2025 Open Enrollment Guide : simplebooklet.com

2 Welcome to 2025 Open Enrollment ...................................................................................................................................... 3 Eligibility ........................................................................................................................................................................................... 4 Open Enrollment Instructions .................................................................................................................................................. 5 Medical ............................................................................................................................................................................................. 7 Benefit Resource Center ........................................................................................................................................................... 9 Connecting Care Clinic ........................................................................................................................................................... 10 PrudentRx .................................................................................................................................................................................... 11 Proximal ........................................................................................................................................................................................ 11 Health Savings Account (HSA) ............................................................................................................................................ 12 Flexible Spending Account .................................................................................................................................................... 12 Dental ............................................................................................................................................................................................. 13 Vision ............................................................................................................................................................................................. 14 Life Insurance ............................................................................................................................................................................. 15 Disability Insurance .................................................................................................................................................................. 16 Post Employment Health Plan (HRA)................................................................................................................................ 19 Accident Insurance ................................................................................................................................................................... 19 Employee Assistance Program (EAP) .............................................................................................................................. 20 Retirement .................................................................................................................................................................................... 21 Important Contacts ................................................................................................................................................................... 22 REQUIRED NOTIFICATIONS ............................................................................................................................................. 23 Welcome to 2025 Open Enrollment

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3 Welcome to 2025 Open Enrollment We are pleased to announce the Benefits Open Enrollment period for 2025. This is your annual opportunity to review, select, and make changes to your benefits package for the upcoming year. What You Need to Know: 1. Open Enrollment Period: November 1st through November 15th. 2. Action Required: All benefit eligible employees must review their benefit options and make their 2025 election to keep, change, or waive coverage. 3. Changes for 2025: Coverages are increasing for both voluntary and employer paid disability policies. This coverage increase will help you meet the financial challenges of inflation and ensure you continue to receive a fair portion of your income while on leave. For the short-term disability benefit, the weekly wage payment to you will increase from $750 to $1,000. For the long-term disability benefit, the monthly wage payment to you will increase from $5,000 to $7,500. If you do not wish to continue with voluntary coverage, please e-mail Blia Vang at blia.vang@appletonwi.gov. How to Enroll: 1. Log into the Appleton Employee Self Service (AESS) Portal: From this portal you will be able to access an electronic copy of the Open Enrollment Guide and make your open enrollment elections (follow the Open Enrollment Instructions in this booklet). 2. Review Available Plans: Please take time to evaluate your health, dental, vision, and other options to ensure they meet your needs and those of your family. 3. Submit Your Selections: Once you’ve made your choices, be sure to submit them before the deadline on November 15, 2024, at 4pm. After this date, you will not be able to make changes until the next Open Enrollment period unless you experience a qualifying life event. If you have any questions or need help navigating the enrollment process, feel free to reach out to me at (920) 832-6458. Sincerely, Blia Vang City of Appleton Benefits Coordinator

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4 Eligibility Eligible Employees: You may enroll in the City of Appleton Employee Benefits Program if you hold an eligible position working 30+ hours per week for medical insurance and 20+ hours per week for dental and vision insurance. Eligible Dependents: If you are eligible for benefits, then so are your dependents. In general, eligible dependents include your spouse and children up to age 26. If your child is mentally or physically disabled, coverage may continue beyond age 26 once proof of the ongoing disability is provided. Children may include natural, adopted, step-children and children obtained through court-appointed legal guardianship. When Coverage Begins: The effective date for your benefits is the 31st day of employment for newly hired employees and dependents in the City of Appleton’s benefit programs. All elections are in effect for the entire plan year and can only be changed during Open Enrollment unless you experience a life event in the middle of a plan year. Family Status Event: A change in family status is a change in your personal life that may impact your eligibility or dependent’s eligibility for benefits. Examples of some family status changes include:  Change of legal marital status (i.e., marriage, divorce, death of spouse, legal separation)  Change in number of dependents (i.e., birth, adoption, death of dependent, ineligibility due to age)  Change in employment or job status (i.e., spouse loses job) Notification of mid-year changes must be made within 30 days (90 days for birth) of the event by contacting Blia Vang at 920-832-6455 or e-mail blia.vang@appletonwi.gov. Failure to request a change of status within 30/90 days after the event will result in having to wait until the next open enrollment period to make your change. Due to Internal Revenue Service (IRS) regulations, changes can only be made to your benefits during open enrollment or if you experience a life event that allows you to make mid-year changes. IMPORTANT REMINDER

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5 Open Enrollment Instructions Steps to completing your enrollment process: Log in to your AESS portal (same portal to access your payroll statement): Go to the Core Connect Intranet site. From there, click on the blue box on the right labeled “AESS”. Next, log into your AESS account. On the top right-corner of the page, click on the paper icon (see picture below). Then click on the Open Enrollment Benefits Guide to review the booklet. Library employees can access the portal through the Library Intranet site. The AESS link is also located at the bottom of the www.appleton.org homepage. Log in using your employee ID number as your username and your unique password to log in. If you have any issues, please contact IT HelpDesk at (920) 832-5893. After successfully logging in, click on the “Benefits” link and then click on the “Open Enrollment” option. All your options will be listed (see picture below). Go through each benefit and make your selection: “Decline”, “No Changes” or “Select” for each. If your 2024 elections are shown, and you do not need to make any changes for the new plan year, click on “No Changes” for each election. If you want to add/remove a dependent, click on “Select”. Then elect the plan option AND select all of your dependents who will be covered in 2025 via the drop-down option. Do not add or edit the populated dependent information unless you wish to drop coverage

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6 for them. Any inconsistent information entered will generate a new record for the dependent as a new enrollment for 2025. To add a new dependent who is not listed in the drop-down menu, click on “+Add New Dependent” and enter all data. If your 2024 election is NOT shown, then click “Select” for every option for the family or single plan. If you select the family plan, you MUST ENTER ALL OF YOUR COVERED DEPENDENTS. If a dependent is currently on the plan, click on “Add Existing” and all your dependents will be available via a drop-down option. Do not add or edit the populated dependent information unless you wish to drop coverage for them. Any inconsistent data entered will generate a new record for the dependent as a new enrollment for 2025. If a dependent is not on the list, then click on “Add New Dependent”. This step must be done for every family member. Once finished, click “Continue” at the bottom of the screen. The next screen is “Review Your Enrollment”. Double check to MAKE SURE all your covered dependents are listed under all the plans you have elected. Verify your Health Savings Account, Flex Spending and Accident selections are correct. If all is set, click on “Submit”. Elections for 2025 must be submitted at 4pm, November 15th. No submissions can be made after enrollment has closed. There are no exceptions to this deadline.

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7 Medical The City continues to offer medical coverage through UMR. The following page offers a brief outline of what is offered under the medical plans. Please refer to the Summary Plan Description for complete plan details. The complete medical Summary Plan Document, and Summary of Benefits and Coverage can be found at the City’s website: www.appleton.org/government/human-resources/employee-benefits. UMR has an app to provide a faster way to manage health care benefits. Through the app, you can:  Access digital ID card  View plan details on-demand  Chat, call, or send a message to UMR’s member support team. Annually, UMR requires updated medical information on other insurance to ensure medical claims are processed accurately and paid correctly. All members will need to submit this to UMR even if they do not have other insurances. This can easily be done by contacting UMR or through the member’s UMR account. Click here to view flyer. It is important to protect member’s personal and medical information. UMR follows strict security procedures to help maintain the security of member’s information and restrict access. Spouse and adult dependents covered under our medical plan can grant online access to view their claims or benefit information. To find more information on granting access, click here to view flyer. Medical Rates Please note: premium rates are taken over 24 pay periods and rates listed are in reference to 1.0 full-time equivalent (FTE). Individuals less than 1.0 FTE premiums will be prorated. Simply scan the QR code or visit your app store to get started. HIGH DEDUCTIBLE HEALTH PLAN (HDHP) 2025 Bimonthly Rate Without Health Screening (10% employee cost share) Bimonthly Rate With Completed Health Screening (5% employee cost share) Employee $34.51 bimonthly $17.25 bimonthly Family $89.44 bimonthly $44.72 bimonthly STANDARD PPO HEALTH PLAN 2025 Bimonthly Rate Without Health Screening (30% employee cost share) Bimonthly Rate With Completed Health Screening (25% employee cost share) Employee $130.70 bimonthly $108.91 bimonthly Family $355.92 bimonthly $296.60 bimonthly

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8 UMR (TPA) Standard Plan 708762 / 767000414647 UMR (TPA) High Deductible Health Plan 708762 / 767000414647 Benefit Coverage In-Network Out-of-Network In-Network Out-of-Network Annual Deductible Individual $2,000 $4,000 $2,000 $4,000 Family $4,000 $8,000 $4,000 $8,000 Coinsurance 90% 70% 90% 70% Maximum Out-of-Pocket Individual $3,100 $6,200 $3,000 $5,000 Family $6,200 $12,400 $6,000 $10,000 Physician Office Visit Primary Care $25 copay per visit 70% after deductible 90% after deductible 70% after deductible Specialty Care $40 copay per visit 70% after deductible 90% after deductible 70% after deductible Preventive Care Adult Periodic Exams 100% 70% after deductible 100% 70% after deductible Well-Child Care 100% 70% after deductible 100% 70% after deductible Diagnostic Services X-ray and Lab Tests 90% after deductible 70% after deductible 90% after deductible 70% after deductible Complex Radiology 90% after deductible 70% after deductible 90% after deductible 70% after deductible Urgent Care Facility $50 copay 70% after deductible 90% after deductible 70% after deductible Emergency Room Facility Charges $100 copay then 90% after deductible $100 copay then 90% after deductible 90% after deductible 90% after deductible Inpatient Facility Charges 90% after deductible 70% after deductible 90% after deductible 70% after deductible Outpatient Facility and Surgical Charges 90% after deductible 70% after deductible 90% after deductible 70% after deductible Mental Health Inpatient 90% after deductible 70% after deductible 90% after deductible 70% after deductible Outpatient 90% after deductible 70% after deductible 90% after deductible 70% after deductible Substance Abuse Inpatient 90% after deductible 70% after deductible 90% after deductible 70% after deductible Outpatient 90% after deductible 70% after deductible 90% after deductible 70% after deductible Other Services Chiropractic 90% after deductible 70% after deductible 90% after deductible 70% after deductible Pharmacy Retail Pharmacy (30 Day Supply) Generic (Tier 1) $10 copay $10 copay after deductible Preferred (Tier 2) $25 copay $25 copay after deductible Non-Preferred (Tier 3) $50 copay $50 copay after deductible Preferred Specialty (Tier 4) 30% co-insurance 30% co-insurance after deductible Mail Order Pharmacy (90 Day Supply) Generic (Tier 1) $30 copay $30 copay after deductible Preferred (Tier 2) $75 copay $75 copay after deductible Non-Preferred (Tier 3) $150 copay $150 copay after deductible Preferred Specialty (Tier 4) 30% co-insurance 30% co-insurance after deductible

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9 Benefit Resource Center Have Questions? Need Help? The City of Appleton is excited to offer access to the USI Benefit Resource Center (BRC), which is designed to provide you with a responsive, consistent, hands-on approach to benefit inquiries. Benefit Specialists are available to research and solve elevated claims issues and assist with any other benefit questions with which you might need assistance. The Benefit Specialists are experienced professionals, and their primary responsibility is to assist you. The Specialists in the Benefit Resource Center are available Monday through Friday 8:00am to 5:00pm Central Standard Time at 855-874-0742 or via e-mail at BRCMT@usi.com. If you need assistance outside of regular business hours, please leave a message and one of the Benefit Specialists will promptly return your call or e-mail message by the end of the following business day. Scan the QR code to learn more.

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11 PrudentRx PrudentRx is a copay card assistance program helping members receive certain specialty medication at zero cost. This program works directly with manufactures to find copay card assistance to offset costs. If no copay card is found, members will still receive the medication at $0. Only specific prescriptions (tier 4) are eligible for copay card assistance. PrudentRx will contact the eligible individual to enroll into this program. Enrollment is required to participate in this benefit program. If you are an eligible individual who chooses not to enroll, you will be subjected to the 30% co-insurance. Individuals enrolled in the High Deducible Health Plan will have to fully satisfy their deductible before they are eligible for the benefits of the card assistance program. If you choose not to enroll and you are covered under the High Deductible Health Plan, you will be subject to the 30% co-insurance after meeting the deductible. Individuals on the Low Deductible Health plan who choose not to enroll in PrudentRx, will be subject to the 30% co-insurance. Proximal The City will continue to offer Proximal in the new year to members on the City’s medical insurance. Proximal is an incentive program which focuses on quality care on eligible events. Members who experience an eligible event and were treated by a designated physician will receive cash benefit paid directly to them! Members who experience an eligible event can receive $300 for the event. If the member chooses a designated provider through Proximal, the member will receive $1,500 for the event. Benefit pays one time per event. Simply go to Proximal.com to register for an account. Through the account you can search for a designated provider and file a claim directly to Proximal. After your covered event, upload a bill or portal snapshot from your doctor on your account. Once Proximal processes your claim, a cash benefit will be sent directly to you. Members have up to 12 months after an event to file a claim. Register today! Scan the QR code, or go to proximal.com Get answers at support@proximal.com Or call 612.453.2199

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12 Health Savings Account (HSA) A Health Savings Account (HSA) is a personal savings account employees can make contributions to. The funds can be used to pay for eligible expenses and/or saved for future qualified medical and retiree healthcare expenses. The City’s HSA administrator is Associated Bank. Contributions are taken bimonthly (24 pay periods). Any unused HSA dollars will roll over from year to year, making HSA a convenient and easy way to save and invest for future eligible expenses. Some benefits to opening an HSA:  Contributions made into an HSA are not taxed.  The money you take out of your HSA to pay for qualified expenses are not taxed.  You can earn tax-free interest on the money you keep in your HSA account.  You also have options to invest the money in your account through Associated Bank. Additional HSA resources can be found under “Tools & Resources” in your HSA account, or visit the Internal Revenue Service website, https://www.irs.gov/publications/p969. Individuals age 55+ by the end of the calendar year can contribute an additional $1,000 catchup. If interested, please e-mail blia.vang@appletonwi.gov by December 6, 2024 to add this additional deduction to your payroll for the 2025 plan year. Flexible Spending Account (FSA) The Flexible Spending Account plan allows you to set aside pre-tax dollars to cover qualified expenses employees would normally pay out of pocket with post-tax dollars. The plan is comprised of a dependent care account only. The money placed in an FSA is not subject to federal or state taxes. Contributions are made bimonthly (24 pay periods). How an FSA works: • Choose a specific amount of money to contribute each pay period, pre-tax, to your account. • This amount is automatically deducted from your pay each pay period. • As you incur eligible expenses, you may submit a claim to be reimbursed by the plan. Important rules to keep in mind: • The IRS has a strict “use it or lose it” rule for Dependent Care FSA. If you do not use the full amount in your FSA by the end of the calendar year, you will lose any remaining funds. • Changing your contribution amount mid-year can happen only under a qualifying life event. • You cannot transfer funds from one FSA to another. At the start of the new plan year, there is a 90-days runout period. Participants can submit prior year expenses within the runout period for reimbursement. When deciding your 2024 annual contribution amount, please plan accordingly as any funds not used by the end of the year will be forfeited. Re-enrollment is required each year. Maximum Annual Dependent Care FSA $5,000

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13 Dental City of Appleton will continue to offer a dental program through Delta Dental. In 2025, the covered age for orthodontia services will increase from age 19 to 26. Delta Dental has additional resources with helpful, up-to-date information. Employees can find answers to commonly asked questions, find a network provider, or download a digital enrollment guide here: deltadentalwi.com/s/enrollment-resources. The chart below is a brief outline of the plan. Please refer to the summary plan description for complete plan details on the Human Resources webpage: www.appleton.org/government/human-resources/employee-benefits. It is recommended when a course of treatment is expected to cost $300 or more, and is of a non-emergency nature, your dentist should submit a treatment plan before treatment begins. This enables you to see your expected out-of-pocket expenses to budget accordingly. There is also a possibility that suggested procedures may be denied, and alternative procedures approved based upon X-rays and supporting documentation. Dental Rate Bimonthly Rate Employee $5.00 Family $10.00 Please note: premium rates are taken over 24 pay periods and rates listed are in reference to 1.0 full-time equivalent (FTE). Individuals less than 1.0 FTE premiums will be prorated. Delta Dental of Wisconsin Inc. PPO/Premier 91812 Annual Deductible Individual $50 Family $150 Waived for Preventive Care? Yes Annual Maximum Per Individual $1,500 Preventive 100% Basic 80% Major 50% Oral Surgery Annual Maximum per person per year $2,000 Surgical procedures 50% Orthodontia Benefit Percentage 50% Adults (and Covered Full-Time Students, if Eligible) Covered Dependent eligible to age 26 Lifetime Maximum $2,500 Benefit Waiting Periods N/A

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14 Vision The City vision plan continues to be provided through DeltaVision, a subgroup of Delta Dental. Employees can find answers to commonly asked questions, find a network provider, or download a digital enrollment guide here: deltadentalwi.com/s/enrollment-resources. Below is a brief chart of this benefit, Please refer to the summary plan document, please visit the Human Resources benefits webpage: www.appleton.org/government/human-resources/employee-benefits. Vision Rate Full Plan Bimonthly Rate Materials Only Plan Bimonthlly Rate Employee $2.87 $2.01 Family $7.14 $5.00 Please note premium rates are taken over 24 pay periods. DeltaVision® Full Plan Materials Only Plan Network EyeMed Insight EyeMed Insight Frame/Contact Allowance $150/$150 $150/$150 Copay (exams/standard plastic lenses) $10/$10 $10 Frequency (exams/lenses or contact/frames) Based on calendar year 12 months/12 months/24 months No exam/12 months/24 months Dependent Age Limit To age 26 Benefit Details In -Network Out-of-Network Reimbursement In-Network Out-of-Network Reimbursement Comprehensive Glasses Exam Member pays $10, plan pays balance $35 N/A N/A Standard Contact Lens* Fit and Follow-Up Member pays up to $40 None N/A N/A Standard Plastic Lenses Single Vision Member pays $10, plan pays balance $25 Member pays $10, plan pays balance $25 Bifocal Member pays $10, plan pays balance $40 Member pays $10, plan pays balance $40 Contact Lenses – In lieu of glasses (Contact lens allowance covers materials only) Conventional $150 allowance, then 15% off balance $120 $150 allowance, then 15% off balance $120 Disposable $150 allowance $120 $150 allowance $120 Medically Necessary*** Paid in full $200 Paid in full $200 *Lenses that are spherical power only, soft lens materials, including planned replacement and conventional lenses. Lenses are to be used in a daily wear (removed prior to sleep) mode only. **Includes all lens powers and designs other than spherical powers (i.e. toric, multifocal, etc.), modes of wear that are extended or overnight schedules, and rigid or gas-permeable materials. ***Medically necessary contacts require authorization from a vision doctor when some conditions are present. Please contact the plan for more information.

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15 Life Insurance Basic Life Insurance provided as an Employer Paid Benefit: Non-Union Employees: All employees who work 20+ hours per week are covered with a term life policy 1X your salary rounded to the next even thousand. The policy maximum coverage is $50,000. Teamsters Employees: All full-time employees have a $20,000 term life policy. APPA Union Employees: All full-time employees have a $50,000 term life policy. Voluntary Life and AD&D Insurance All employees working 20 or more hours/week have the option to purchase additional life insurance through New York Life at time of hire. If you are interested in purchasing or requesting to increase/decrease/cancel your coverage, please contact Blia Vang at blia.vang@appletonwi.gov or (920) 832-6455 for appropriate paperwork. If this benefit was waived during your initial eligibility, you will need to submit an Evidence of Insurability to Underwriting to be approved for this benefit. Available Coverage: Benefit Amount Maximum Employee Units of $10,000 Lesser of 7 times salary or $500,000 Spouse Units of $10,000 $250,000 Child(ren) $10,000 $10,000 Age Employee Cost Per $1,000 Spouse Cost Per $1,000 0-19 $0.080 $0.080 20-24 $0.080 $0.080 25-29 $0.080 $0.080 30-34 $0.090 $0.090 35-39 $0.130 $0.130 40-44 $0.210 $0.210 45-49 $0.340 $0.340 50-54 $0.510 $0.510 55-59 $0.770 $0.770 60-64 $1.260 $1.260 65-69 $2.280 $2.280 70-74 $3.230 N/A 75-79 $6.970 N/A How to Calculate Your Monthly Cost: Step 1: Use the rate chart to find your Monthly rate based on your age as of your effective date. Step 2: Multiply this rate by your desired coverage amount, in units of 1,000. Step 3: The result is the Monthly cost. Child Cost Per $1,000 = $0.200 Example: Bob is 27 years old with $100,000 coverage amount. $0.08 x ($100,000)/$1,000 = $8.00 per month Actual per pay period premiums may differ slightly due to rounding. The rates above reflect the total cost. All spouse rates are based on spouse age. Rates vary by age and may be subject to change in the future. Rates are taken over 24 pay periods. Benefits will reduce based on age (see Benefits Reduction Schedule for details found on the Human Resources benefit webpage: www.appleton.org/government/human-resources/employee-benefits).

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16 Disability Insurance Coverages are increasing for both voluntary and employer paid disability policies in 2025. This coverage increase will help you meet the financial challenges of inflation and ensure you continue to receive a fair portion of your income while on leave. For the short-term disability benefit, the weekly benefit payment will increase from $750 to $1,000. For the long-term disability benefit, the monthly benefit payment will increase from $5,000 to $7,500. If you do not wish to continue with voluntary coverage, please e-mail Blia Vang at blia.vang@appletonwi.gov. Long-Term Disability Insurance Non-Union Employees: This benefit provides long-term income protection through New York Life. The benefit covers 60% of your monthly base salary up to $7,500. Benefit payments begin after meeting the 90 days elimination period. Please see the summary plan description for complete plan details and Certificate of Coverage for benefit duration on the Human Resources benefits webpage: www.appleton.org/government/human-resources/employee-benefits. Fire, APPA, and Teamster Union Employees: City of Appleton offers long-term income protection through New York Life in the event you become unable to work due to a non-work-related illness or injury on a voluntary basis. See Certificate of Coverage for benefit duration. Please see the summary plan description for complete plan details on the Human Resources benefits webpage. Premiums are taken over 24 pay periods. Plan Option 1 - This benefit covers 60% of your monthly base salary up to $7,500. Benefit payments begin after 90 days of disability. This plan pays out until the employee can return to work or for a maximum of 5 years. Plan Option 2 - This benefit covers 60% of your monthly base salary up to $7,500. Benefit payments begin after 180 days of disability. This plan pays out until employee can return to work or until age 65. To calculate the cost of your coverage, follow these steps: Step 1. Enter your gross or pre-tax monthly pay (not counting commissions, bonus or overtime). Please note this amount cannot exceed $8,333. $ ______________ Step 2. Enter the rate for your age group (see the chart below). $ ______________ Step 3. Multiply gross pay (line 1) by the rate for your age group (line 2). $ ______________ Step 4. Divide by 100 to determine the amount of premium that will be deducted from your paycheck each month. $ ______________

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17 Option 1 Plan: If you are between these ages: Your cost per 100 of Monthly Covered Earnings Under 25 0.200 25 – 29 0.230 30 – 34 0.290 35 – 39 0.370 40 – 44 0.500 45 – 49 0.660 50 – 54 0.890 55 - 59 1.100 60 - 64 1.320 65 & Over 1.900 Option 2 Plan: If you are between these ages: Your cost per 100 of Monthly Covered Earnings Under 25 0.126 25 – 29 0.140 30 – 34 0.160 35 – 39 0.220 40 – 44 0.290 45 – 49 0.410 50 – 54 0.580 55 - 59 0.820 60 - 64 1.490 65 & Over 2.100 Short-Term Disability Insurance All employees are eligible to purchase short-term disability insurance on a voluntary basis. City of Appleton offers a short-term disability option through New York Life. Please see the summary plan description for complete plan details and Certificate of Coverage for benefit duration on the Human Resources benefits webpage: www.appleton.org/government/human-resources/employee-benefits. Premiums are taken over 24 pay periods. Plan Option 1 - This benefit covers 60% of your weekly base salary up to $1,000 per week. The benefit begins after 14 days of injury or illness and lasts up to 11 weeks. Plan Option 2 - This benefit covers 60% of your weekly base salary up to $1,000 per week. The benefit begins after 30 days of injury or illness and lasts up to 26 weeks. Premiums are taken over 24 pay periods. To calculate the cost of your coverage, follow these steps: Step 1. Enter your gross or pre-tax weekly pay (not counting commissions, bonus or overtime). $ ______________ Step 2. Multiply by .60 to determine your weekly benefit. Round to nearest dollar. This amount cannot exceed $1000. $ ______________ Step 3. Enter the rate for your age group (see the chart below). $ ______________ Step 4. Multiply your weekly benefit (Step 2) by the rate for your age group (Step 3). $ ______________ Step 5. Divide by 10 to determine the amount of premium that will be deducted from your paycheck each month. $ ______________ (Please Note: All benefits in this plan are paid on a weekly basis, regardless of your regular pay period.)

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18 Option 1 Plan If you are between these ages: Your cost per $10 of Weekly Benefit Under 25 0.232 25 – 29 0.249 30 – 34 0.226 35 – 39 0.208 40 – 44 0.231 45 – 49 0.243 50 – 54 0.278 55 - 59 0.359 60 - 64 0.434 65 & Over 0.486 Option 2 Plan If you are between these ages: Your cost per $10 of Weekly Benefit Under 25 0.226 25 – 29 0.245 30 – 34 0.231 35 – 39 0.226 40 – 44 0.249 45 – 49 0.295 50 – 54 0.371 55 - 59 0.445 60 - 64 0.540 65 & Over 0.579 Changing Disability Insurance Coverage If you are interested in purchasing or requesting to cancel your coverage, please contact Blia Vang at blia.vang@appletonwi.gov or (920) 832-6455 for appropriate paperwork. If this benefit was waived during your initial eligibility period, you will need to submit an Evidence of Insurability to Underwriting to be approved for this benefit. Please see the summary plan description for complete plan details on the Human Resources benefits webpage; www.appleton.org/government/human-resources/employee-benefits

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19 Post Employment Health Plan (HRA) The City’s PEHP/HRA is through MidAmerica. All full-time employees have an active account while employed with the City. Each month of service the City contributes $10 to this account. To view your account balance and manage the mutual fund(s) visit www.myMidAmericaJourney.com. The default fund is set to a mutual fund fixed rate or you can move it to another available fund option in MidAmerica. Once you separate from the City, the funds in this account will be available to be used to for any qualified medical expenses. Accident Insurance Accident insurance is an affordable voluntary insurance to help you pay for out-of-pocket costs you may experience after an accident. It pays you benefits for specific injuries and events resulting from a covered accident. The amount paid depends on the type of injury and care received. Premiums are taken over 24 pay periods. Bimonthly Rates Policy Type Bimonthly Amount Employee only $6.21 Employee & Spouse $10.29 Employee & Children $11.72 Family $15.80 Accident insurance provides a Wellness Benefit. Which is an annual benefit payment if you complete a health screening test. Example of health screening tests but are not limited to: City’s annual health screening, Pap test, serum cholesterol test for HDL and LDL levels, mammography, colonoscopy, and/or stress test on bicycle or treadmill. The annual benefit is $100 for completing a health screening test. If your spouse and/or children have this coverage, they are also covered by the Wellness Benefit. Your spouse’s benefit amount is also $100. The benefit for child coverage is $50 with an annual maximum of $200 for children’s benefit per family. The Wellness Benefit is processed by VOYA. Click here to see more information on Wellness Benefit and how to file your Wellness Benefit claim.

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20 Employee Assistance Program (EAP) Life does not always go smoothly. All of us experience times when a personal problem or crisis affects the way we function at work or home. Your Employee Assistance Program (EAP) is a problem-solving resource available to you and your household members. A professional counselor will assist you in assessing your situation, finding options, making choices, or locating further help. It’s free... Your employer covers the cost of initial assessment, additional problem-solving sessions and referral services. If there is a need for further counseling or treatment, your counselor will help you explore various options. It’s confidential... Your EAP has been set up with ComPsych Corporation, an outside counseling resource to assure confidentiality. No one at work will know you have chosen to seek help unless you choose to tell them. No individually-identifiable information is ever shared with the City and you will remain anonymous at all times. ComPsych Corporation is only a phone call away at 844-393-4982 or online at guidanceresources.com ComPsych offers discounts on local and national hotels, tickets and more! Go to their website and register for an account to view the offerings. You will need the Web ID: CityofAppleton. Scan the QR code to directly go to their site.

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21 Retirement Wisconsin Retirement System (WRS) All employees working more than 1200 hours per year are automatically enrolled in the state pension upon hire. Both the employee and employer contribute each payroll (26 pay periods) to this benefit. Visit www.etf.wi.gov to learn more and to calculate an unofficial projection of your WRS benefits. Contributor 2025 % per payroll ALL EMPLOYEES 6.95% EMPLOYER General 6.95% EMPLOYER - Protective with Social Security 14.95% EMPLOYER - Protective without Social Security 18.95% Deferred Compensation – 457 Plan The City’s retirement savings plan through Voya Financial helps you to set a little aside regularly for the kind of retirement you can look forward to. The earlier you begin to set aside funding, the better it grows. Contributions are made over 26 pay periods. You can enroll in the plan, view plan information, review investment options and performance, access retirement articles/seminars/newsletters and schedule meetings with Julie Rodriguez, our Voya rep. If you auto-enroll upon hire, you can register for an account here: Appleton.beready2retire.com. If you opt-out of the auto-enroll process at time of hire and are interested in starting a Deferred Comp plan, please follow these self-enrollment steps: Access your account on the Go Get the “Voya Retire” mobile app to check your account balance and much more on your smartphone. Access your account by Phone 1-800-584-6001 You can access your account by phone 24 hours a day, seven days a week. Keep in mind when calling you may need your PIN. If you’re calling and have lost or misplaced your PIN, request a PIN reminder through the automated system or hold for a Customer Service Associate.

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22 Important Contacts Carrier Customer Service Additional information regarding benefit plans can be found at www.appleton.org or contact Blia Vang at 832-6455 or blia.vang@appletonwi.gov. Please contact Human Resources to complete any changes to your benefits that are not related to your initial or annual enrollment. BENEFIT TYPE CARRIER PHONE NUMBER WEBSITE Medical UMR (800) 826-9781 www.umr.com Dental Delta Dental of Wisconsin Inc. (800) 236-3712 www.deltadentalwi.com Vison Delta Dental of Wisconsin Inc (Branch of Delta Dental) (800) 236-3712 www.deltadentalwi.com Voluntary Life and AD&D New York Life Insurance Company (CIGNA) (800) 732-1603 www.newyorklife.com Short Term Disability (STD) New York Life Insurance Company (CIGNA) Claim intake: (800) 362-4462 www.newyorklife.com Long Term Disability (LTD) New York Life Insurance Company (CIGNA) Claim Intake (800) 362-4462 www.newyorklife.com Employee Assistance Program (EAP) ComPsych Corporation (844) 393-4982 www.guidanceresources.com Flex Spending - Daycare Diversified Benefit Services, Inc. (800) 234-1229 www.dbsbenefits.com PEHP/HRA MidAmerica (855) 329-0095 www.myMidAmericaJourney.com Connecting Care Clinic ThedaCare (920) 225-1467 www.mythedacare.org Prudent Rx Prudent Rx (800) 578-4403 Proximal Proximal (612) 453-2199 www.Proximal.com This brochure summarizes the benefit plans that are available to City of Appleton eligible employees and their dependents. Official plan documents, policies and certificates of insurance contain the details, conditions, maximum benefit levels and restrictions on benefits. These documents govern your benefits program. If there is any conflict, the official documents prevail. These documents are available upon request through the Human Resources Department. Information provided in this brochure is not a guarantee of benefits.

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23 REQUIRED NOTIFICATIONS Important Legal Notices Affecting Your Health Plan Coverage If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:  All stages of reconstruction of the breast on which the mastectomy was performed;  Surgery and reconstruction of the other breast to produce a symmetrical appearance;  Prostheses; and  Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. Therefore, the following deductibles and coinsurance apply: $2,000/$4,000 and 10% coinsurance. If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). 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 30 days after the marriage, birth, adoption, or placement for adoption. Further, if you decline enrollment for yourself or eligible dependents (including your spouse) while Medicaid coverage or coverage under a State CHIP program is in effect, you may be able to enroll yourself and your dependents in this plan if:  coverage is lost under Medicaid or a State CHIP program; or  you or your dependents become eligible for a premium assistance subsidy from the State. In either case, you must request enrollment within 60 days from the loss of coverage or the date you become eligible for premium assistance. To request special enrollment or obtain more information, contact the person listed at the end of this summary. CONTACT INFORMATION Questions regarding any of this information can be directed to: Blia Vang Blia.Vang@appletonwi.gov THE WOMEN’S HEALTH CANCER RIGHTS ACT OF 1998 (WHCRA) NOTICE OF SPECIAL ENROLLMENT RIGHTS NOTICE REGARDING WELLNESS PROGRAMS CONTACT INFORMATION

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24 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Your Information. Your Rights. Our Responsibilities. Recipients of the notice are encouraged to read the entire notice. Contact information for questions or complaints is available at the end of the notice. Your Rights You have the right to:  Get a copy of your health and claims records  Correct your health and claims records  Request confidential communication  Ask us to limit the information we share  Get a list of those with whom we’ve shared your information  Get a copy of this privacy notice  Choose someone to act for you  File a complaint if you believe your privacy rights have been violated Your Choices You have some choices in the way that we use and share information as we:  Answer coverage questions from your family and friends  Provide disaster relief  Market our services and sell your information Our Uses and Disclosures We may use and share your information as we:  Help manage the health care treatment you receive  Run our organization  Pay for your health services  Administer your health plan  Help with public health and safety issues  Do research  Comply with the law  Respond to organ and tissue donation requests and work with a medical examiner or funeral director  Address workers’ compensation, law enforcement, and other government requests  Respond to lawsuits and legal actions Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get a copy of health and claims records  You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.  We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct health and claims records  You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.  We may say “no” to your request, but we’ll tell you why in writing, usually within 60 days.

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25 Request confidential communications  You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.  We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not. Ask us to limit what we use or share  You can ask us not to use or share certain health information for treatment, payment, or our operations.  We are not required to agree to your request. Get a list of those with whom we’ve shared information  You can ask for a list (accounting) of the times we’ve shared your health information for up to six years prior to the date you ask, who we shared it with, and why.  We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you  If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.  We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated  You can complain if you feel we have violated your rights by contacting us using the information at the end of this notice.  You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/hipaa/filing-a-complaint/index.html.  We will not retaliate against you for filing a complaint. Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:  Share information with your family, close friends, or others involved in payment for your care  Share information in a disaster relief situation If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.  In these cases we never share your information unless you give us written permission: Marketing purposes Sale of your information Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Help manage the health care treatment you receive We can use your health information and share it with professionals who are treating you. Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.

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26 Pay for your health services We can use and disclose your health information as we pay for your health services. Example: We share information about you with your dental plan to coordinate payment for your dental work. Administer your plan We may disclose your health information to your health plan sponsor for plan administration. Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge. Run our organization  We can use and disclose your information to run our organization and contact you when necessary.  We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans. Example: We use health information about you to develop better services for you. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html. Help with public health and safety issues We can share health information about you for certain situations such as:  Preventing disease  Helping with product recalls  Reporting adverse reactions to medications  Reporting suspected abuse, neglect, or domestic violence  Preventing or reducing a serious threat to anyone’s health or safety Do research We can use or share your information for health research. Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Respond to organ and tissue donation requests and work with a medical examiner or funeral director  We can share health information about you with organ procurement organizations.  We can share health information with a coroner, medical examiner, or funeral director when an individual dies. Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you:  For workers’ compensation claims  For law enforcement purposes or with a law enforcement official  With health oversight agencies for activities authorized by law  For special government functions such as military, national security, and presidential protective services Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities  We are required by law to maintain the privacy and security of your protected health information.  We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.  We must follow the duties and privacy practices described in this notice and give you a copy of it.

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28 Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2024. 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

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29 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 Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: https://www.in.gov/medicaid/ Phone: 1-800-457-4584 IOWA – Medicaid and CHIP (Hawki) KANSAS – Medicaid Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563 HIPP Website: https://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp 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/people-we-serve/children-and-families/health-care/health-care-programs/programs-and-services/other-insurance.jsp Phone: 1-800-657-3739 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

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30 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. 5218 NEW JERSEY – Medicaid and CHIP NEW YORK – Medicaid Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 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.dhs.pa.gov/Services/Assistance/Pages/HIPP-Program.aspx 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 Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669 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

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31 To see if any other states have added a premium assistance program since January 31, 2024, or for more information on special enrollment rights, contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137. OMB Control Number 1210-0137 (expires 1/31/2026) 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

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Page 32 of 34 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..12 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. 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)

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Page 33 of 34 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 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.

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Page 34 of 34 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 information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums X X A regular employee of the City of Appleton who is scheduled to work at their job at least 30 hours per week; or a person who retires while covered under the Plan. The subscriber’s legal spouse or a child of the Subscriber. The term child includes any of the following: a natural child; a stepchild; a legally adopted child; a child placed for adoption; a child for whom legal guardianship has been awarded to the Subscriber or the Subscriber’s spouse; a child of a Dependent (until the Dependent who is the parent turns 18)