Program (EAP) Guardian Phone: 1 (800) 386-7055 Website: www.worklife.uprisehealth.com Access code: worklife Added Value Programs Guardian Phone: 1 (877) 433-6789 Website: www.willprep.uprisehealth.com Username: WillPrep Password: GLIC09
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 5 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Enrolling and Eligibility Who is Eligible? If you are a full-time employee, you are eligible to enroll in benefits described in this guide. You are eligible for benefits on the first of the month following date of hire. You may enroll your eligible dependents in the same plans you choose for yourself, including medical, dental, vision and voluntary life insurance coverage. Eligible dependents may include the following: When you enroll dependents, we have the right to ask that you submit copies of the following (if applicable): Marriage Certificate, an Affidavit of Domestic Partnership or Common Law Marriage Birth Certificate(s) Adoption Papers or papers to show legal adoption proceedings have started If you do not provide this documentation within 30 days of hire, your dependents will not be enrolled in benefits. Domestic Partner Coverage You may cover your same-sex or opposite sex domestic partner for certain benefits. For Domestic Partner coverage, you must submit an Affidavit of Domestic Partnership verifying eligibility of your domestic partner. The Affidavit of Domestic Partnership is available within Paylocity. A Domestic Partner must be at least 18 years of age and you must have resided in the same household for at least 12 months. Please note, coverage for Domestic Partners is paid by the employee on a post- tax basis and imputed income will apply. Declaration Of Domestic Partnership (eforms.com) Domestic Partner coverage is subject to imputed income. This means that the employee pays taxes on the value of the health benefits that their domestic partner receives. Domestic Partner imputed income is in addition to the monthly plan cost that the employee pays. You are required to submit the affidavit no later than May 15, 2025. Failure to do so will result in no coverage for your domestic partner effective June 1, 2025. Enrolling for Coverage Your enrollment period is a valuable time to review your benefits and choose the best options for you and your family. Review the 2025-2026 Employee Benefits Guide to understand the coverage available and changes to the PMC Benefits Program. You can enroll in coverage within 30 days of your hire date or during the annual open enrollment period. Newly hired full-time employees enrolling for the first time, will make their benefit elections via Paylocity, our online enrollment tool. You can make your benefit elections during the enrollment window, and coverage begins on the first of the month following date of hire. If you enroll after the 1st of the month, but still within your 30-day window, the benefits will be retroactive to the 1st of the month in which you were hired. Please visit https://access.paylocity.com/ to access your account profile. Everyone can access their benefits information via the Paylocity Portal to enroll and/or amend their benefits. Your legal spouse Your Domestic Partner (same & opposite sex) Your children up to age 26 Your unmarried dependent children over age 26 who are incapable of self-care because of a disability and who rely on you for support
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 6 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Eligibility and Enrolling Passive Enrollment This year’s annual enrollment is a Passive Enrollment for Medical, Dental, Vision, Accident, Critical Illness, and Hospital Indemnity. It is important to note that there are cost changes for the Medical and you must login and confirm or waive all elections. ACTION REQUIRED: You MUST make an election for Short-Term Disability (STD) and Long-Term Disability (LTD) if you wish to have coverage. If you do NOT enroll in STD and/or LTD you will NOT have coverage beginning June 1, 2025. Additionally, if you wish to re-enroll in the Health Savings Account (HSA) and/or the Flexible Spending Account (FSA), and/or the Dependent Care benefit, you MUST re-enroll each year. Please note that we are changing vendors to Bank of America. Changing Your Coverage During the Year Whether you are a newly hired employee or a current employee enrolling during the annual open enrollment, the elections you make at this time will remain in effect until PMC’s next open enrollment period, unless you have a qualifying life event (as defined by the IRS) that allows a mid-year plan change. These changes include (but are not limited to): Birth or adoption of a baby or child Loss of other healthcare coverage Eligibility for new healthcare coverage Marriage Divorce Change in child’s dependent status If you experience a qualifying life event, or if you have questions, please contact Human Resources (HR). You have 30 days after a qualifying event to notify HR and request a change to your benefit elections. Note: The benefit changes you make must be consistent with the life event. When Dependent Children Age Out Dependent children can remain on the medical, dental and/or vision coverage(s) until the end of the calendar year in which they turn 26, at which time their coverage will be cancelled. Coverage under Voluntary Life and AD&D ends on their 26th birthday.
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 7 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. *Embedded deductible and out-of-pocket (OOP), means that a “per member” deductible and OOP are embedded within the “per family” thresholds. Each covered family member is subject only to their “per member” deductible or OOP, and the family’s exposure as a whole is limited by the family deductible and OOP limits. **Spousal Surcharge: If your spouse is eligible for medical coverage through his or her employer and doesn’t enroll in those benefits, but elects to enroll in PMC’s medical benefits, a monthly spousal surcharge will be added to your premium. The monthly spousal surcharge is $125. If your spouse isn’t eligible for benefits through his or her employer, is not employed, or is self-employed, you will not be charged a monthly surcharge if they enroll in PMC’s benefits. Spousal affidavit must be completed and returned to HR by May 15, 2025. If NOT, then spouse coverage will terminate June 1, 2025. New hires will have 30 days from date of hire to provide the affidavit. Medical & Prescription Drug Benefits Plan Year – June 1st through May 31st PMC offers a comprehensive benefits program to help you and your family protect your health and financial security. Your benefits are a valuable part of your compensation; we encourage you to learn how your plans work so you can get the most from them. These plans encourage you to seek care from In-Network providers, which provide a higher level of benefit. You may choose to use Out-Of-Network providers, but if you do, your benefits will be reduced, and your out-of-pocket expense will increase. These plans do not require you to select a primary care provider, nor is it necessary to obtain a referral in order to see a specialist. The following chart provides a summary of the key features of the Medical benefit options. Complete benefit summaries are available on the Paylocity Portal. The below refers to the member portion of the benefit. $2,000 PPO $3,500 HDHP Network Name: Aetna CPOS II (Open Access) Medical Key Features In-Network In-Network Annual Deductible (Based on Calendar Year) Individual / Family *Embedded $2,000 / $6,000 *Embedded $3,500 / $7,000 Out-of-Pocket Maximum Individual / Family $4,000 / $12,000 $5,950 / $11,900 Coinsurance 20% 20% Physician Services Office Visit Specialist Visit $30 copay $60 copay 20% after deductible 20% after deductible Preventative Care 100% covered 100% covered Lab and X-Ray Services 20% after deductible 20% after deductible Inpatient Hospital Services 20% after deductible 20% after deductible Urgent Care $75 Copay 20% after deductible Emergency Room $250 Copay 20% after deductible Prescription Drugs Copays are after Medical Deductible has been met Retail (30-day supply) $10/$35/$60 $10/$35/$60 Mail Order (90-day supply) $20/$70/$120 $20/$70/$120 Mail Order Specialty $40 or $60 $40 or $60 Semi-Monthly Employee Payroll Contributions (24 Pay Periods) Employee Only $62.50 $35.00 **Employee + Spouse $200.00 $85.00 Employee + Child(ren) $135.00 $60.00 **Family $292.50 $110.00
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 8 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Medical & Prescription Drug Benefits Medical Key Reminders To limit your Out-of-Pocket expenses, please seek services from an Aetna provider. To find a provider, visit https://www.aetna.com/individuals-families/find-a-doctor.html. If services are provided by a non-Aetna provider, the member is responsible for any amounts exceeding the “allowable charges,” in which case balance billing could occur. Dependent Child Age Limits: Covered to end of the year in which they turn age 26. Prescription Drug Coverage We know prescription drug coverage is important to you and your family, so when you elect medical coverage, you are automatically covered under the prescription drug plan. You may fill your prescriptions at participating retail pharmacies. Under the prescription drug coverage, the mail order option allows you to buy qualified prescriptions in larger 90-day quantities for a slightly higher copay amount as a 31-day supply at the retail pharmacy. Mail order saves you time in trips to the pharmacy because prescriptions are delivered right to your door. Here is a link to the Aetna prescription drug site: Find a Medication: Prescription Drug List (Formulary), Coverage & Costs | Aetna There are several categories of drugs under the plans. The differences between these categories are described below: Tier 1 – Preferred Generic: Frequently prescribed generic drugs. Tier 2 – Non-Preferred Generic: Generic drugs with higher costs than preferred generics. Tier 3 – Preferred Brand: Lowest cost brand name drugs. Find individualized information on your benefit coverage, determine tier status, check the status of claims and search for network pharmacies by logging on to www.Aetna.com or by calling Aetna. Choose Generics - The member will pay the applicable copay (if any) only if the physician requires a brand-name medication. However, if a generic version is available and the member requests the brand-name drug instead, the member will be responsible for paying the applicable copay plus the cost difference between the generic and brand-name medication. To avoid additional costs, be sure to discuss generic options with your physician when receiving a prescription. Please Note: After two refills of your maintenance medication, you will need to obtain a 90-day supply from one of the below: 1. CVS Caremark Mail Service Pharmacy 2. CVS Pharmacy stores Mail order provides you additional discounts to your refill. If you do not want to utilize mail order, you MUST call in advance and opt out of the program. If you don’t opt out, you will pay the full cost of your prescription on the third fill. You can call 888-792-3862 for assistance opting out.
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 9 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Where To Seek Care You think you may be sick, but your primary care physician is booked through the end of the month. You have a question about the side effects of a new medication, but the pharmacy is closed. Instead of immediately choosing an expensive trip to the emergency room or relying on questionable information from the internet, take a look below at various care centers and resources and the types of care they provide. *This is sample of services and may not be all-inclusive. **Cost and time information represent average only and are not tied to a specific condition or treatment. When would I use this? You need routine care or treatment for a current health issue. Your primary doctor knows you and your health history, can access your medical records, provide routine care, and manage your medications. What type of care would they provide?* Strains, sprains Minor broken bones Minor infections Primary Care Center Telehealth Urgent Care Center Emergency Room What type of care would they provide? Routine checkups Immunizations Preventive Services Manage your general health What are the costs and time considerations? Often requires a copay and/or coinsurance. Normally requires an appointment. Usually, little wait time with scheduled appointment. When would I use this? You need care for minor illnesses and ailments but would prefer not to leave home. These services are available by phone and online (via webcam). What type of issues can they treat?* Cold & flu symptoms Allergies Bronchitis Urinary tract infection Sinus problems What are the costs and time considerations? Often requires a copay and/or coinsurance. Access to care is usually immediate. Certain states may not allow for prescriptions through telemedicine or virtual visits. When would I use this? You need care quickly, but it is not a true emergency. Urgent care centers offer treatment for non-life-threatening injuries or illnesses. What are the costs and time considerations?** Often requires a copay and/or coinsurance that is generally higher than an office visit. Walk-in patients welcome but waiting periods may be longer as patients with more urgent needs will be treated first. When would I use this? You need immediate treatment for a serious life-threatening condition. If a situation seems life threatening, call 911 or your local emergency number right away. What type of issues can they treat?* Heavy bleeding Chest pain Major burns Minor burns X-Rays Spinal injuries Severe head injury Broken bones What are the costs and time considerations?** Often requires a much higher copay and/or coinsurance. Open 24/7 but waiting periods may be longer because patients with life-threatening emergencies will be treated first. Do Your Homework What may seem like an urgent care center could actually be a standalone ER. These newer facilities come with a higher price tag, so ask for clarification if the word emergency appears in the company name.
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 10 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Health Savings Account (HSA) Plan Year – June 1st through May 31st PMC will offer an HSA to those who enroll in the $3,500 HDHP plan. What is an HSA? The HSA provides you with the ability to save and use pretax dollars to pay for eligible medical expenses (i.e., deductible). You can save approximately 25 percent of each dollar spent on medical expenses when you participate. Contributions to your HSA are withdrawn from your paycheck on a pre-tax basis. This means you don’t pay federal income tax, Social Security taxes, or local income taxes on the portion of your paycheck you contribute to the HSA. See “HSA Taxation” on page 10. In addition to the company contribution, you may elect to make a personal contribution, which is 100% tax deductible from your gross income. The “combined” contributions made into your HSA account cannot exceed the following IRS limits set for calendar year 2025: The PMC Monthly Employer HSA Contributions are as follows: What are the benefits of an HSA? Funds roll over – No “use it or lose it” provision. Earns interest – Monies accrue tax-free interest. Portable – Yours to keep. If you leave your employer, your HSA funds go with you. You can use the funds in your HSA for your spouse and child(ren), even if they are not enrolled in your medical plan. You can change the amount that you contribute or stop contributing altogether whenever you like. Changes are effective on the next payroll. Please contact the HR department to make a change. You are eligible to enroll in an HSA if: You are enrolled in the $3,500 HDHP plan You have no other traditional medical coverage or prescription coverage You or your spouse are not enrolled in a General-Purpose Healthcare FSA You are not claimed as a dependent on another person’s tax return You are not enrolled in Medicare, Medicaid nor have received care within the last three months through the Veteran’s Administration for something that was not connected to a service disability How to Open Your Health Savings Account Employees enrolled in the $3,500 HDHP plan can open an HSA with Bank of America. Please note that it is important that employees provide the required documentation to Bank of America in a timely manner to assist with the opening of your HSA. If this documentation is not provided timely, it may result in delays of HSA contributions (both employee and employer contributions) being made to the account. Employee Only $166.67 ($2,000/year) Employee + Spouse $200.00 ($2,400/year) Employee + Child(ren) $200.00 ($2,400/year) Family $200.00 ($2,400/year) • $4,300 single • $8,550 family (any level of coverage including one or more dependents) • If you are 55 or over, you can add an additional contribution of $1,000
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 11 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Understanding Health Savings Account (HSA) IRS-Qualified Medical Expenses You can use your HSA to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse, or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free. HSA funds can be used to reimburse yourself for past medical expenses if the expense was incurred after your HSA was established. While you do not need to submit any receipts to Bank of America, you must save your bills and receipts for tax purposes. Examples of IRS-Qualified Medical Expenses: Acupuncture Ambulance Annual Physical Examination Bandages Birth Control Pills, contraceptive devices Body Scan Breast Pumps and Supplies Breast Reconstruction Surgery Chiropractor Contact Lenses Crutches Dental Treatment Diagnostic Devices Disabled Dependent Care Expenses Eye Exam Eyeglasses Eye Surgery Hearing Aids Home Care Hospital Services Insurance Premiums Laboratory Fees Lactation Expenses Learning Disability Long-Term Care Medicines Nursing Home Nursing Services Optometrist Oxygen Physical Examination Pregnancy Test Kit Prothesis Psychiatric Care Special Education Sterilization Stop-Smoking Programs Surgery Transplants Vasectomy Vision Correction Surgery Weight-Loss Program Wheelchair Wig X-Ray Fees Ineligible medical expenses may include: Baby Sitting, Childcare and Nursing Services for a Normal, Healthy Baby Controlled Substances Cosmetic Surgery Dancing Lessons Diaper Service Electrolysis or Hair Removal Flexible Spending Account Funeral Expenses Future Medical Care Hair Transplant Health Club Dues Health Coverage Tax Credit Health Savings Accounts Household Help Illegal Operations and Treatments Maternity Clothes Medicines and Drugs from other Countries Nonprescription Drugs and Medicines Nutritional Supplements Personal Use Items Swimming Lessons Teeth Whitening Veterinary Fees This list is not all-inclusive; additional expenses may qualify, and the items listed below are subject to change in accordance with IRS regulations. For more information or clarification on individual list items, refer to Publication 502 or consult a tax professional. HSA State Taxation: There are currently three states that, unlike the federal government, subject your HSA contributions (employee and employer) to state income taxes. The three states are New Jersey, California and Alabama. Similarly, these three states also subject earnings (interest and capital gains) on your HSA to state taxation. There are currently two other states, New Hampshire and Tennessee, that subject earnings on the account (but not the contributions) to state taxes. Tax laws are subject to change. Please contact your state tax authority or consult with a tax advisor to confirm the details for your state.
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 12 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Flexible Spending Accounts (FSA) Section 125 Plan An FSA allows you to place money in a tax-sheltered, short-term account for use in paying for approved healthcare expenses. Enrollment occurs before the beginning of each plan year, or for new employees, during your initial enrollment period. You must enroll each year in order to participate in the Healthcare and Dependent Care Reimbursement Accounts. The amount you designate will be taken from your paycheck in equal amounts throughout the plan year. Keep your receipts and Explanation of Benefits (EOBs) in the event that Bank of America or the IRS requests additional information on your transaction. General Purpose HealthCare FSA Contribution Limit - $3,300 (2025-2026) General Purpose Health Care FSA is for those NOT enrolled in the $3,500 HDHP Plan or have a regular PPO plan elsewhere. You are eligible to contribute to an FSA and use the funds for medical, dental and vision expenses not covered by the plan. The Health Care FSA contribution will be deducted from your paycheck over the course of the year. Since you pay no taxes on the money placed in the FSA, you effectively adjust your annual taxable salary. Contributions available first day of new plan year. Limited Purpose HealthCare FSA Contribution Limit - $3,300 (2025-2026) Limited Purpose Health Care FSA is for those enrolled in the $3,500 HDHP Plan. You are eligible to contribute to an FSA and use the funds for dental and vision expenses not covered by the plan. The FSA contribution will be deducted from your paycheck over the course of the year. Since you pay no taxes on the money placed in the FSA, you effectively adjust your annual taxable salary. Contributions available first day of new plan year. Dependent Care FSA Contribution Limit (2025-2026): $5,000 if you are a single employee or married filing jointly $2,500 if you are married and filing separately Money only available as contributed via your payroll deductions IMPORTANT: Elections cannot be changed during the plan year unless you have a qualified change in family status like birth, death, marriage, or divorce. Unused General Purpose and Limited Purpose FSA amounts in excess of $660 will be forfeited, so plan carefully before making your elections. General Purpose and Limited Health Care FSA Rollover Provision Up to $660 of 2024-2025 unused FSA dollars can be used to reimburse 2025-2026 eligible FSA expenses. Claims must be incurred between June 1, 2025, and May 31, 2026. These claims may be submitted for reimbursement between June 1, 2025, and August 31, 2026.
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 13 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Dental Benefits Plan Year – June 1st through May 31st Dental coverage is important to your overall health and wellness. You can enroll in dental benefits through Delta Dental of Tennessee for yourself and your family. The dental plans feature a network of dentists and specialists who have agreed to provide services at a discounted price. If you choose to go to a dentist out of the network, you may be balanced billed for any charges over what is considered “reasonable and customary”. The great thing about Delta Dental of Tennessee is that the reimbursement for what is considered reasonable, and customary is in the 90th percentile of fees charged in your area. This helps minimize any balancing billing but remember that the best way to maximize the benefit is by visiting an in-network dentist. Please note, ID Cards are not required for you to receive services. Providers can confirm coverage with your Social Security Number. The following chart shows the features of the Dental benefit option. A complete benefit summary is available on our Paylocity Portal. Key Features Delta Dental PPO Network Delta Dental Premier Network Out-of-Network Network Delta Dental PPO Delta Dental Premier Calendar Year Deductible Individual / Family $0/$0 $50 / $150 $50 / $150 Calendar Year Maximum Benefit $1,500 $1,500 $1,500 Services Preventative & Diagnostic Services (Deductible does not apply) Covered at 100% Covered at 100% Covered at 100% Basic Services Covered at 100% Covered at 80% Covered at 80% Major Services Covered at 60% Covered at 50% Covered at 50% Orthodontia Covered at 50% Covered at 50% Covered at 50% Lifetime maximum $1,250 $1,250 $1,250 Age Limitation 19 19 19 Reimbursement Negotiated Fee Schedule 90th percentile Semi-Monthly Employee Payroll Contributions (24 Pay Periods) Employee Only $4.21 Employee + Spouse $17.05 Employee + Child(ren) $19.09 Family $27.50 Limit your Out-of-Pocket expenses by seeking services from a Delta Dental in-network dentist. Network Name: Delta Dental PPO and Delta Dental Premier
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 14 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Limit your Out-of-Pocket expenses by seeking services from a VSP in-network provider. Network Name: VSP Choice Voluntary Vision Benefits Plan Year – June 1st through May 31st Your vision health is an important part of complete wellness. Delta Dental of Tennessee is pleased to present your vision benefits which are designed to give you and your covered family members the care, value, and service to help maintain good vision and overall health. Please note, ID Cards are not required for services and vision providers can verify coverage by providing your Social Security Number (SSN). The following chart shows the features of the Vision benefit option. A complete benefit summary is available on our Paylocity Portal. Vision Key Features In-Network Member Cost Out-of-Network Reimbursement Annual Eye Exam (Once every 12 months) $10 copay Up to $45 Lenses (Every 12 months in lieu of contact lenses) Single $25 copay Up to $30 Bifocal $25 copay Up to $50 Trifocal $25 copay Up to $65 Standard Frames (Once every 12 months) $150 allowance, Additional 20% off balance over allowance Up to $70 Contact Lenses (Every 12 months in lieu of frames and lenses) Conventional $150 allowance Up to $105 Medically Necessary $25 copay Up to $210 Semi-Monthly Employee Payroll Contributions (24 Pay Periods) Employee Only $1.00 Employee + Spouse $3.25 Employee + Child(ren) $3.50 Family $5.50
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 15 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Life and Accidental Death & Dismemberment (AD&D) Insurance Plan Year – June 1st through May 31st Group Life and AD&D Coverage is available through Guardian. Life and AD&D insurance is an important benefit as it provides your beneficiaries financial protection in the event of a tragic loss. PMC provides full-time employees with group life and accidental death and dismemberment (AD&D) insurance and pays for 100% of the coverage. The amount provided by PMC is $50,000. Age Reduction: If you are age 65 or older, the amount of your Group Life Insurance will reduce to the following percentage of its original value: Age of Employee Reduction 65 but less than 70 35% 70 or older 50% Terminate upon retirement Please make sure to add your beneficiary information upon enrollment.
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 16 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Evidence of Insurability (EOI): is required if you did not apply for coverage when you were initially eligible (as a new entrant) or if you are requesting an amount of coverage that exceeds the maximum guaranteed issue amount in your plan. You will have 31 days to provide a complete EOI. Once your EOI is reviewed by Guardian, they will notify you in writing, approving, or denying your request for coverage. If you do not complete EOI within 31 days or are denied the increase by the carrier, coverage will revert back to your original election(s). Amounts over the GI are subject to Evidence of Insurability (EOI). Members utilizing the electronic EOI process (www.guardiananytime.com/eoi) will need to enter your Group Number 00561984. Life and Accidental Death & Dismemberment (AD&D) Insurance Plan Year – June 1st through May 31st Voluntary Life and AD&D If you need additional Life insurance to meet your financial needs, Guardian allows you to purchase Voluntary Life and AD&D insurance through after-tax payroll deductions for yourself your spouse and your child(ren). Life insurance is about more than paying for memorial services—it is about making sure your family can maintain its standard of living if something happens to you. The amount of coverage your family needs depends on your personal situation (other income, monthly expenses, short and long-term debt such as credit card or mortgage expenses, etc.). Evidence of Insurability (EOI) Rules Employee Benefit Amount: Life/AD&D Increments of $10,000 to a maximum of $250,000. New Entrants: Guarantee Issue (GI) Amount $150,000 Spouse (spouse age based on employee age) Benefit Amount: Life/AD&D Increments of $5,000 to a maximum of $250,000. Not to exceed 100% of the employee election. New Entrants: GI Amount $25,000 Child(ren) Benefit Amount: Life/AD&D $5,000 or $10,000 New Entrants: GI Amount $10,000 New entrant: If you elect coverage when you are initially eligible, EOI is required only for any amount over $150,000. New entrant: If you elect coverage for your spouse or domestic partner when you are initially eligible, EOI is required only for any amount over $25,000. Employees who previously declined coverage during their initial enrollment (as new entrant) can elect coverage for themselves and their spouse but must complete the required EOI form. Coverage for your over age dependent child(ren) ends at the end of the month in which they turn 26. Annual Enrollment: Employees who previously elected coverage for themselves can increase their coverage up to $50,000, up to GI amount without providing EOI. If you wish to increase your coverage by greater than $50,000, or above the GI amount you must complete the required EOI form. Annual Enrollment: Employees who previously elected coverage for their spouse and/or dependent child(ren), and request to increase coverage by any amount, you must complete the required EOI form.
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 17 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Disability Income Benefits Plan Year – June 1st through May 31st PMC offers employees the ability to purchase STD and LTD coverage. If you become disabled and cannot work, no benefit becomes more important to your financial security than Disability Income protection. Disability coverage provides income protection in the event that you experience a non-occupational injury or illness that prevents you from working. You have access to Short-Term Disability (STD) and Long-Term Disability (LTD) insurance through Guardian. Your per pay cost will be found in the online enrollment. Short-Term Disability Insurance (STD) If an eligible employee is sick more than 7 consecutive days or disabled for more than 1 calendar day on an approved leave of absence per company policy, they must use PTO to satisfy the elimination period. Once that is exhausted an application can be made for short-term disability benefit, which will pay 60% of your weekly pay up to a maximum benefit of $1,000 per week, for a maximum of 13 weeks. You pay 100% of this coverage. Long Term Disability Insurance (LTD) If an employee is disabled for more than three consecutive months, application can be made for long-term disability benefits, which will pay 60% of your salary. You pay 100% of this coverage. Elimination Period 7 days illness / 0 days injury Income Replacement 60% of your pre-disability earning Maximum Benefit $1,000 weekly Maximum Benefit Period 13 weeks Pre-existing Condition 3 month lookback; 12-month exclusion Elimination Period 90 days Income Replacement 60% of your pre-disability earning Maximum Benefit $5,000 Monthly Maximum Benefit Period Social Security Normal Retirement Age (SSNRA) Pre-existing Condition 6 month lookback; 24-month exclusion Helpful Terms Elimination Period – The period of time you have to wait before benefits begin, starting the day you become ill or injured. Maximum Monthly Benefit – The highest dollar amount a disabled employee can receive on a monthly basis under the LTD plan. Pre-Disability Earnings – The amount of a policyholder’s wages or salary in effect on the day before the disability began. Maximum Benefit Period – The maximum length of time during which benefits will be paid.
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 18 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Voluntary Benefits Plan Year – June 1st through May 31st PMC offers a suite of voluntary benefits to you and your family. Aetna offers the following voluntary benefits: Accident Insurance Accidents are usually followed by a series of bills. Even if you have good insurance, you may still have to cover out-of-pocket costs such as doctor bills, ambulance fees, and hospital expenses. Accident insurance from Aetna can help protect you, your spouse, and your dependent children from the unexpected expenses of an accident. Critical Illness Insurance Critical illness coverage offers specialized benefits to supplement other health insurance when you and your family may be most vulnerable, during the working years. Includes coverage for heart/stroke, cancer, and other critical illnesses. Please see the benefit summary for detailed coverage information, including conditions that pay a percentage of the elected benefit, and specific conditions covered under the plan. Dislocations Open (Surgery) Closed (No Surgery) Hip $6,000 $3,000 Knee/Kneecap $3,000 $1500 Ankle, or Bones of the Foot $1,500 $750 Elbow, Wrist, or Lower Jaw $1,200 $600 Shoulder $1,200 $600 Collarbone $300 or $1,200 $150 or $600 Finger or Toe $300 $150 Hospital Stay Non-ICU Admission (Initial Day) $1,000 ICU Admission (Initial Day) $2,000 Non-ICU (Daily) $200 ICU (Daily) $400 Semi-Monthly Payroll Deductions (24 Pay Periods) Employee Only $4.70 Employee + Spouse $8.08 Employee + Child(ren) $9.02 Employee + Family $12.13 Coverage Information Employee Volume Amount $10,000 or $20,000 Spouse Volume Amount 50% of employee’s benefit Child Volume Amount 50% of employee’s benefit Health Screening Benefit $50 benefit payable to any covered person on your plan one time each year, once you provide proof of an eligible health screening
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 19 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Voluntary Benefits Plan Year – June 1st through May 31st Hospital Indemnity Insurance Hospital indemnity insurance works to complement your medical insurance by providing a cash payout for hospital visits. This plan will pay out a lump sum of monies for specific claims associated with a hospital admission, or a daily benefit for a covered hospital stay, such as having inpatient surgery, being in the ICU, etc. This can also be used in conjunction with the accident and/or critical illness insurance. Hospital Indemnity Hospital Admission (Initial Day) 1/plan year & must be 24+ hour inpatient stay $1,000 Hospital Daily (Begins on day 2 of stay) $100 Hospital Daily in ICU (Begins on day 2 of stay) $200 Newborn Routine Care/stay $100 Observation Unit (Initial Day) 1/plan year $100 Substance Abuse Daily $100 Behavioral Health Daily $100 Rehabilitation Unit Daily (Related to an illness or accident) $50 Semi-Monthly Payroll Deductions (24 Pay Periods) Employee Only $7.07 Employee + Spouse $15.75 Employee + Child(ren) $12.11 Employee+ Family $20.01
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 20 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Added Value Programs Employee Assistance Program (EAP) The Employee Assistance Program (EAP) provides a network of experienced professionals who can offer counseling for you and your dependents facing difficult legal, emotional, or financial issues. Counselors and qualified professionals are available 24 hours a day, 365 days a year, and all calls are completely confidential – nothing is reported back to your employer. Services include online resources, 3 in-person counseling sessions, and unlimited telephonic counseling. The EAP is available to all benefit eligible employees. For more support or information please visit worklife.uprisehealth.com (Access Code: worklife ) or talk with a specialist at 1-800-386-7055. Will Preparation and Estate Guidance No matter how well you plan your life, you can be sure unforeseen challenges will arise. If you are enrolled in Voluntary Life and AD&D insurance, you have access to uprisehealth through Guardian to help manage these challenges. The uprisehealth program provides access to a wide array of services to help you and your loved ones through life’s difficulties. Services include: Online Will Preparation – Having a will is important because it allows you to designate who will receive your property and assets when you die. Without one, your state determines how your estate is distributed. Estate Guidance – Find step-by-step instructions to name an executor to manage your estate, choose a guardian for your children, specify wishes for your property and provide funeral and burial instructions. Guidance Resources – Access to articles, tutorials, videos, and “Ask the Expert” advice on a wide range of topics — including legal, financial, family, and career. It is a way to stay “in the know” on important matters that impact both your personal and professional life. It is easy to access uprisehealth services, just call 1-877-433-6789 or visit willprep.uprisehealth.com Username: WillPrep Password: GLIC09 Topics Include: Family Parenting Addictions Emotional Legal Financial Relationships Stress
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 21 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Important Notices Notice of Patient Protections & Prior Authorization Procedures Your Aetna plans allow you to visit any doctor or hospital you choose. However, Prior Authorization is required for certain services. Make sure Your Provider obtains Prior Authorization before any planned hospital stays (except maternity admissions), skilled nursing and rehabilitative facility admissions, certain outpatient procedures, Advanced Radiological Imaging services, certain Specialty Drugs, and Durable Medical Equipment costing $500 or more. Contact Aetna Customer Service using the number on the back of your medical ID card or online at www.aetna.com to find out which services require Prior Authorization. You can also call the customer service department to find out if your admission or other service has received Prior Authorization. For more information, please refer to your Evidence of Coverage document located online at www.aetna.com. Women’s Health and Cancer Rights Act of 1998 Patients who undergo a mastectomy, and who elect breast reconstruction in connection with the mastectomy, are entitled to coverage for: • Reconstruction of the breast on which the mastectomy was performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance; and • Prostheses and treatment of physical complications at all stages of the mastectomy, including Lymphedemas, in a manner determined in consultation with the attending physician and the patient. The coverage may be subject to Coinsurance and Deductibles consistent with those established for other benefits. For more information, please refer to your Evidence of Coverage document located online at www.aetna.com. Newborns and Mothers’ Health Protection Act Under federal law, group health plans and health insurance issuers offering group health insurance coverage generally may not 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 delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the attending provider (e.g., your physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier. Also, under federal law, plans and issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a plan or issuer may not, under federal law, require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your Out-of-Pocket costs, you may be required to obtain precertification. For information on precertification, contact your plan administrator. 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 31 days after you or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, 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 31 days after the marriage, birth, adoption, or placement for adoption. To request special enrollment or obtain more information, contact Human Resources. 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.
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 22 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. 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 March 17, 2025. Contact your State for more information on eligibility – ALABAMA – Medicaid ALASKA – Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447 The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: https://health.alaska.gov/dpa/Pages/default.aspx ARKANSAS – Medicaid CALIFORNIA – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447) Health Insurance Premium Payment (HIPP) Program Website: http://dhcs.ca.gov/hipp Phone: 916-445-8322 Fax: 916-440-5676 Email: hipp@dhcs.ca.gov COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) FLORIDA – Medicaid Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/State Relay 711 CHP+: https://hcpf.colorado.gov/child-health-plan-plus CHP+ Customer Service: 1-800-359-1991/State Relay 711 Health Insurance Buy-In Program (HIBI): https://www.mycohibi.com/ HIBI Customer Service: 1-855-692-6442 Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.html Phone: 1-877-357-3268 GEORGIA – Medicaid INDIANA – Medicaid GA HIPP Website: https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp Phone: 678-564-1162, Press 1 GA CHIPRA Website: https://medicaid.georgia.gov/programs/third-party-liability/childrens-health-insurance-program-reauthorization-act-2009-chipra Phone: 678-564-1162, Press 2 Health Insurance Premium Payment Program All other Medicaid Website: https://www.in.gov/medicaid/ http://www.in.gov/fssa/dfr/ Family and Social Services Administration Phone: 1-800-403-0864 Member Services Phone: 1-800-457-4584
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 23 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. IOWA – Medicaid and CHIP (Hawki) KANSAS – Medicaid Medicaid Website: Iowa Medicaid | Health & Human Services Medicaid Phone: 1-800-338-8366 Hawki Website: Hawki - Healthy and Well Kids in Iowa | Health & Human Services Hawki Phone: 1-800-257-8563 HIPP Website: Health Insurance Premium Payment (HIPP) | Health & Human Services (iowa.gov) HIPP Phone: 1-888-346-9562 Website: https://www.kancare.ks.gov/ Phone: 1-800-792-4884 HIPP Phone: 1-800-967-4660 KENTUCKY – Medicaid LOUISIANA – Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: https://kynect.ky.gov Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov/agencies/dms Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP) MAINE – Medicaid MASSACHUSETTS – Medicaid and CHIP Enrollment Website: https://www.mymaineconnection.gov/benefits/s/?language=en_US Phone: 1-800-442-6003 TTY: Maine relay 711 Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms Phone: 1-800-977-6740 TTY: Maine relay 711 Website: https://www.mass.gov/masshealth/pa Phone: 1-800-862-4840 TTY: 711 Email: masspremassistance@accenture.com MINNESOTA – Medicaid MISSOURI – Medicaid Website: https://mn.gov/dhs/health-care-coverage/ Phone: 1-800-657-3672 Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005 MONTANA – Medicaid NEBRASKA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084 Email: HHSHIPPProgram@mt.gov Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178 NEVADA – Medicaid NEW HAMPSHIRE – Medicaid Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900 Website: https://www.dhhs.nh.gov/programs-services/medicaid/health-insurance-premium-program Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext. 15218 Email: DHHS.ThirdPartyLiabi@dhhs.nh.gov
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 24 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. NEW JERSEY – Medicaid and CHIP NEW YORK – Medicaid Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Phone: 1-800-356-1561 CHIP Premium Assistance Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 (TTY: 711) Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA – Medicaid NORTH DAKOTA – Medicaid Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100 Website: https://www.hhs.nd.gov/healthcare Phone: 1-844-854-4825 OKLAHOMA – Medicaid and CHIP OREGON – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 Website: http://healthcare.oregon.gov/Pages/index.aspx Phone: 1-800-699-9075 PENNSYLVANIA – Medicaid and CHIP RHODE ISLAND – Medicaid and CHIP Website: https://www.pa.gov/en/services/dhs/apply-for-medicaid-health-insurance-premium-payment-program-hipp.html Phone: 1-800-692-7462 CHIP Website: Children's Health Insurance Program (CHIP) (pa.gov) CHIP Phone: 1-800-986-KIDS (5437) Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line) SOUTH CAROLINA – Medicaid SOUTH DAKOTA - Medicaid Website: https://www.scdhhs.gov Phone: 1-888-549-0820 Website: http://dss.sd.gov Phone: 1-888-828-0059 TEXAS – Medicaid UTAH – Medicaid and CHIP Website: Health Insurance Premium Payment (HIPP) Program | Texas Health and Human Services Phone: 1-800-440-0493 Utah’s Premium Partnership for Health Insurance (UPP) Website: https://medicaid.utah.gov/upp/ Email: upp@utah.gov Phone: 1-888-222-2542 Adult Expansion Website: https://medicaid.utah.gov/expansion/ Utah Medicaid Buyout Program Website: https://medicaid.utah.gov/buyout-program/ CHIP Website: https://chip.utah.gov/ VERMONT– Medicaid VIRGINIA – Medicaid and CHIP Website: Health Insurance Premium Payment (HIPP) Program | Department of Vermont Health Access Phone: 1-800-250-8427 Website: https://coverva.dmas.virginia.gov/learn/premium-assistance/famis-select https://coverva.dmas.virginia.gov/learn/premium-assistance/health-insurance-premium-payment-hipp-programs Medicaid/CHIP Phone: 1-800-432-5924 WASHINGTON – Medicaid WEST VIRGINIA – Medicaid and CHIP Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022 Website: https://dhhr.wv.gov/bms/ http://mywvhipp.com/ Medicaid Phone: 304-558-1700 CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447) WISCONSIN – Medicaid and CHIP WYOMING – Medicaid Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002 Website: https://health.wyo.gov/healthcarefin/medicaid/programs-and-eligibility/ Phone: 1-800-251-1269
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 25 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. To see if any other states have added a premium assistance program since March 17, 2025, 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. Notice of Privacy Practices Aetna is required to maintain the privacy of all medical information as required by applicable laws and regulations; provide a notice of privacy practices to all Members; inform Members of the Plan’s legal obligations; and advise Members of additional rights concerning their medical information. For more information, please refer to your Evidence of Coverage document located online at www.aetna.com. All Members will be notified of any changes by receiving a new notice of the Plan’s privacy practices. You may request a copy of this notice of privacy practices at any time by contacting Aetna. Uniformed Services Employment and Reemployment Rights Act of 1994 A Subscriber may continue his or her Coverage and Coverage for his or her Dependents during military leave of absence in accordance with the Uniformed Services Employment and reemployment Rights Act of 1994. When the Subscriber returns to work from a military leave of absence, the Subscriber will be given credit for the time the Subscriber was covered under the Plan prior to the leave. Important Notice from Psychiatric Medical Care (PMC) About Your Prescription Drug Coverage and Medicare for plans: • $2,000 PPO Plan • $3,500 HDHP Plan Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage PMC and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Certain plans may also offer more coverage for a higher monthly premium. 2. PMC has determined that the prescription drug coverage offered by the Aetna Plans are, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 26 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? Since the coverage under your Aetna is creditable, depending on how long you go without creditable prescription drug coverage you may pay a penalty to join a Medicare drug plan. Starting with the end of the last month that you were first eligible to join a Medicare drug plan but didn’t join, if you go 63 continuous days or longer without prescription drug coverage that’s creditable, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Aetna coverage will not be affected. You can keep this coverage if you elect part D, and this plan will coordinate with Part D coverage. If you do decide to join a Medicare drug plan and drop your current PMC coverage, be aware that you and your dependents will not be able to get this coverage back until next Annual Open Enrollment or a mid-year qualifying event. For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You will get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: • Visit www.medicare.gov • Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Date: 06/01/2025 Name of Entity/Sender: Psychiatric Medical Care, LLC Office Contact/Position: Maggie Music / Chief Human Resource Officer Phone: (615) 335-0781 Address: 8 Cadillac Drive, Suite 230, Brentwood, TN 37027 Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 27 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. Health Insurance Marketplace Coverage Options and Your Health Coverage PART A: General Information Even if you are offered health coverage through your employment, you may have other coverage options through the Health Insurance Marketplace (“Marketplace”). To assist you as you evaluate options for you and your family, this notice provides some basic information about the Health Insurance Marketplace and health coverage offered through your employment. 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 in your geographic area. Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium and other out-of-pocket costs, but only if your employer does not offer coverage, or offers coverage that is not considered affordable for you and doesn’t meet certain minimum value standards (discussed below). The savings that you're eligible for depends on your household income. You may also be eligible for a tax credit that lowers your costs. Does Employment-Based Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that is considered affordable for you and meets certain minimum value standards, you will not be eligible for a tax credit, or advance payment of the tax credit, for your Marketplace coverage and may wish to enroll in your employment-based health plan. However, you may be eligible for a tax credit, and advance payments of the 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 is considered affordable for you or meet minimum value standards. If your share of the premium cost of all plans offered to you through your employment is more than 9.12%1 of your annual household income, or if the coverage through your employment does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit, and advance payment of the credit, if you do not enroll in the employment-based health coverage. For family members of the employee, coverage is considered affordable if the employee’s cost of premiums for the lowest-cost plan that would cover all family members does not exceed 9.12% of the employee’s household income..1 2 Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered through your employment, then you may lose access to whatever the employer contributes to the employment-based coverage. Also, this employer contribution -as well as your employee contribution to employment-based coverage- is generally excluded from income for federal and state income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. In addition, note that if the health coverage offered through your employment does not meet the affordability or minimum value standards, but you accept that coverage anyway, you will not be eligible for a tax credit. You should consider all of these factors in determining whether to purchase a health plan through the Marketplace. When Can I Enroll in Health Insurance Coverage through the Marketplace? You can enroll in a Marketplace health insurance plan during the annual Marketplace Open Enrollment Period. Open Enrollment varies by state but generally starts November 1 and continues through at least December 15. Outside the annual Open Enrollment Period, you can sign up for health insurance if you qualify for a Special Enrollment Period. In general, you qualify for a Special Enrollment Period if you’ve had certain qualifying life events, such as getting married, having a baby, adopting a child, or losing eligibility for other health coverage. Depending on your Special Enrollment Period type, you may have 60 days before or 60 1 Indexed annually; see https://www.irs.gov/pub/irs-drop/rp-22-34.pdf for 2023. 2 An employer-sponsored or other employment-based 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. For purposes of eligibility for the premium tax credit, to meet the “minimum value standard,” the health plan must also provide substantial coverage of both inpatient hospital services and physician services. Form Approved OMB No. 1210-0149 (expires 12-31-2026)
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 28 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. days following the qualifying life event to enroll in a Marketplace plan. There is also a Marketplace Special Enrollment Period for individuals and their families who lose eligibility for Medicaid or Children’s Health Insurance Program (CHIP) coverage on or after March 31, 2023, through July 31, 2024. Since the onset of the nationwide COVID-19 public health emergency, state Medicaid and CHIP agencies generally have not terminated the enrollment of any Medicaid or CHIP beneficiary who was enrolled on or after March 18, 2020, through March 31, 2023. As state Medicaid and CHIP agencies resume regular eligibility and enrollment practices, many individuals may no longer be eligible for Medicaid or CHIP coverage starting as early as March 31, 2023. The U.S. Department of Health and Human Services is offering a temporary Marketplace Special Enrollment period to allow these individuals to enroll in Marketplace coverage. Marketplace-eligible individuals who live in states served by HealthCare.gov and either- submit a new application or update an existing application on HealthCare.gov between March 31, 2023 and July 31, 2024, and attest to a termination date of Medicaid or CHIP coverage within the same time period, are eligible for a 60-day Special Enrollment Period. That means that if you lose Medicaid or CHIP coverage between March 31, 2023, and July 31, 2024, you may be able to enroll in Marketplace coverage within 60 days of when you lost Medicaid or CHIP coverage. In addition, if you or your family members are enrolled in Medicaid or CHIP coverage, it is important to make sure that your contact information is up to date to make sure you get any information about changes to your eligibility. To learn more, visit HealthCare.gov or call the Marketplace Call Center at 1-800-318-2596. TTY users can call 1-855-889-4325. What about Alternatives to Marketplace Health Insurance Coverage? If you or your family are eligible for coverage in an employment-based health plan (such as an employer-sponsored health plan), you or your family may also be eligible for a Special Enrollment Period to enroll in that health plan in certain circumstances, including if you or your dependents were enrolled in Medicaid or CHIP coverage and lost that coverage. Generally, you have 60 days after the loss of Medicaid or CHIP coverage to enroll in an employment-based health plan, but if you and your family lost eligibility for Medicaid or CHIP coverage between March 31, 2023 and July 10, 2023, you can request this special enrollment in the employment-based health plan through September 8, 2023. Confirm the deadline with your employer or your employment-based health plan. Alternatively, you can enroll in Medicaid or CHIP coverage at any time by filling out an application through the Marketplace or applying directly through your state Medicaid agency. Visit https://www.healthcare.gov/medicaid-chip/getting-medicaid-chip/ for more details. How Can I Get More Information? For more information about your coverage offered through your employment, please check your health plan’s summary plan description or contact ______________________________________________________________________________________________________________________. 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.
PMC 2025-2026 EMPLOYEE BENEFITS GUIDE | PAGE 29 The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. 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 (if different from above) 12. Email address Here is some basic information about health coverage offered by this employer: • As your employer, we offer a health plan to: All employees. Eligible employees are: Some employees. Eligible employees are: • With respect to dependents: We do offer coverage. Eligible dependents are: 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. ** 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. If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the employer X X Full-time employees working 30+ hours per week Psychiatric Medical Care, LLC 20-0247392 8 Cadillac Drive, Suite 230 (615) 647-0750 Brentwood TN 37027 Maggie Music mmusic@psychmc.com 1. Legal Spouse 2. Domestic Partners (same and opposite sex) 3. Dependents up to age 26 X
The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums. The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for employers, but will help ensure employees understand their coverage choices. 13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months? Yes (Continue) 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue) No (STOP and return this form to employee) 14. Does the employer offer a health plan that meets the minimum value standard*? Yes (Go to question 15) No (STOP and return form to employee) 15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $70.00 b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don't know, STOP and return form to employee. 16. What change will the employer make for the new plan year? Employer won't offer health coverage Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly X X X
The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. NOTES: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
The information in this Enrollment Guide is presented for illustrative purposes and the text contained herein 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 the 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 your Guide, contact Human Resources. ADDRES: 8 Cadillac Dr. Suite 230 Brentwood, TN 37027 PHONE: (615) 647-0750