TICKNOR
Important Contacts Medical Dental Vision EMI Group 8650 Phone 800 662 5851 Website www EMIHEalth com Basic Voluntary Life AD D Voluntary Short Term Group 0CCHL Mutual of Omaha Jodie Ellis Chief Executive Officer Phone 682 305 7152 Jodie ellis ticknorenterprises com Brandi Clayton Regional Director of Human Resources Phone 254 968 3313 brandi clayton ticknorenterprises com Accident Cancer Critical Illness Phone 800 325 4368 Website www coloniallife com Toni Melton Agent Phone 903 434 4783 tmelton higginbotham net Kerri Moulton ACSR Account Manager Phone 903 434 4752 kmoulton higginbotham net NEED to file a claim Have questions on a denied claim or a bill Gayle Peacock ACSR Claim Specialist Phone 903 434 4780 gpeacock higginbotham net This brochure highlights the main features of Ticknor Enterprises benefits program and does not include all plan rules and details The terms of your benefit plans are governed by legal documents including insurance contracts Should there be any inconsistencies between this brochure and the legal plan docu ments the plan documents are the final authority
Table of Contents Eligibility 4 Easy Steps to Enroll Benefits in Hand Instructions Table of Contents Medical Summary Minimum Essential Coverage MEC Plan Dental Vision Basic Life with AD D Voluntary Life with AD D Voluntary Short Term Disability Colonial Accident Critical Illness Hospital Indemnity Rates Summary of Payroll Deductions Appendex A HSA Information Finding a Medical Provider Finding a MEC Provider Finding a Dental Vision Provider EMI Health Mobile App Diabetes Management Appendex B Fully Plan Summaries Discount Dental and Vision included in MEC Summaries FAQ Life Insurance FAQ Short Term Disability Required Notices Page 1 2 3 5 7 9 10 11 12 15 17 19 20 21 22 23 24 25 26 29 30 36 38 39 40
Eligibility Ticknor Enterprises is pleased to provide insurance benefits You may select the insurance that best fits your needs You are eligible for benefits if you are a regular full time employee working an average of 32 hours per week Enrollment must be completed within 31 days of the date of eligibility Once your enrollment is completed no changes will be allowed until the next annual open enrollment period unless you have a Qualifying Life Event or your hours worked per week drop below the minimum New Hire Eligibility Waiting Period Class 1 Senior Management First of the month following 30 days Class 2 Management First of the month following 60 days Class 3 All other Eligible Employees 90 days from hire date The policy year runs from January 1 2024 to December 31 2024 however the company reserves the right to make changes to the policies at anytime as well as the right to require appropriate documentation to prove your dependent relationship status including marriage birth tax returns and other legal documents You may also enroll eligible dependents for benefits coverage The cost to you for dependent coverage will vary depending on the number of dependents you enroll in the plan and the particular plans you choose When covering dependents you must select the same plans for your dependents as you select for yourself Eligible Dependents Include Your legally married spouse Children under the age of 26 regardless of status dependency or marital status Natural Child Legally Adopted Child Step child student Qualifying Life Events Once you elect your benefit options they will remain in effect for the entire plan year until the following Open Enrollment You may only change coverage during the plan year if you have a Qualifying Life Event and you must do so within 30 days of the event Qualifying Life Events Include Marriage divorce legal separation or annulment Birth adoption or placement for adoption of an eligible child Death of a spouse or child Change in your spouse s employment that affects benefits eligibility Change in your child s eligibility for benefits reaching the age limit Change in residence that affects your eligibility for coverage Significant change in coverage or cost in your your spouse s or child s benefit plans FMLA Leave COBRA event Court Judgement or Decree If you have a Qualifying Life Event and want to request a mid year change you must notify Human Resources and complete your election changes within 30 days following the event Be prepared to provide documentation to support the Qualifying Life Event Network Ticknor Enterprises offers 3 medical plans provided by EMI All 3 plans use the Aetna network Ticknor Enterprises also offers 2 MEC plans Both plans use the First Health Limited Benefit Network Child for who you or your spouse are the legal guardian as long as you have the sole legal right and obligation to provide support and medical care Children who are fully dependent on you for support due to a mental or physical disability and who are indicated as such on your federal tax return coverage may continue past age 26 1
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Benefits In Hand ENROLL IN YOUR BENEFITS One step at a time Step 1 Log In Go to www benefitsinhand com and click Login Returning users Log in with the username and password you selected If you have forgotten your password Click Reset a forgotten password First time users Click on your Registration Link in the email sent to you by your admin or Register as a new user Create an account and create your own username and password Company Identifier Matlock2023 Step 2 Welcome After you login click Let s Begin to complete your required tasks Step 3 Onboarding For first time users if applicable Complete any assigned onboarding tasks before enrolling in your benefits Once you ve completed your tasks click Start Enrollment to begin your enrollments T I P if you hit Dismiss complete later you ll be taken to your Home Page You ll still be able to start enrollments again by clicking Start Enrollments Step 4 Start Enrollments After clicking Start Enrollment you ll need to complete some personal dependent information before moving to your benefit elections T I P Have dependent details handy To enroll a dependent in coverage you will need their date of birth and Social Security number 3 Erollment Instructions
Benefits In Hand Step 5 Benefit Elections To enroll dependents in a benefit click the checkbox next to the dependent s name under Who am I enrolling Below your dependents you can view your available plans and the cost per pay To elect a benefit click Select Plan underneath the plan cost Click Save Continue at the bottom of each screen to save your elections If you do not want a benefit click Don t want this benefit at the bottom of the screen and select a reason from the drop down menu Step 6 Forms If you have elected benefits that require a beneficiary designation Primary Care Physician or completion of an Evidence of Insurability form you will be prompted to add in those details Step 7 Review Confirm Elections Review the benefits you selected on the enrollment summary page to make sure they are correct then click Sign Agree to complete your enrollment You can either print a summary of your elections for your records or login at any point during the year to view your summary online T I P If you miss a step you ll see Enrollment Not Complete in the progress bar w ith the incomplete steps highlighted Click on any incomplete steps to complete them Step 8 HR Tasks if applicable To complete any required HR tasks click Start Tasks If your HR department has not assigned any tasks you re finished Enrollment Instructions You can login to review your 4 benefits 24 7
Medical Summary Carrier EMI Health Plan Name Base Plan T 6500 HSA Middle Plan T 7500 Buy Up Plan T 2500 100 In Network Deduc ble Ind Family Maximum Out of Pocket Ind Family Coinsurance Physician Services Primary Care Specialist Virtual Visits WellVia Simple Lab X ray Other Services Hospital Admission Outpa ent Surgery Emergency Room Urgent Care Complex Imaging Prescrip on Drugs Rx Deduc ble Tier I Tier II Tier III 6 500 13 000 7 000 14 000 80 20 Deduc ble 20 Deduc ble 20 Deduc ble 20 Deduc ble 20 Deduc ble 20 Deduc ble 20 Deduc ble 20 Deduc ble 20 Deduc ble 20 Integrated with Medical 20 a er Deduc ble 30 a er Deduc ble 50 a er Deduc ble Aetna 7 500 15 000 8 500 17 000 80 20 40 75 0 0 Deduc ble 20 Deduc ble 20 500 100 Deduc ble 20 None 10 45 150 2 500 5 000 5 000 10 000 100 0 30 60 0 0 Deduc ble Deduc ble 250 75 Deduc ble None 10 35 150 Tier IV Mail Order 90 day supply Out of Network Deduc ble Ind Family Maximum Out of Pocket Ind Family Coinsurance Employee Semi Monthly Payroll Deduc on 25 up to 250 a er Ded 20 30 50 a er Ded Specialty 0 or 25 up to Specialty 0 or 25 up to 250 250 2X Copay 2X Copay 12 000 24 000 18 000 30 000 50 50 15 000 30 000 17 000 34 000 50 50 5 000 10 000 10 000 20 000 50 50 Employee Employee Spouse Employee Child ren Employee Family 28 20 341 29 284 36 654 37 68 39 425 64 360 69 782 90 174 60 817 79 562 49 1 122 78 5 This is only a brief summary of benefits Please refer to full benefit summary for your complete plan description
TeleMedicine Reach a doctor 24 7 365 70 of doctor visits can be handled over the phone and 40 of urgent care visits can be managed using TeleMedicine Save t ime and money while st ill gett ing t he t reat ment you need t hrough EMI Healt h TeleMed offered through Recuro When to Use TeleMed Recuro doctors diagnose acute non emergent medical conditions and prescribe medications when clinically appropriate Speak with a doctor anytime and pay no consultation fee rather than paying the high costs associated with office visits urgent care visits and emergency room visits Just call 855 6RECURO Video consultat ions are available as well from 7 AM 7 PM Common Conditions Acid Reflux Ear Pain Pink Eye Allerg ies Fever Ra shes Ast hma Gout Sinus Conditions Bladder Infection Hea d a c he Sore Throat Bro nc hit is Hemo rrho id s Stomach Virus Cold Flu High Blood Pressure Thyroid Conditions Co nst ip a t io n Joint Pain Urinary Tract Infections Co ug h Na usea Yeast Infections Inaccordancewithtelemedicineguidelines ear infectionsareonlydiagnosedfor patientsthat are18 yearsof ageor older Common Medications Alb ut ero l Flo na se Alleg ra Ibuprofen 800 mg Ast hma Leva q uin Lip it o r Na so nex Many Others EM I M KTG TELEM EDAND M H 1119 1241 855 6RECURO Download the Recuro mobile app EMI Health 5101South Commerce Drive Murray Utah 84107 Tol6l Free 800 662 5851 Web emihealth com
Minimum Essential Coverage Base Plan MEC Base All services are subject to the EMI Health Maximum Allowable Charges There will be no benefit when using a Non participating Provider THIS IS A MINIMUM ESSENTIAL COVERAGE PLAN BENEFITS ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES Read your plan document carefully MEC 2024 Contract Year GENERAL INFORMATION Benefit Accumulator Dependent Age Limit PRESCRIPTION DRUG BENEFITS If brand is purchased when generic is available member pays the copay plus the difference between the generic and the brand price Participating Pharmacy 30 day supply Non Participating Pharmacy Mail Order 90 day supply Specialty Pharmacy PREVENTIVE SERVICES Routine Physical Exam 1 visit per Year Routine Gynecological Exam 1 visit per Year Routine Pap Smear Mammogram 1 per Year Routine Well Baby Exams Covered Immunizations Routine Vision Exam 1 visit per Year Routine Hearing Exam 1 visit per Year Eligible Preventive Facility Services MEC BASE PLAN Participating Provider Option YOU PAY Calendar Year 26 YOU PAY ACA Preventive Care Mandates Covered 100 All Others Discount Only Not Covered ACA Preventive Care Mandates Covered 100 All Others Discount Only Not Covered YOU PAY Covered 100 Covered 100 Covered 100 Covered 100 Covered 100 Covered 100 Covered 100 Covered 100 PROVIDER NETWORK Nationwide except Utah Utah First Health Limited Benefit Network EMI Health MEC Network PLEASE NOTE This is a summary only and does not guarantee benefits All benefits are subject to the terms limitations and exclusions set forth in the Plan document and in the Summary Plan Description SPD handbook of the Plan Any discrepancies between this summary the SPD handbook and the Plan document are resolved in favor of the Plan document For more information refer to the SPD handbook or the Plan document or contact EMI Health Customer Service Department As an added benefit in addition to this medical plan members have access to EMI TeleMed TeleMed TeleMed Semi Monthly Pay Rates Employee Only 0 00 Employee Sp 7 83 Employee Child 11 48 Family 19 30 YOU PAY 0 Administered by Educators Health Plans Life Accident and Health Inc EMI Health Customer Service 801 270 2880 or 1 800 662 5851 Self Funded Employee Medical Benefit Plan Includes Discount Dental Vision 7
Minimum Essential Coverage Enhanced Plan MEC Enhanced All services are subject to the EMI Health Maximum Allowable Charges There will be no benefit when using a Non participating Provider THIS IS A MINIMUM ESSENTIAL COVERAGE PLAN BENEFITS ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES Read your plan document carefully MEC Enhanced 22023 Contract Year GENERAL INFORMATION Benefit Accumulator Dependent Age Limit PRESCRIPTION DRUG BENEFITS If brand is purchased when generic is available member pays the copay plus the difference between the generic and the brand price MEC ENHANCED Participating Provider Option YOU PAY Calendar Year 26 YOU PAY Participating Pharmacy 30 day supply Non Participating Pharmacy Mail Order 90 day supply Specialty Pharmacy PREVENTIVE SERVICES Routine Physical Exam 1 visit per Year Routine Gynecological Exam 1 visit per Year Routine Pap Smear Mammogram 1 per Year Routine Well Baby Exams Covered Immunizations Routine Vision Exam 1 visit per Year Routine Hearing Exam 1 visit per Year Eligible Preventive Facility Services PHYSICIAN PROFESSIONAL SERVICES Convenience Clinic Max 3 visits per year Physician Office Visits primary care Max 3 visits per year Physician Office Visits secondary care Max 3 visits per year Major Diagnostic Test CT Scan MRI NMR office Max 1 per year Minor Diagnostic Test Radiology Lab office or outpatient Max 3 per year Injections office Max 3 per year Surgery office Max 1 per year Anesthesiology office Max 3 per year URGENT CARE CLINIC Urgent Care Clinic Max 3 visits per year MEDICAL SUPPLIES EQUIPMENT Diabetic Testing Supplies 90 day supply Medical Supplies office Max 3 per year ACA Preventive Care Mandates Covered 100 Generic 10 Preferred 50 Non Preferred Not Covered Not Covered ACA Preventive Care Mandates Covered 100 Generic 10 Preferred 50 Non Preferred Not Covered Not Covered YOU PAY Covered 100 Covered 100 Covered 100 Covered 100 Covered 100 Covered 100 Covered 100 Covered 100 YOU PAY 20 20 50 250 50 Covered 100 Covered 100 Covered 100 YOU PAY 50 YOU PAY 30 Covered 100 PROVIDER NETWORK Nationwide except Utah Utah Includes Discount Dental Vision TeleMed TeleMed Semi Monthy Pay Rates Employee Only 37 00 Employee Sp 69 50 Employee Child 83 50 Family 111 00 First Health Limited Benefit Network EMI Health MEC Network Administered by Educators Health Plans Life Accident and Health Inc EMI Health Customer Service 801 270 2880 or 1 800 662 5851 Self Funded Employee Medical Benefit Plan YOU PAY 0 8
5101 SOUTH COMMERCE DRIVE MURRAY UT 84107 Corporate 801 262 7475 Customer Service 800 662 5851 EMIHealth com Group Plan Underwritten Administered by Plan Type Effective Date Benefit Year Ticknor Enterprises Matlock Plan 8650 Summit Plus Indemnity Educators Health Plans Life Accident and Health Inc Voluntary Fully Insured 1 1 2024 Calendar Voluntary Dental Type 1 Preventive Oral Exams Cleanings X rays Fluoride Type 2 Basic Fillings Oral Surgery Type 3 Major Crowns Bridges Prosthodontics Type 4 Orthodontics Dependent children ages 7 through 18 Adults In Network 100 80 50 Discount Only Discount Only Out of Network 100 up to R C 80 up to R C 50 up to R C No Coverage No Coverage Endodontics Periodontics Sealants Space Maintainers Type 3 Major Type 3 Major Type 2 Basic Type 2 Basic Type 3 Major Type 3 Major Type 2 Basic Type 2 Basic Waiting periods Type 2 Basic Type 3 Major Type 4 Orthodontics None 12 Month Waiting Period N A Deductible Per Person Family Max Deductible Applies To In and Out of Network Deductibles are Combined 50 00 50 00 150 00 150 00 Type 2 Type 3 Type 2 Type 3 Annual Maximum Per Person Orthodontic Lifetime Maximum 1 000 00 N A Network Utah Premier EMI Health N A Network Texas Outside Utah Summit Plus Cigna N A Fee Schedule Summit Plus R C 80th Semi Monthly Payroll Rates Employee Employee Spouse Employee Child Employee Spouse Child ren 15 20 31 65 32 55 50 00 Provisions Limitations Exclusions Exams including Periodontal Cleanings and Fluoride 2 per year Fluoride Up to age 16 Sealants Up to age 16 Space Maintainers Up to age 16 Bitewing X Rays Up to 4 twice per year Periapical X Rays 6 per year Panoramic X Ray 1 every 3 years Impacted Teeth Covered in Type 2 Basic Anesthesia Age 8 and over for the extraction of impacted teeth only Covered in Type 3 Major Anesthesia For children age 7 and under once per year Covered in Type 3 Major Implants Implant Abutments Not Covered Crowns Pontics Abutments Onlays and Dentures 1 every 5 years per tooth Fillings on the same surface 1 every 18 months Benefits illustrated are in summary only Refer to your certificate for a complete description of benefits limitations and exclusions When using a Non participating Provider the insured is responsible for all fees in excess of the Reasonable and Customary Charges R C Anesthesia is not subject to waiting periods EHPL TX D SUMMIT SCH A 9
Corporate 801 262 7475 Customer Service 800 662 5851 EMIHealth com Group Plan Effective Date Plan Type Ticknor Enterprise Matlock Plan 8650 VSP Plus 10 130 1 1 2024 Voluntary Voluntary Vision In Network Out of Network Network WellVision Exam 10 Co pay VSP Choice Plus Up to 65 Lenses Glass or Plastic Single Vision Lined Bifocal Lined Trifocal Lenticular Lens Options Progressive Standard no line Premium Progressive Options Custom Progressive Options Plastic Gradient Dye Solid Plastic Dye Photochromic Lenses Polycarbonate for Adults Polycarbonate for Children under 18 Coatings Scratch Resistant Coating Anti Reflective Coating UV Protection Additional lens enhancements Frames Allowance Based on Retail Pricing Additional Pairs of Glasses Elective Contact Lenses In Lieu of Frame Lenses Elective contact lens fitting evaluation services and prescription contact lenses are covered up to plan allowance 15 discount given off contact lens fitting and evaluation services excluding materials 10 Co pay 10 Co pay 10 Co pay 10 Co pay 0 Co pay 95 105 Co pay 150 175 Co pay 17 Co pay 15 Co pay 75 Co pay 31 Co pay SV 35 Co Pay Multifocal 0 Co pay 17 Co pay 41 Co pay 16 Co pay Up to 25 Discount 130 Allowance at any VSP doctor or 70 at Costco Sam s Club or Walmart Up to 20 Off Retail 130 Allowance Up to 30 Up to 50 Up to 65 Up to 100 The reimbursement outlined under the Lenses section is a total reimbursement for lenses and any lens enhancements elected The reimbursement outlined under the Lenses section is a total reimbursement for lenses and any lens enhancements elected Up to 80 N A Up to 115 Frequency Exam Lenses Frame or Contacts Every 12 Months Refractive Surgery LASIK Up to 500 in Savings Not Covered Employee Employee Spouse Employee Child ren Employee Spouse Child ren Semi Monthly Payroll Rates 4 65 9 95 10 70 15 30 Notes This is a summary of plan benefits The actual Policy will detail all plan limitations and exclusions 20 discount off unlimited additional pairs of glasses offered through any VSP Choice Providers within 12 months of last covered eye exam Discounts average 15 20 off or 5 off a promotional offer for laser surgery including PRK LASIK Custom LASIK and IntraLase3 Underwritten by Educators Health Plans Life Accident Health EHPL TX V VSP SCH D 10
Life AD D Benefits ABOUT YOUR EMPLOYER PAID LIFE AND AD D INSURANCE Ticknor Enterprises is pleased to provide Basic Life insurance and Accidental Death and Dismemberment AD D coverage to all full time employees Life insurance is an important part of your financial security especially if others depend on you for support Even if you are single your beneficiary can use your Life insurance to pay off your debts such as credit cards mortgages and other final expenses AD D coverage helps protect you and your family from the unforeseen financial hardship of a serious accident that causes death or dismemberment AD D insurance provides you specified benefits for a covered accidental bodily injury that directly causes dismemberment i e the loss of a hand foot or eye In the event that death occurs from an accident 100 of the AD D benefit would be Designating a Beneficiary A beneficiary is the person or entity you designate to receive the death benefits of your life insurance policy You can name more than one beneficiary and you can change beneficiaries at any time If you name more than one beneficiary identify the Coverage Basic Life AD D Benefit Reduction Mutual of Omaha Benefit Type Flat 10 000 10 000 To 65 at age 65 To 50 at age 70 Insurance coverage will be delayed if you are not an active employee because of an injury sickness temporary layoff or leave of absence on the date that insurance would otherwise become effective The policy provisions may vary or not be available in all states The policy has exclusions and limitations which may affect any bene 11
Voluntary Term Life Insurance We ve Got You Covered As an active employee of Matlock Place Health Rehabilitation you have access to a life insurance policy from United of Omaha Life Insurance Company It replaces the income you would have provided and helps pay funeral costs manage debt and cover ongoing expenses How much insurance is enough When determining how much life insurance you need think about the expenses you may encounter now and through every stage of your life Coverage guidelines and benefits are outlined in the chart below ELIGIBILITY ALL ELIGIBLE EMPLOYEES Eligibility Requirement Dependent Eligibility Requirement Premium Payment You must be actively working a minimum of 32 hours per week to be eligible for coverage To be eligible for coverage your dependents must be able to perform normal activities and not be confined at home in a hospital or in any other care facility and any child ren must be under age 26 In order for your spouse and or child ren to be eligible for coverage you must elect coverage for yourself The premiums for this insurance are paid in full by you COVERAGE GUIDELINES Minimum Guarantee Issue Maximum For You Spouse Child ren 10 000 5 000 1 000 5 times annual salary up to 150 000 100 of employee s benefit up to 25 000 100 of employee s benefit 500 000 in increments of 10 000 but no more than 5 times annual salary 100 of employee s benefit in increments of 5 000 up to 250 000 100 of employee s benefit in increments of 1 000 up to 10 000 45103 12 G000CCHL
Subject to any reductions shown below Guarantee Issue is available to new hires Amounts over the Guarantee Issue will require a health application evidence of insurability For late entrants all amounts will require a health application evidence of insurability BENEFITS Life Insurance Benefit Amount Accidental Death Dismemberment AD D Benefit Amount FEATURES Living Care Accelerated Death Benefit Waiver of Premium Annual Benefit Amount Increase Additional AD D Benefits Portability Conversion SERVICES Hearing Discount Program Will Prep Services Within the coverage guidelines defined above you select the amount of life insurance coverage you want This plan includes the option to select coverage for your spouse and dependent child ren Child ren include those up to age 26 In the event of death the benefit paid will be equal to the benefit amount after any age reductions less any living care accelerated death benefits previously paid under this plan For you your spouse and your dependent child ren The Principal Sum amount is equal to the amount of the life insurance benefit AD D coverage is available if you or your dependents are injured or die as a result of an accident and the injury or death is independent of sickness and all other causes The benefit amount depends on the type of loss incurred and is either all or a portion of the Principal Sum 80 of the amount of the life insurance benefit is available to you if terminally ill not to exceed 250 000 If it is determined that you are totally disabled your life insurance benefit will continue without payment of premium subject to certain conditions If you enroll for even the minimum amount of coverage during your initial enrollment you have the ability to increase your coverage at your next enrollment by up to 20 000 provided the total amount of insurance does not exceed your maximum benefit amount This feature allows you to secure additional life insurance protection in the event your needs change ex you get married or have a child Amounts over the Guarantee Issue will require evidence of insurability proof of good health In addition to basic AD D benefits you are protected by the following benefits Child Education Seat Belt Airbag Spouse Education Common Carrier Paralysis Coma Allows you to continue this insurance program for yourself and your dependents should you leave your employer for any reason without having to provide evidence of insurability information about your health You will be responsible for the premium for the coverage If your employment or class membership ends you may apply for an individual life insurance policy from Mutual of Omaha without having to provide evidence of insurability information about your health You will be responsible for the premium for the coverage The Hearing Discount Program provides you and your family discounted hearing products including hearing aids and batteries Call 1 888 534 1747 or visit www amplifonusa com mutualofomaha to learn more We work with Epoq Inc to offer employees online will prep tools In just a few clicks you can complete a basic will or other documents to protect your family and property To get started visit www willprepservices com 13
Voluntary Term Life and AD D Coverage Selection and Premium Calculation Please note that the premium amounts presented below may vary slightly from the amounts provided on your enrollment form due to rounding To select your benefit amount and calculate your premium do the following 1 Locate the benefit amount you want from the top row of the employee premium table Your benefit amount must be in an increment of 10 000 Refer to the Coverage Guidelines section for minimums and maximums if needed 2 Find your age bracket in the far left column 3 Your premium amount is found in the box where the row your age and the column benefit amount intersect 4 Enter the benefit and premium amounts into their respective areas in the Voluntary Life and AD D section of your enrollment form If the benefit amount you want to select is greater than any amount in the table below select the benefit amount from the top row that when multiplied by another number results in the benefit amount you want For example if you want 150 000 in coverage you obtain your premium amount by multiplying the rate for 50 000 times 3 Age 0 34 35 39 40 44 45 49 50 54 55 59 60 64 65 69 70 74 75 79 80 10 000 0 55 0 65 0 90 1 40 2 15 3 25 4 95 8 70 15 45 25 30 51 05 EMPLOYEE PREMIUM TABLE 24 PAYROLL DEDUCTIONS PER YEAR 20 000 30 000 40 000 50 000 60 000 70 000 80 000 90 000 1 10 1 65 2 20 2 75 3 30 3 85 4 40 4 95 1 30 1 95 2 60 3 25 3 90 4 55 5 20 5 85 1 80 2 70 3 60 4 50 5 40 6 30 7 20 8 10 2 80 4 20 5 60 7 00 8 40 9 80 11 20 12 60 4 30 6 45 8 60 10 75 12 90 15 05 17 20 19 35 6 50 9 75 13 00 16 25 19 50 22 75 26 00 29 25 9 90 14 85 19 80 24 75 29 70 34 65 39 60 44 55 17 40 26 10 34 80 43 50 52 20 60 90 69 60 78 30 30 90 46 35 61 80 77 25 92 70 108 15 123 60 139 05 50 60 75 90 101 20 126 50 151 80 177 10 202 40 227 70 102 10 153 15 204 20 255 25 306 30 357 35 408 40 459 45 100 000 5 50 6 50 9 00 14 00 21 50 32 50 49 50 87 00 154 50 253 00 510 50 Follow the method described above to select a benefit amount and calculate premiums for optional dependent spouse and or child ren coverage Your spouse s rate is based on your age so find your age bracket in the far left column of the Spouse Premium Table Your spouse s premium amount is found in the box where the row the age and the column benefit amount intersect Your spouse s benefit amount must be in an increment of 5 000 Refer to the Coverage Guidelines section for minimums and maximums if needed Age 0 34 35 39 40 44 45 49 50 54 55 59 60 64 65 69 70 74 75 79 80 5 000 0 28 0 33 0 45 0 70 1 08 1 63 2 48 4 35 7 73 12 65 25 53 SPOUSE PREMIUM TABLE 24 PAYROLL DEDUCTIONS PER YEAR 10 000 15 000 20 000 25 000 30 000 35 000 40 000 0 55 0 83 1 10 1 38 1 65 1 93 2 20 0 65 0 98 1 30 1 63 1 95 2 28 2 60 0 90 1 35 1 80 2 25 2 70 3 15 3 60 1 40 2 10 2 80 3 50 4 20 4 90 5 60 2 15 3 23 4 30 5 38 6 45 7 53 8 60 3 25 4 88 6 50 8 13 9 75 11 38 13 00 4 95 7 43 9 90 12 38 14 85 17 33 19 80 8 70 13 05 17 40 21 75 26 10 30 45 34 80 15 45 23 18 30 90 38 63 46 35 54 08 61 80 25 30 37 95 50 60 63 25 75 90 88 55 101 20 51 05 76 58 102 10 127 63 153 15 178 68 204 20 45 000 2 48 2 93 4 05 6 30 9 68 14 63 22 28 39 15 69 53 113 85 229 73 50 000 2 75 3 25 4 50 7 00 10 75 16 25 24 75 43 50 77 25 126 50 255 25 1 000 0 10 ALL CHILDREN PREMIUM TABLE 24 PAYROLL DEDUCTIONS PER YEAR 2 000 3 000 4 000 5 000 6 000 7 000 8 000 9 000 0 20 0 30 0 40 0 50 0 60 0 70 0 80 0 90 10 000 1 00 Regardless of how many children you have they are included in the All Children premium amounts listed in the table above 14
Voluntary Short Term Disability Insurance We ve Got You Covered As an active employee of Matlock Place Health Rehabilitation you have access to a disability income insurance policy from United of Omaha Life Insurance Company A disability income insurance policy can help provide security when you need it plus give you peace of mind so you can recover faster and get back on the job sooner Coverage guidelines and benefits are outlined below ELIGIBILITY ALL ELIGIBLE EMPLOYEES Eligibility Requirement You must be actively working a minimum of 30 hours per week to be eligible for coverage Premium Payment The premiums for this insurance are paid in full by you BENEFITS Elimination Period If you become disabled there is an elimination period before benefits are payable Your benefits begin On the 15th day of your disabling injury On the 15th day of your disabling illness Weekly Benefit Your benefit is equivalent to 60 of your before tax weekly earnings not to exceed the plan s maximum weekly benefit amount less other income sources Maximum Benefit Period Maximum Weekly Benefit The premium for your short term disability coverage is waived while you are receiving benefits Up to 11 weeks 1 500 44910 15 G000CCHL
Minimum Weekly Benefit Partial Disability Benefits DEFINITIONS Definition of Disability Definition of Weekly Earnings FEATURES Vocational Rehabilitation Benefit Portability Reasonable Accommodation SERVICES Hearing Discount Program 25 If you become disabled and can work part time but not full time you may be eligible for partial disability benefits which will help supplement your income until you are able to return to work full time Disability and disabled mean that because of an injury or illness a significant change in your mental or functional abilities has occurred for which you are prevented from performing at least one of the material duties of your regular job and are unable to generate current earnings which exceed 99 of your weekly earnings from your regular job You can be totally or partially disabled during the elimination period Weekly earnings for salaried employees is the gross annual salary in effect immediately prior to the date disability begins divided by 52 Weekly earnings for hourly employees is the hourly rate of pay multiplied by the average number of hours worked per week during the 6 month period immediately prior to the date disability begins If employed for part of the prior 6 month period weekly earnings is the hourly rate of pay multiplied by the average number of hours worked If you become disabled and participate in the vocational rehabilitation program you will be eligible for a monthly benefit increase of 5 The portability feature allows you to apply for disability insurance through a trust policy should your employment end without having to provide evidence of insurability You will be responsible for paying the premium for coverage Provides a benefit to the employer to assist in covering costs incurred to make workplace modifications for you to return to work The Hearing Discount Program provides you and your family discounted hearing products including hearing aids and batteries Call 1 888 534 1747 or visit www amplifonusa com mutualofomaha to learn more VOLUNTARY SHORT TERM DISABILITY PREMIUM CALCULATION Use the rates in the Age Premium Factor Table to calculate your premium for voluntary short term disability coverage in the worksheet below using the example as a guide SEMI MONTHLY PREMIUM CALCULATION List your weekly earnings Maximum is 2 500 Multiply by the premium factor Your Estimated Semi Monthly Premium EXAMPLE 42 year old employee earning 40 000 a year 769 23 0 0183000 14 08 This is an estimate of premium cost Actual deductions may vary slightly due to rounding and payroll frequency AGE 25 25 29 30 44 45 49 50 54 55 59 60 64 65 69 70 PREMIUM FACTOR 0 0177000 0 0180000 0 0183000 0 0186000 0 0234000 0 0279000 0 0324000 0 0369000 0 0414000 16
Voluntary benefits Choices to protect what you ve worked so hard to build Each individual s lifestyle and needs are different from the next Voluntary benefits from Colonial Life offer a broad range of financial protection options for employees and their families Accident Insurance Group Accident A guaranteed issue composite rated group accident product with multiple coverage levels to fit employer and employee needs All plans are compliant with health savings accounts HSA and provide all employees the same benefits and rates Spouse and eligible dependent children coverage is also available Guarantee Issue Special Risk Insurance Group Cancer A cancer product that helps pay some of the direct and indirect costs related to cancer diagnosis and treatment Choose from 3 levels and up to 10K diagnosis benefit Guarantee Issue for first enrollment and new hires Ticknor Enterprises Important coverage features With most products coverage is available to spouses and eligible dependent children Benefits are paid directly to the insured unless specified otherwise With most products employees can continue coverage with no increase in premiums if they retire or change jobs With most products employees may receive benefits regardless of any other insurance Premiums are payroll deducted for easy administration NS 16028 Supplemental Health insurance Group Hospital Indemnity A hospital confinement indemnity product that pays benefits to help cover out of pocket expenses associated with a covered hospital stay This HSA compliant plan is guaranteed issue plans that ask no health questions Scan the QR Codes for full benefit information To learn more or for enrollment assistance contact 317 414 9680 ColonialLife com 17 3 17 NS 16028
Deductions per year 24 Group Accident for TX l On Off Job Accident Coverage Preferred ISSUE AGE NAMED INSURED 17 99 7 47 EMPLOYEE SPOUSE 12 32 Applicable to policy forms GACC1 0 P GACC1 0 C ONE PARENT FAMILY 14 28 TWO PARENT FAMILY 19 14 Group Critical Illness GCI6000 for TX l Plan 4 Cancer Cancer Benefits Wellbeing Assistance Benefit 50 Benefit Applicable to policy forms GCI6000 P GCI6000 C R GCI6000 CB R GCI6000 BB R GCI6000 HB R GCI6000 INF R GCI6000 PD Cancer Benefits Level 1 ISSUE AGE NAMED INSURED 5 000 17 74 9 11 NAMED INSURED AND SPOUSE 15 50 NAMED INSURED AND DEPENDENT CHILD REN 9 11 NAMED INSURED SPOUSE AND DEPENDENT CHILD REN 15 50 Cancer Benefits Level 2 ISSUE AGE NAMED INSURED 5 000 17 74 Cancer Benefits Level 3 ISSUE AGE 10 83 NAMED INSURED 5 000 17 74 13 10 NAMED INSURED AND SPOUSE 18 07 NAMED INSURED AND DEPENDENT CHILD REN 10 83 NAMED INSURED SPOUSE AND DEPENDENT CHILD REN 18 07 NAMED INSURED AND SPOUSE 22 58 NAMED INSURED AND DEPENDENT CHILD REN 13 10 NAMED INSURED SPOUSE AND DEPENDENT CHILD REN 22 58 Group Hospital Indemnity Medical Bridge GMB7000 for TX Composite l Without Wellbeing Assistance Observation Room Applicable to Policy Forms GMB7000 P GMB7000 C HOSPITAL CONFINEMENT LEVEL ISSUE AGE Level 3 1500 17 99 NAMED INSURED 8 26 EMPLOYEE SPOUSE ONE PARENT FAMILY TWO PARENT FAMILY 17 68 11 28 20 71 Important Notice Insurance coverage has exclusions and limitations that may affect benefits payable For a complete description of benefits limitations and exclusions please refer to an outline of coverage sample policy certificate proposal description or see your Colonial Life benefits counselor Coverage type benefits and rates vary by state Coverage may not be available in all states Rates provided are illustrative and your actual premium may be different depending on your particular situation and plan choices Colonial Life products are underwritten by Colonial Life Accident Insurance Company for which Colonial Life is the marketing brand 2022 Colonial Life Accident Insurance Company Colonial Life and the Colonial Life logo separately and in combination are service marks of Colonial Life Accident Insurance Company All rights reserved Jamie Pope jamie colonialtx com 409 782 1910 Underwritten by Colonial Life Accident Insurance Company See page 1 for Important Notice 18
Summary of Payroll Deductions This worksheet will help you calculate your benefit costs for medical dental and vision This is not an enrollment form Below is a breakdown of the semi monthly rates per paycheck Group Medical Ticknor Enterprises contributes 512 80 per month per employee EMI Medical Base Plan T 6500 QHDHP Middle Plan T 7500 Buy Up Plan T2500 100 Employee 28 20 68 39 174 60 Emp Sp 341 29 425 64 817 79 Emp Child 284 36 360 69 562 49 Ticknor Enterprises contributes 55 per month per employee EMI Mec Plan MEC Base Plan MEC Enhanced Plan 0 00 37 00 7 83 69 50 11 48 83 50 Family 654 37 782 90 1 122 78 19 30 111 00 Voluntary Group Dental EMI Dental Employee Summit 15 20 Emp Sp 31 65 Emp Child 32 55 Family 50 00 Voluntary Group Vision EMI Vision Employee Emp Sp VSP 10 130 4 65 9 95 Voluntary Group Life and AD D Fill In rate from rate grid provided in booklet Mutual of Omaha Employee Emp Sp Semi Monthly Rate per paycheck Emp Child 10 70 Emp Child Family 15 30 Family Voluntary Short Term Long Term Disability Fill In rate from rate grid provided in booklet Mutual of Omaha Semi Monthly Rate per paycheck Short Term Disability Long Term Disability Voluntary Colonial Products Fill In rate from rate grid provided in booklet Accident Cancer Hospital Indemnity Semi Monthly Rate per paycheck Ticknor Enterprises provides 10 000 in Basic Life and AD D coverage at 100 no cost to you Your Total 2024 Benefit Cost Per Pa19y Period ___________________
Appendix A HSA Information Finding a Medical Provider Finding a MEC Provider Finding a Dental Vision Provider EMI Health Mobile App Diabetes Management 20
HSA Information Health Saving Account HSA If you enroll in the Base Plan T6500 QHDHP you are eligible to open a Health Savings Account HSA An HSA is a personal saving account which you can use to pay qualified out of pocket medical expenses with pretax dollars You own and control the money in your health savings account The money in your account including interest and investment earnings grows taxfree and as long as the funds are used to pay for qualified medical expenses they are spent tax free HSA Eligibility You are eligible to open contribute to an HSA if you Are enrolled in an HSA eligible HDHP Are not covered by other non HDHPs such as your spouse s health plan Health Care Flexible Spending Account or Health Reimbursement Arrangement Are not eligible to be claimed as a dependent on someone else s tax return Are not enrolled in Medicare or TRICARE Have not received Veterans Administration benefits You can use the money in your HSA to pay for qualified medical expenses now or in the future Your HSA can be used for your expense and those of your spouse and dependents even if they are not covered by the HDHP Contributions Your contributions to your HSA may not exceed the amount established by the IRS The annual contribution maximum is based on the coverage option you elect Individual 4 150 Family filing jointly 8 300 Employees age 55 and older are allowed to make an additional annual catch up contribution of up to 1 000 Opening an HSA When you enroll in the EMI HSA plan you will have an option to open a HSA You NOT the company are responsible for maintaining ALL records and receipts for HSA reimbursements in the event of an IRS audit Please note You may open an HSA at any financial institution of your choice 21
Finding a Provider Using in net work providers and facilities gets you the most coverage for healthcare services and saves you money Aet na National Net work Provider Search As a member of EMI Health you have access to the nationwide Aetna network of doctors hospitals and other facilities You have access to in network providers everywhere you go in the United States helping you save money and protecting you from getting balance billed To find an in network provider follow these simple steps Go to emihealth com 1 Click on Find a Provider along the upper part of the home page Enter your plan name and state 2 Choose medical as the type of provider choose Care Plus as your plan name and select your st at e from t he drop down list Click on the Aet na logo 3 When you see this pop up click on the Aetna logo t o be t aken t o t heir provider search t ool 4 Enter your location and click Search From there you can filter for specialists facilities languages and more That s all there is to it You will see a list of participating providers along with contact information address and the abilit y to map the location of their offices You can also download the results as a PDF to keep or take with you Traveling outside your state You are covered by a national network So if you are traveling follow the same steps as before and input the new location To search for medical providers in Utah you will not be redirected to the Aetna tool Instead enter your location on the EMI Health provider search tool selecting Utah as your state You will then be taken to the results page and you can then filter by specialties locations languages and more You can map the provider s location get contact information and download your results to a PDF 22
MEC Provider Search The First Health Limited Net work provider search ensures that you are going to an in net work provider and preventing unnecessary costs How to find a provider Go to emihealth com Click Find a Provider Medical Under the Plans section select MEC and choose your state from the State drop down menu Dent a l Under the Plans section select Value and choose your state from the State drop down menu Vision Under the Plans section select VSP Choice and choose your state from the State drop down menu A pop up window will appear after you ve selected your state Click the First Health Limited Net work logo You will be taken to the First Health website Click Start now A pop up window will appear after you ve selected your state Click Search A pop up window will appear Click Continue You will be taken to the Careington website Customize your search by marking what you d like to search physician hospital urgent care center etc Customize your search by marking what you d like to search Hit Search for Providers Hit Search Now to find your providers Quest ions As always we are here to help Call customer service at 800 662 5851 23 Click Search EM I M KTG M EC PROV SRCH 0 119 1133
Looking for dental and vision providers It s easy to find in network dental and vision providers near you using the EMI Health Provider Search tool Go to emihealth com 1 Click on Find a Provider along the upper part of the home page 2 Select the t ype of provider Select dental or vision 3 Enter your plan name found on your ID card These are the plan options you will see Dent a l Premier Choice Advantage Advantage Plus Choice Value Summit Summit Plus Vision Opt icar e VSP Choice VSP Choice Plus If you have the Summit or Summit Plusdental plans you will be redirected toCigna s dental provider search Enter your location information and click Search 4 You can also select Use My Locat ion This feature will automatically populate the state and zip code where you are searching Filter and sort your results 5 Now you can filter your results for locations specialties facilities languages and more Click Search each time you adjust a filter to refresh the results list That s all there is to it You will see a list of participating providers along with contact information address and the abilit y to map the location of their offices You can also download the results as a PDF to keep or take with you Search on the go In addition to being another convenient way to search for providers and facilities the EMI Health mobile app allows you to do even more Access your ID Card View and download your plan grids so you always know the benefits you have View your EOBs and search by person service date and more Update your profile information like email address password or securit y questions 24
The EMI Health Mobile App Your benefits Anytime Anywhere Provider Search Find in network providers and facilities Customer Service Need t o t alk t o a p erson No problem Call u s f rom t h e ap p Other Feat ures Access current and past issues of the Hope Health newsletter Update your profile information like email address password or securit y questions ID Card Access your ID Card from anywhere at any time EOBs View your EOBs and search by person service date and more Plan Information View and download your plan grids so you always know the benefits you have Log in Register Download the app and log in using your My EMI Health username and password If you haven t registered your account you can do so in the app or online at emihealth com Scan this QR code with your phone to download 25
Diabetes Management Your medical plan covers diabetic equipment and supplies under the major medical benefit and or Prescription Drug Pharmacy Benefit Contact customer service for the specifics of your plan Here are some common coverages Diabetic Testing Supplies Diabetic testing supplies such as blood sugar glucose test strips and lancets may be covered through your Major Medical or Prescription Drug Benefit Major Medical Benefits Coverage falls under the Medical Supplies Equipment benefit Refer to the Diabetic Testing Supplies line item of your Schedule of Benefits for your member cost share The following suppliers are participating providers on EMI Health plans If you obtain supplies through any other medical provider or facility benefits are subject to your Non Participating Provider benefit option if any Byram Healthcare 800 775 4372 Edgepark Cardinal 877 21 5 2568 JQ Medical Supply 801 942 8582 Prescription Drug Pharmacy Benefit Refer to the Prescription Drug section of your Schedule of Benefits for your member cost share The 2022 formulary includes OneTouch and Freestyle All other brands are excluded from coverage Continuous Glucose Monitoring Systems CGMS and Sensors CGMS and sensors may be covered through your Major Medical or Prescription Drug Benefit subject to preauthorization criteria and plan review Refer to the Durable Medical Equipment and Prescription Drug sections of your Schedule of Benefits for your member cost share EMI MKT G DIABETES0921 0175 26
Insulin Pump and Insulin Pump Supplies Insulin pumps are covered through your Major Medical Benefit subject to preauthorization criteria and plan review Refer to the Durable Medical Equipment section of your Schedule of Benefits for your member cost share Insulin pump supplies cartridges and infusion sets may be covered through your Major Medical or Prescription Drug Benefit Refer to the Durable Medical Equipment and Prescription Drug sections of your Schedule of Benefits for your member cost share Insulin Insulin is covered under the Prescription Drug Benefit You may receive up to a 30 day supply per retail copayment or up to a 90 day supply per mail order copayment Refer to the Prescription Drug section of your Schedule of Benefits for member cost share Preferred insulin copayments will be capped at 25 per 30 day supply and 75 per 90 day supply through the Cigna Express Scripts Patient Assurance Program Preferred insulins are Humalog Humulin and Semglee Prescription Drugs Prescription drugs are covered under the Prescription Drug Benefit This includes Glucagon GLPI agents e g Byetta Bydureon and Tradjenta and oral agents for Type 2 diabetes e g Glucophage Avandia and Amaryl Refer to the Prescription Drug section of your Schedule of Benefits for member cost share Blood sugar testing monitors glucose control solutions and weight loss medications are NOT covered under the Major Medical or Prescription Drug Benefits Questions As always we are here to help Call customer service at 800 662 5851 27
25 cap for insulin supply With the Patient Assurance Program Insulin can be expensive The high cost of insulin is a major factor in non adherence for people with diabetes These numbers show some of the concerns for people with diabetes and why EMI Health is implementing this program to help our members 25 54 5 427 Missing 1dose Admit to rationing insulin due to high monthly costs Estimated cost increase in out of pocket spending for insulin Additional medical care cost for non adherent diabetic patients Increasesrisk of eye kidney and nerve complicationsthat are otherwise avoidable But not with EMI Health The Patient Assurance Program ensures that members with diabetes will pay no more than 25 for a 30 day supply of insulin even for the high deductible plans This significantly reduces out of pocket costs allowing our members to focus on their well being instead of on the cost of their medication Higher Adherence Lower Cost Better Budget Predictabilit y Simpler Experience Common questions and answers W hat do I need t o do t o get t his reduced price As a member of EMI Health you don t have to take any additional steps to benefit from this program You will get your prescription same as you have before but you ll pay a lot less W hat if I am on a high deduct ible plan Until you meet your out of pocket maximum your monthly cost for eligible insulin products will be capped at 25 regardless of whether you are on a traditional plan or a high deductible plan Monthly cost savings with Patient Assurance Program 450 Does t his program apply t o all brands of insulin Not all insulin products are participating in this program However the following brands are participating Humalog Humulin and Semglee For specific questions about brands not in the formulary contact EMI Health Customer Service or Express Scripts 28 25 Average cost of insulin out of pocket Cost for EMI Health members EM I M KTG PAP INSULIN 0 222 1239
Appendix B Base Plan Summary Middle Plan Summary Buy Up Plan Summary MEC Dental Summary MEC Vision Summary FAQ Voluntary Life Voluntary STD Required Notices 29
Base Plan T 6500 HSA Administered by Educators Health Plans Life Accident and Health Inc EMI Health Customer Service 801 262 7475 or 1 800 662 5851 Self Funded Employee Medical Benefit Plan All services are subject to the EMI Health Maximum Allowable Charge When using a Non participating Provider the Covered Person is responsible for all fees in excess of the Maximum Allowable Charge Higginbotham Private Exchange Care Plus 2024 Contract Year Participating Non Participating T 6500 QHDHP Provider Option Provider Option GENERAL INFORMATION YOU PAY Benefit Accumulator Dependent Age Limit Out of Pocket Maximum Per Person Family Per Year Medical Deductible Per Person Family Per Year Please note Non Preauthorization Patient Penalty 7 000 14 000 6 500 13 000 Not Applicable Calendar Year 26 18 000 36 000 12 000 24 000 50 Reduction in Benefits Non Preauthorization Provider Sanction PRESCRIPTION DRUG BENEFITS If brand is purchased when generic is available member pays the copay plus the difference between the generic and the brand price 50 Reduction in Payment YOU PAY Not Applicable Participating Pharmacy up to 30 day supply Generic 20 Preferred 30 Non Preferred 50 Non Participating Pharmacy Mail Order up to 90 day supply Not Covered Generic 20 Preferred 30 Non Preferred 50 Specialty Pharmacy up to 90 day supply All fills must be purchased through Express Scripts Specialty Pharmacy 25 250 Max Specialty Pharmacy SaveOnSP Program 1 800 683 1074 http emihealth com pdf saveon pdf Must enroll to receive 0 Copay PREVENTIVE SERVICES Routine Physical Exam 1 visit per Year Routine Gynecological Exam 1 visit per Year Family History Exam 1 visit per Year Covered 100 Covered 100 Covered 100 YOU PAY Not Covered Not Covered Not Covered Routine Pap Smear Mammogram 1 per Year Routine Well Baby Exams Covered Immunizations Routine Vision Exam 1 visit per Year Covered 100 Covered 100 Covered 100 Covered 100 Not Covered Not Covered Not Covered Not Covered Routine Hearing Exam 1 visit per Year Covered 100 Not Covered PHYSICIAN PROFESSIONAL SERVICES YOU PAY Physician Office Visits primary care Physician Office Visits secondary care Physician Office Visits after hours 20 20 20 50 50 50 Physician Visits Inpatient 20 50 Physician Visits Outpatient Major Diagnostic Test CT Scan MRI NMR office Minor Diagnostic Test Radiology Lab office Minor Diagnostic Test Radiology Lab Inpatient Minor Diagnostic Test Radiology Lab Outpatient Injections office Surgery office Surgery Inpatient Surgery Outpatient 20 20 20 20 20 20 20 20 20 50 50 50 50 50 50 50 50 50 Anesthesiology office Anesthesiology Inpatient Anesthesiology Outpatient Routine Prenatal Delivery Dependent maternity included 20 20 20 20 50 50 50 50 Home Health and Hospice Care in lieu of Hospital for supplies see Medical Supplies and Equipment 20 50 Rehabilitation Therapy Outpatient physical speech occupational cardiac or pulmonary 20 visits per Year per injury illness 20 50 Chiropractic Therapy 20 visits per Year Allergy Testing 20 20 50 50 30
Higginbotham Private Exchange Care Plus 2024 Contract Year Participating Non Participating T 6500 QHDHP Provider Option Provider Option Allergy Treatment Serum 20 50 HOSPITAL FACILITY BENEFITS YOU PAY Physician Professional Services are not included in this section Medical Surgical Maternity Intensive Care semi private room 20 50 Medical Surgical Maternity Intensive Care Inpatient Ancillary 20 50 Skilled Nursing Facility 30 days per Year Admission must be within 5 days of discharge from Hospital Confinement 20 50 Medical Surgical Care Outpatient 20 50 Emergency Room ER 20 20 Major Diagnostic Test CT Scan MRI NMR Outpatient 20 50 Minor Diagnostic Test X ray Lab Inpatient 20 50 Minor Diagnostic Test X ray Lab Outpatient 20 50 Newborn 20 50 Urgent Care Clinic 20 50 Eligible Preventive Services Covered 100 Not Covered REHABILITATION THERAPY BENEFIT YOU PAY Inpatient physical speech occupational cardiac or pulmonary 40 days per person per Year 20 50 ACCIDENT AND LIFE THREATENING CONDITION YOU PAY Medical Surgical Physician Facility ER Covered as any other condition Ambulance Land Air Accident Life threatening Orthodontic Injury Treatment 20 20 Covered as a Participating Benefit to the Maximum Allowable Charge Dental Injury Treatment 20 TRANSPLANT BENEFIT YOU PAY Heart Liver Pancreas Bone Marrow Cornea Lung Kidney Covered as any other condition Not Covered MEDICAL SUPPLIES EQUIPMENT YOU PAY Diabetic Testing Supplies 90 day supply 30 50 Medical Supplies 20 50 Medical Supplies office 20 50 Durable Medical Equipment Prosthetics Orthotic Devices 20 50 Hearing Aids 2 500 per Year 20 50 Orthotic Supplies foot inserts arch supports 20 50 Growth Hormone 20 50 MENTAL HEALTH DRUG ALCOHOL TREATMENT YOU PAY Inpatient Services non residential 20 50 Residential Treatment 30 days per Year 20 50 Outpatient Services 20 50 Physician Office Visits Psychologist LCSW APRN Psychiatrist 20 50 ADDITIONAL BENEFITS YOU PAY TMJ Syndrome diagnosis non surgical treatment 20 Not Covered Orthognathic Mandibular Osteotomy 20 Not Covered Total Parenteral Nutrition TPN 20 Not Covered Initial assessment and diagnosis of Primary Infertility 20 Not Covered Reduction Mammoplasty 20 Not Covered Autism Applied Behavior Analysis 20 50 Services designated are subject to first dollar Medical Deductible Services designated premiums balance billed charges charges for services this Plan doesn t cover amounts in excess of benefit limits and penalties for failure to obtain Preauthorization do not accumulate toward your Out of pocket Maximum PROVIDER NETWORK Utah EMI Health Care Plus Texas Aetna National PPO Outside of Utah and Texas Aetna National PPO PLEASE NOTE This is a summary only and does not guarantee benefits All benefits are subject to the terms limitations and exclusions set forth in the Plan document and in the Summary Plan Description SPD handbook of the Plan Any discrepancies between this summary the SPD handbook and the Plan document are resolved in favor of the Plan document For more information including Preauthorization refer to the SPD handbook or the Plan document or contact EMI Health Customer Service Department 31
Middle Plan T 7500 Administered by Educators Health Plans Life Accident and Health Inc EMI Health Customer Service 801 262 7475 or 1 800 662 5851 Self Funded Employee Medical Benefit Plan All services are subject to the EMI Health Maximum Allowable Charge When using a Non participating Provider the Covered Person is responsible for all fees in excess of the Maximum Allowable Charge Higginbotham Private Exchange Care Plus 2024 Contract Year Participating Non Participating T 7500 Provider Option Provider Option GENERAL INFORMATION YOU PAY Benefit Accumulator Dependent Age Limit Out of Pocket Maximum Per Person Family Per Year Please note Medical Deductible Per Person Family Per Year Please note Non Preauthorization Patient Penalty 8 500 17 000 7 500 15 000 Not Applicable Calendar Year 26 17 000 34 000 15 000 30 000 50 Reduction in Benefits Non Preauthorization Provider Sanction PRESCRIPTION DRUG BENEFITS If brand is purchased when generic is available member pays the copay plus the difference between the generic and the brand price 50 Reduction in Payment YOU PAY Not Applicable Participating Pharmacy up to 30 day supply Generic 10 Preferred 45 Non Preferred 150 Non Participating Pharmacy Mail Order up to 90 day supply Not Covered Generic 20 Preferred 90 Non Preferred 300 Specialty Pharmacy up to 90 day supply All fills must be purchased through Express Scripts Specialty Pharmacy 25 250 Max Specialty Pharmacy SaveOnSP Program 1 800 683 1074 http emihealth com pdf saveon pdf Must enroll to receive 0 Copay PREVENTIVE SERVICES Routine Physical Exam 1 visit per Year Routine Gynecological Exam 1 visit per Year Family History Exam 1 visit per Year Covered 100 Covered 100 Covered 100 YOU PAY Not Covered Not Covered Not Covered Routine Pap Smear Mammogram 1 per Year Routine Well Baby Exams Covered Immunizations Routine Vision Exam 1 visit per Year Covered 100 Covered 100 Covered 100 Covered 100 Not Covered Not Covered Not Covered Not Covered Routine Hearing Exam 1 visit per Year Covered 100 Not Covered PHYSICIAN PROFESSIONAL SERVICES YOU PAY Physician Office Visits primary care Physician Office Visits secondary care Physician Office Visits after hours 40 50 75 50 75 50 Physician Visits Inpatient 20 50 Physician Visits Outpatient Major Diagnostic Test CT Scan MRI NMR office Minor Diagnostic Test Radiology Lab office Minor Diagnostic Test Radiology Lab Inpatient Minor Diagnostic Test Radiology Lab Outpatient Injections office Surgery office Surgery Inpatient Surgery Outpatient 20 20 Covered 100 20 Covered 100 Covered 100 Covered 100 20 20 50 50 50 50 50 50 50 50 50 Anesthesiology office Anesthesiology Inpatient Anesthesiology Outpatient Routine Prenatal Delivery Dependent maternity included Covered 100 20 20 20 50 50 50 50 Home Health and Hospice Care in lieu of Hospital for supplies see Medical Supplies and Equipment 20 50 Rehabilitation Therapy Outpatient physical speech occupational cardiac or pulmonary 20 visits per Year per injury illness 40 50 Chiropractic Therapy 20 visits per Year Allergy Testing 40 50 20 50 32
Higginbotham Private Exchange Care Plus 2024 Contract Year Participating Non Participating T 7500 Provider Option Provider Option Allergy Treatment Serum 20 50 HOSPITAL FACILITY BENEFITS YOU PAY Physician Professional Services are not included in this section Medical Surgical Maternity Intensive Care semi private room 20 50 Medical Surgical Maternity Intensive Care Inpatient Ancillary 20 50 Skilled Nursing Facility 30 days per Year Admission must be within 5 days of discharge from Hospital Confinement 20 50 Medical Surgical Care Outpatient 20 50 Emergency Room ER 500 500 Major Diagnostic Test CT Scan MRI NMR Outpatient 20 50 Minor Diagnostic Test X ray Lab Inpatient 20 50 Minor Diagnostic Test X ray Lab Outpatient Covered 100 50 Newborn 20 50 Urgent Care Clinic 100 50 Eligible Preventive Services Covered 100 Not Covered REHABILITATION THERAPY BENEFIT YOU PAY Inpatient physical speech occupational cardiac or pulmonary 40 days per person per Year 20 50 ACCIDENT AND LIFE THREATENING CONDITION YOU PAY Medical Surgical Physician Facility ER Covered as any other condition Ambulance Land Air Accident Life threatening Orthodontic Injury Treatment 20 50 Covered as a Participating Benefit to the Maximum Allowable Charge Dental Injury Treatment 20 TRANSPLANT BENEFIT YOU PAY Heart Liver Pancreas Bone Marrow Cornea Lung Kidney Covered as any other condition Not Covered MEDICAL SUPPLIES EQUIPMENT YOU PAY Diabetic Testing Supplies 90 day supply 90 50 Medical Supplies 20 50 Medical Supplies office Covered 100 50 Durable Medical Equipment Prosthetics Orthotic Devices 20 50 Hearing Aids 2 500 per Year 20 50 Orthotic Supplies foot inserts arch supports 20 50 Growth Hormone 20 50 MENTAL HEALTH DRUG ALCOHOL TREATMENT YOU PAY Inpatient Services non residential 20 50 Residential Treatment 30 days per Year 20 50 Outpatient Services 20 50 Physician Office Visits Psychologist LCSW APRN Psychiatrist 40 50 ADDITIONAL BENEFITS YOU PAY TMJ Syndrome diagnosis non surgical treatment 50 Not Covered Orthognathic Mandibular Osteotomy 50 Not Covered Total Parenteral Nutrition TPN 50 Not Covered Initial assessment and diagnosis of Primary Infertility 50 Not Covered Reduction Mammoplasty 50 Not Covered Autism Applied Behavior Analysis 20 50 Services designated are subject to first dollar Medical Deductible Services designated premiums balance billed charges charges for services this Plan doesn t cover amounts in excess of benefit limits and penalties for failure to obtain Preauthorization do not accumulate toward your Out of pocket Maximum PROVIDER NETWORK Utah EMI Health Care Plus Texas Aetna National PPO Outside of Utah and Texas Aetna National PPO PLEASE NOTE This is a summary only and does not guarantee benefits All benefits are subject to the terms limitations and exclusions set forth in the Plan document and in the Summary Plan Description SPD handbook of the Plan Any discrepancies between this summary the SPD handbook and the Plan document are resolved in favor of the Plan document For more information including Preauthorization refer to the SPD handbook or the Plan document or contact EMI Health Customer Service Department 33
Buy Up PlanT 2500 100 Administered by Educators Health Plans Life Accident and Health Inc EMI Health Customer Service 801 262 7475 or 1 800 662 5851 Self Funded Employee Medical Benefit Plan All services are subject to the EMI Health Maximum Allowable Charge When using a Non participating Provider the Covered Person is responsible for all fees in excess of the Maximum Allowable Charge Higginbotham Private Exchange Care Plus 2024 Contract Year Participating Non Participating T 2500 100 Provider Option Provider Option GENERAL INFORMATION YOU PAY Benefit Accumulator Dependent Age Limit Out of Pocket Maximum Per Person Family Per Year Please note Medical Deductible Per Person Family Per Year Please note Non Preauthorization Patient Penalty 5 000 10 000 2 500 5 000 Not Applicable Calendar Year 26 10 000 20 000 5 000 10 000 50 Reduction in Benefits Non Preauthorization Provider Sanction PRESCRIPTION DRUG BENEFITS If brand is purchased when generic is available member pays the copay plus the difference between the generic and the brand price 50 Reduction in Payment YOU PAY Not Applicable Participating Pharmacy up to 30 day supply Generic 10 Preferred 35 Non Preferred 150 Non Participating Pharmacy Mail Order up to 90 day supply Not Covered Generic 20 Preferred 70 Non Preferred 300 Specialty Pharmacy up to 90 day supply All fills must be purchased through Express Scripts Specialty Pharmacy 25 250 Max Specialty Pharmacy SaveOnSP Program 1 800 683 1074 http emihealth com pdf saveon pdf Must enroll to receive 0 Copay PREVENTIVE SERVICES Routine Physical Exam 1 visit per Year Routine Gynecological Exam 1 visit per Year Family History Exam 1 visit per Year Covered 100 Covered 100 Covered 100 YOU PAY Not Covered Not Covered Not Covered Routine Pap Smear Mammogram 1 per Year Routine Well Baby Exams Covered Immunizations Routine Vision Exam 1 visit per Year Covered 100 Covered 100 Covered 100 Covered 100 Not Covered Not Covered Not Covered Not Covered Routine Hearing Exam 1 visit per Year Covered 100 Not Covered PHYSICIAN PROFESSIONAL SERVICES YOU PAY Physician Office Visits primary care Physician Office Visits secondary care Physician Office Visits after hours 30 50 60 50 60 50 Physician Visits Inpatient Covered 100 50 Physician Visits Outpatient Major Diagnostic Test CT Scan MRI NMR office Minor Diagnostic Test Radiology Lab office Minor Diagnostic Test Radiology Lab Inpatient Minor Diagnostic Test Radiology Lab Outpatient Injections office Surgery office Surgery Inpatient Surgery Outpatient Covered 100 Covered 100 Covered 100 Covered 100 Covered 100 Covered 100 Covered 100 Covered 100 Covered 100 50 50 50 50 50 50 50 50 50 Anesthesiology office Anesthesiology Inpatient Anesthesiology Outpatient Routine Prenatal Delivery Dependent maternity included Covered 100 Covered 100 Covered 100 Covered 100 50 50 50 50 Home Health and Hospice Care in lieu of Hospital for supplies see Medical Supplies and Equipment Covered 100 50 Rehabilitation Therapy Outpatient physical speech occupational cardiac or pulmonary 20 visits per Year per injury illness 30 50 Chiropractic Therapy 20 visits per Year Allergy Testing 30 Covered 100 50 50 34
Higginbotham Private Exchange Care Plus 2024 Contract Year Participating Non Participating T 2500 100 Provider Option Provider Option Allergy Treatment Serum Covered 100 50 HOSPITAL FACILITY BENEFITS YOU PAY Physician Professional Services are not included in this section Medical Surgical Maternity Intensive Care semi private room Covered 100 50 Medical Surgical Maternity Intensive Care Inpatient Ancillary Covered 100 50 Skilled Nursing Facility 30 days per Year Admission must be within 5 days of discharge from Hospital Confinement Covered 100 50 Medical Surgical Care Outpatient Covered 100 50 Emergency Room ER 250 250 Major Diagnostic Test CT Scan MRI NMR Outpatient Covered 100 50 Minor Diagnostic Test X ray Lab Inpatient Covered 100 50 Minor Diagnostic Test X ray Lab Outpatient Covered 100 50 Newborn Covered 100 50 Urgent Care Clinic 75 50 Eligible Preventive Services Covered 100 Not Covered REHABILITATION THERAPY BENEFIT YOU PAY Inpatient physical speech occupational cardiac or pulmonary 40 days per person per Year Covered 100 50 ACCIDENT AND LIFE THREATENING CONDITION YOU PAY Medical Surgical Physician Facility ER Covered as any other condition Ambulance Land Air Accident Life threatening Orthodontic Injury Treatment 20 50 Covered as a Participating Benefit to the Maximum Allowable Charge Dental Injury Treatment 20 TRANSPLANT BENEFIT YOU PAY Heart Liver Pancreas Bone Marrow Cornea Lung Kidney Covered as any other condition Not Covered MEDICAL SUPPLIES EQUIPMENT YOU PAY Diabetic Testing Supplies 90 day supply 70 50 Medical Supplies Covered 100 50 Medical Supplies office Covered 100 50 Durable Medical Equipment Prosthetics Orthotic Devices Covered 100 50 Hearing Aids 2 500 per Year Covered 100 50 Orthotic Supplies foot inserts arch supports Covered 100 50 Growth Hormone Covered 100 50 MENTAL HEALTH DRUG ALCOHOL TREATMENT YOU PAY Inpatient Services non residential Covered 100 50 Residential Treatment 30 days per Year Covered 100 50 Outpatient Services Covered 100 50 Physician Office Visits Psychologist LCSW APRN Psychiatrist 30 50 ADDITIONAL BENEFITS YOU PAY TMJ Syndrome diagnosis non surgical treatment 50 Not Covered Orthognathic Mandibular Osteotomy 50 Not Covered Total Parenteral Nutrition TPN 50 Not Covered Initial assessment and diagnosis of Primary Infertility 50 Not Covered Reduction Mammoplasty 50 Not Covered Autism Applied Behavior Analysis Covered 100 50 Services designated are subject to first dollar Medical Deductible Services designated premiums balance billed charges charges for services this Plan doesn t cover amounts in excess of benefit limits and penalties for failure to obtain Preauthorization do not accumulate toward your Out of pocket Maximum PROVIDER NETWORK Utah EMI Health Care Plus Texas Aetna National PPO Outside of Utah and Texas Aetna National PPO PLEASE NOTE This is a summary only and does not guarantee benefits All benefits are subject to the terms limitations and exclusions set forth in the Plan document and in the Summary Plan Description SPD handbook of the Plan Any discrepancies between this summary the SPD handbook and the Plan document are resolved in favor of the Plan document For more information including Preauthorization refer to the SPD handbook or the Plan document or contact EMI Health Customer Service Department 35
INCLUDED IN BOTH MEC PLANS Dental Discount Plan Corporate 801 262 7475 Customer Service 800 662 5851 EMIHealth com Plan Administered by Plan Type Benefit Year Value Educators Health Plans Life Accident and Health Inc Voluntary Discount Plan Calendar Type 1 Preventive Oral Exams Cleanings X rays Fluoride Type 2 Basic Fillings Oral Surgery Type 3 Major Crowns Bridges Prosthodontics Type 4 Orthodontics Dependent children ages 7 through 18 Adults Endodontics Periodontics Sealants Space Maintainers In Network Only 20 to 70 Savings See Member Schedule Discount Only 20 to 60 Savings See Member Schedule Discount Only 20 to 50 Savings See Member Schedule Discount Only Discount Only Discount Only 20 to 50 Savings See Member Schedule Discount Only 20 to 50 Savings See Member Schedule Discount Only 20 to 60 Savings See Member Schedule Discount Only 20 to 60 Savings See Member Schedule Discount Only Waiting periods Type 2 Basic Type 3 Major Type 4 Orthodontics None None None Deductible Per Person Family Max Deductible Applies To 0 00 0 00 N A Annual Maximum Per Person Orthodontic Lifetime Maximum N A N A Network Utah Network Texas Outside Utah Value EMI Health Value Careington Fee Schedule Value The Program provides discounts only at certain health care providers for health care services the Program holder is obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the Program Member Fees are subject to change January 1st of each year Notes Fee for service discount program not an insured product 36
INCLUDED IN BOTH MEC PLANS Vision Discount Plan Corporate 801 262 7475 Customer Service 800 662 5851 EMIHealth com Plan Plan Type VSP Vision Savings Pass Voluntary or Contributory Network WellVision Exam Contact Lens Exam Retinal Screening Lenses Glass or Plastic Single Vision Lined Bifocal Lined Trifocal Polycarbonate for Children under 18 Lens Enhancements Progressive Scratch Resistant Anti Reflective Frames Sunglasses In Network VSP Choice 50 with purchase of a complete pair of prescription glasses1 15 savings on a contact lens exam2 Guaranteed pricing with WellVision Exam not to exceed 39 40 with purchase of a complete pair of prescription glasses 60 with purchase of a complete pair of prescription glasses 75 with purchase of a complete pair of prescription glasses 0 with purchase of a complete pair of prescription glasses Average savings of 20 25 Average savings of 20 25 Average savings of 20 25 25 savings when a complete pair of prescirption glasses is purchased 20 savings on unlimited non prescription sunglasses from any VSP doctor within 12 months of your last WellVision Exam Frequency Exam Lenses Frame or Contacts Eye exam is limited to once per calendar year per member Unlimited use on materials Notes VSP Vision Savings Pass is a discount vision program that offers immediate savings This is not an insurance plan 1 This cost is only available with the purchase of a complete pair of prescription glasses otherwise you ll receive 20 savings on an eye exam only 2 Applies only to contact lens exam not materials You are responsible for 100 of the contact lens material cost 37
BASIC VOLUNTARY LIFE INSURANCE Who is eligible for this insurance You must be actively working performing all normal duties of your job at least 30 hours per week Your dependent s must be performing normal activities and not be confined at home or in a hospital care facility and any child ren must be under age 26 What is Guarantee Issue The amount of insurance applied for without answering any health questions or which does not require evidence of insurability Coverage amounts over the Guarantee Issue Amount will require evidence of insurability What is Evidence of Insurability Evidence of Insurability or proof of good health may be required if you are a late entrant and or you request any additional coverage above your guarantee issue amount Can I take this insurance with me if I change jobs am no longer a member of this group In the event this insurance ends due to a change in your employment membership status with the group or for certain other reasons you or your insured spouse may have the right to continue this insurance under the Portability or Conversion provision subject to certain conditions Are there any limitations reductions or exclusions The benefits payable are based on the following Insurance benefits and guarantee issue amounts are subject to age reductions At age 65 amounts reduce to 65 At age 70 amounts reduce to 50 Life insurance benefits will not be paid if the insured s death is the result of suicide within two years from the date coverage begins If this occurs the sum of the premiums paid will be returned to the beneficiary The same applies for any future increases in coverage under this plan Information about the AD D exclusions for this plan will be included in the summary of coverage which you will receive after enrolling All exclusions may not be applicable or may be adjusted as required by state regulations This information describes some of the features of the benefits plan Benefits may not be available in all states Please refer to the certificate booklet for a full explanation of the plan s benefits exclusions limitations and reductions Should there be any discrepancy between the certificate booklet and this outline the certificate booklet will prevail Availability of benefits is subject to final acceptance and approval of the group application by the underwriting company Life insurance and accidental death dismemberment insurance are underwritten by United of Omaha Life Insurance Company 3300 Mutual of Omaha Plaza Omaha NE 68175 Policy form number 7000GM U EZ 2010 or state equivalent in NC 7000GM U EZ 2010 NC United of Omaha Life Insurance Company is licensed nationwide except New York 38
VOLUNTARY SHORT TERM DISABILITY INSURANCE Who is eligible for this insurance You must be actively working performing all normal duties of your job at least 30 hours per week How long will my benefits be paid Benefits begin after the end of the elimination period and can be payable up to the maximum benefit period as long as you remain disabled Will my benefits be reduced by other sources of income Yes depending on the type of income you receive Your benefit amount may be reduced by other sources of income such as retirement government plans other group disability plans paid family leave salary continuance sick leave settlements on payments received and no fault benefits Does this plan cover me if I become disabled due to an injury at work No your STD insurance only provides benefits for off the job coverage for disabilities due to injury or sickness Are there any limitations or exclusions The benefits payable are subject to the following Your plan is subject to a pre existing condition limitation A pre existing condition is one for which you have received medical treatment consultation care or services including diagnostic measures or if you were prescribed or took prescription medications in the predetermined time frame prior to your effective date of coverage The pre existing condition under this plan is 3 6 which means any condition that you receive medical attention for in the 3 months prior to your effective date of coverage that results in a disability during the first 6 months of coverage would not be covered Benefits are not payable for any disability or loss that Results from an act of declared or undeclared war or armed aggression Results from participation in a riot or commission of or attempt to commit a felony Results from elective or cosmetic surgery or procedure or resulting complications unless such surgery or procedure is medically necessary for the appropriate diagnosis and treatment of your injury or illness Arises out of or in the course of employment with the policyholder for benefits under any workers compensation or occupational disease law or receives any settlement from the workers compensation carrier Results whether the insured person is sane or insane from an intentionally self inflicted injury or illness or attempted suicide Occurs while incarcerated or imprisoned for any period exceeding 31 days Is solely a result of a failed drug test Is solely a result of a loss of a professional license occupation license or certification All exclusions may not be applicable or may be adjusted as required by state regulations Can I take this insurance with me if I change jobs am no longer a member of this group In the event this insurance ends due to a change in your employment membership status with the group or for certain other reasons you have the right to port your coverage to a group trust plan subject to certain conditions This information describes some of the features of the benefits plan Benefits may not be available in all states Please refer to the certificate booklet for a full explanation of the plan s benefits exclusions limitations and reductions Should there be any discrepancy between the certificate booklet and this summary the certificate booklet will prevail Benefits availability is subject to final acceptance and approval of the group application by the underwriting company Disability income insurance is underwritten by United of Omaha Life Insurance Company 3300 Mutual of Omaha Plaza Omaha NE 68175 1 800 769 7159 United of Omaha Life Insurance Company is licensed nationwide except in New York Policy form number G2018MP 39
Required Notices Women s Health and Cancer Rights Act of 1998 In October 1998 Congress enacted the Women s Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Women s Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a mastectomy is also entitled to the following benefits 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 and Prostheses and treatment of physical complications of the mastectomy including lymphedema Health plans must determine the manner of coverage in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and coinsurance amounts that are consistent with those that apply to other benefits under the plan Special Enrollment Rights This notice is being provided to ensure that you understand your right to apply for group health insurance coverage You should read this notice even if you plan to waive coverage at this time Loss of Other Coverage or Becoming Eligible for Medicaid or a state Children s Health Insurance Program CHIP If you are declining coverage for yourself or your dependents because of other health insurance or group health plan coverage you may be able to later 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 enroll within 31 days after your or your dependents other coverage ends or after the employer that sponsors that coverage stops contributing toward the other coverage If you or your dependents lose eligibility under a Medicaid plan or CHIP or if you or your dependents become eligible for a subsidy under Medicaid or CHIP you may be able to enroll yourself and your dependents in this plan You must provide notification within 60 days after you or your dependent is terminated from or determined to be eligible for such assistance Marriage Birth or Adoption If you have a new dependent as a result of a marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must enroll within 31 days after the marriage birth or placement for adoption For More Information or Assistance To request special enrollment or obtain more information contact Ticknor Enterprises 1500 W Abram Street Arlington TX 76013 682 305 7152 Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it This notice has information about your current prescription drug coverage with Ticknor Enterprises and about your options under Medicare s prescription drug coverage This information can help you decide whether or not you want to enroll in a Medicare drug plan Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice If neither you nor any of your covered dependents are eligible for or have Medicare this notice does not apply to you or the dependents as the case may be However you should still keep a copy of this notice in the event you or a dependent should qualify for coverage under Medicare in the future Please note however that later notices might supersede this notice 1 Medicare prescription drug coverage became available in 2006 to everyone with Medicare You can get this coverage through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that offers prescription drug coverage All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare Some plans may also offer more coverage for a higher monthly premium 2 Ticknor Enterprises has deter mined that the pr escr iption drug coverage offered by the BlueCross BlueShield medical plan is on average for all plan participants expected to pay out as much as the standard Medicare prescription drug coverage pays and is considered Creditable Coverage The HSA plan is not considered Creditable Coverage Because your existing coverage is on average at least as good as standard Medicare prescription drug coverage you can keep this coverage and not pay a higher premium a penalty if you later decide to enroll in a Medicare prescription drug plan as long as you later enroll within specific time periods You can enroll in a Medicare prescription drug plan when you first become eligible for Medicare If you decide to wait to enroll in a Medicare prescription drug plan you may enroll later during Medicare Part D s annual enrollment period which runs each year from October 15 through December 7 but as a general rule if you delay your enrollment in Medicare Part D after first becoming eligible to enroll you may have to pay a higher pre 40
Required Notices You should compare your current coverage including which drugs are covered at what cost with the coverage and cost of the plans offering Medicare prescription drug coverage in your area See the Plan s summary plan description for a summary of the Plan s prescription drug coverage If you don t have a copy you can get one by contacting Ticknor Enterprises at the phone number or address listed at the end of this section If you choose to enroll in a Medicare prescription drug plan and cancel your current prescription drug coverage be aware that you and your dependents may not be able to get this coverage back To regain coverage you would have to re enroll in the Plan pursuant to the Plan s eligibility and enrollment rules You should review the Plan s summary plan description to determine if and when you are allowed to add coverage Remember Keep this Cr editable Cover age notice If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage 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 whether or not you are required to pay a higher premium a penalty Date 1 1 2024 Ticknor Enterprises 1500 W Abram Street Arlington TX 76013 682 305 7152 If you cancel or lose your current coverage and do not have prescription drug coverage for 63 days or longer prior to enrolling in the Medicare prescription drug coverage your monthly premium will be at least 1 per month greater for every month that you did not have coverage for as long as you have Medicare prescription drug coverage For example if nineteen months lapse without coverage your premium will always be at least 19 higher than it would have been without the lapse in coverage For more information about this notice or your current prescription drug coverage Contact the Human Resources Department at 682 305 7152 NOTE You will receive this notice annually and at other times in the future such as before the next period you can enroll in Medicare prescription drug coverage and if this coverage changes You may also request a copy For more information about your options under Medicare prescription drug coverage Notice of HIPAA Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can access this information Please review it carefully The Health Insurance Portability and Accountability Act of 1996 HIPAA imposes numerous requirements on employer health plans concerning the use and disclosure of individual health information This information known as protected health information PHI includes virtually all individually identifiable health information held by a health plan whether received in writing in an electronic medium or as oral communication This notice describes the privacy practices of the Employee Benefits Plan referred to in this notice as the Plan sponsored by Spring Creek Enterprises hereinafter referred to as the plan sponsor The Plan is required by law to maintain the privacy of your health information and to provide you with this notice of the Plan s legal duties and privacy practices with respect to your health information It is important to note that these rules apply to the Plan not the plan sponsor as an employer 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 prescription 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 877 486 2048 If you have limited income and resources extra help paying for Medicare prescription drug coverage is available Information about this help is available from the Social Security Administration SSA online at www socialsecurity gov or you can call them at 800 772 1213 TTY users should call 800 325 0778 You have the right to inspect and copy protected health information which is maintained by and for the Plan for enrollment payment claims and case management If you feel that protected health information about you is incorrect or incomplete you may ask the Human Resources Department to amend the information For a full copy of the Notice of Privacy Practices describing how protected health information about you may be used and disclosed and how you can get access to the information contact the Human Resources Department Complaints If you believe your privacy rights have been violated you may complain to the Plan and to the Secretary of Health and Human Services You will not be retaliated against for filing a complaint To file a complaint please contact the Privacy Officer Ticknor Enterprises 1500 W Abram Street Arlington TX 76013 682 305 7152 41
Required Notices Premium Assistance Under Medicaid and the Children s Health Insurance Program CHIP If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your employer your State may have a premium assistance program that can help pay for coverage using funds from their Medicaid and CHIP programs If you or your children are not eligible for Medicaid or CHIP you won t be eligible for these premium assistance programs but you may be able to buy individual 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 you can contact your State Medicaid or CHIP office to find out if premium assistance is available If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1 877 KIDS NOW or www insurekidsnow gov to find out how to apply If you qualify you can ask the State if it has a program that might help you pay the premiums for an employer sponsored plan 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 are not already enrolled This is called a special enrollment opportunity and you must request coverage within 60 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan 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 July 31 2018 Contact your State for further information on eligibility TEXAS Medicaid Website http www gethipptexas com Phone 1 800 440 0493 To see if any more States have added a premium assistance program since July 31 2018 or for more information on special enrollment rights you can contact either U S Department of Labor Employee Benefits Security Administration www dol gov ebsa 1 866 444 EBSA 3272 U S Department of Health and Human Services Centers for Medicare Medicaid Services www cms hhs gov 1 877 267 2323 Menu option 4 Ext 61565 Continuation of Coverage Rights Under COBRA The right to COBRA continuation coverage was created by a federal law the Consolidated Omnibus Budget Reconciliation Act of 1985 COBRA COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end For more information about your rights and obligations under the Plan and under federal law you should review the Plan s Summary Plan Description or contact the Plan Administrator You may have other options available to you when you lose group health coverage For example you may be eligible to buy an individual plan through the Health Insurance Marketplace By enrolling in coverage through the Marketplace you may qualify for lower monthly premiums and lower out of pocket costs Additionally you may qualify for a 30 day special enrollment period for another group health plan for which you are eligible such as a spouse s plan even if that plan generally doesn t accept late enrollees What is COBRA continuation coverage COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event This is also called a qualifying event Specific qualifying events are listed later in this notice After a qualifying event COBRA continuation coverage must be offered to each person who is a qualified beneficiary You your spouse and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event Under the Plan qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage If you re an employee you ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events Your hours of employment are reduced or Your employment ends for any reason other than your gross misconduct If you re the spouse of an employee you ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events Your spouse dies Your spouse s hours of employment are reduced Your spouse s employment ends for any reason other than his or her gross misconduct Your spouse becomes entitled to Medicare benefits under Part A Part B or both or You become divorced or legally separated from your spouse 42
Required Notices New Health Insurance Marketplace Coverage Options and Your Health Coverage The Marketplace can help you evaluate your coverage options including your eligibility for coverage through the Marketplace and its cost Please visit HealthCare gov for more information including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area PART A General Information With key parts of the health care law now in effect there is a new way to buy health insurance the Health Insurance Marketplace To assist you in evaluating options for you and your family this notice provides some basic information about the new Marketplace and employment based health coverage offered by the employer What is the Health Insurance Marketplace The Marketplace is designed to help you find health insurance that meets your needs and fits your budget The Marketplace offers one stop shopping to find and compare private health insurance options You may also be eligible for a new kind of tax credit that lowers your monthly premium right away Open enrollment for health insurance coverage through the Marketplace begins in November for coverage starting as early as January 1 Can I Save Money on my Health Insurance Premiums in the Marketplace You may qualify to save money and lower your monthly premium but only if your employer does not offer coverage or offers coverage that doesn t meet certain standards The savings on your premium that you re eligible for depends on your household income Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace Yes If you have an offer of health coverage from your employer that meets certain standards you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer s health plan However you may be eligible for a tax credit that lowers your monthly premium or a reduction in certain cost sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards If the cost of a plan from your employer that would cover you and not any other members of your family is more than 9 5 of your household income for the year or if the coverage your employer provides does not meet the minimum value standard set by the Affordable Care Act you may be eligible for a tax credit Note If you pur chase a health plan thr ough the Mar ketplace instead of accepting health coverage offered by your employer then you may lose the employer contribution if any to the employer offered coverage Also this employer contribution as well as your employee contribution to employer offered coverage is often excluded from income for Federal and State income tax purposes Your payments for coverage through the Marketplace are made on an after tax basis 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 PART B Information About Health Coverage Offered by Your Employer Continued Here is some basic information about health coverage offered by this employer As your employer we offer a health plan to Full time associate who work a minimum of 32 hours per week and are at least 18 years of age are eligible to participate in the benefits program Enrollment must be completed within 31 days of the date of eligibility Once your enrollment is completed no changes will be allowed until the next annual open enrollment period unless you have Qualifying Life Event or your hours worked per week drop below the minimum Additional information regarding Eligibility can be found on pg 3 With respect to dependents Your eligible dependents include Your legally married spouse Your children from birth to age 26 Your unmarried dependent children of any age who are mentally or physically disabled and who are dependent on you for support Children include Natural children Legally adopted children or children place with you for adoption Stepchildren Children for whom you or your spouse are the legal guardian as long as you have the sole legal right and obligation to provide support and medical care Dependent coverage takes effect on the same date your coverage 43
Required Notices Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events The parent employee dies The parent employee s hours of employment are reduced The parent employee s employment ends for any reason other than his or her gross misconduct The parent employee becomes entitled to Medicare benefits Part A Part B or both The parents become divorced or legally separated or the child stops being eligible for coverage under the Plans as a dependent child Second qualifying event extension of 18 month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage for a maximum of 36 months if the Plan is properly notified about the second qualifying event This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies becomes entitled to Medicare benefits under Part A Part B or both gets divorced or legally separated or if the dependent child stops being eligible under the Plan as a dependent When is COBRA continuation coverage available The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred The employer must notify the Plan Administrator of the following qualifying events The end of employment or reduction of hours Death of the employee The employee s becoming entitled to Medicare benefits under Part A Part B or both For all other qualifying events divorce or legal separation of the employee and spouse or a dependent child s losing eligibility for coverage as a dependent child you must notify the Plan Administrator within 60 days after the qualifying event occurs How is COBRA continuation coverage provided Once the Plan Administrator receives notice that a qualifying event has occurred COBRA continuation coverage will be offered to each of the qualified beneficiaries Each qualified beneficiary will have an independent right to elect COBRA continuation coverage Covered employees may elect COBRA continuation coverage on behalf of their spouses and parents may elect on behalf of their children COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work Certain qualifying events or a second qualifying event during the initial period of coverage may permit a beneficiary to receive a maximum of 36 months of coverage There are also ways this 18 month period of COBRA continuation coverage can be extended Disability extension of 18 month period of COBRA continuation coverage This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred Are there other coverage options besides COBRA Continuation Coverage Yes Instead of enrolling in COBRA continuation coverage there may be other coverage options for you and your family through the Health Insurance Marketplace Medicaid or other group health plan coverage options such as a spouse s plan through what is called a special enrollment period Some of these options may cost less than COBRA continuation coverage You can learn more about many of these options at www healthcare gov If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below For more information about your rights under the Employee Retirement Income Security Act ERISA including COBRA the Patient Protection and Affordable Care Act and other laws affecting group health plans contact the nearest Regional or District Office of the U S Department of Labor s Employee Benefits Security Administration EBSA in your area or visit www dol gov ebsa Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA s website For more information about the Marketplace visit www healthcare gov Keep your Plan informed of address changes To protect your family s rights let the Plan Administrator know about any changes in the addresses of family members You should also keep a copy for your records of any notices you send to the Plan Administrator If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator timely you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage for a maximum of 29 months The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18 month period of COBRA continuation coverage Plan Contact Information Ticknor Enterprises 1500 W Abram Street Arlington TX 76013 682 305 7152 44
Required Notices 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 hourly 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 discounts Newborns and Mothers Health Protection Act NMHPA Group health plans health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the mother s or newborn s attending provider after consulting the mother from discharging the mother or her newborn earlier than 48 hours or 96 hours as applicable In any case plans issuers may not under federal law require that a provider obtain authorization from the Plan or the issuer for prescribing a length of stay not in excess of 48 hours or 96 hours Notice Regarding Wellness Program The employee wellness program is a voluntary program administered according to federal rules permitting employersponsored wellness programs that seek to improve employee health or prevent disease including the Americans with Disabilities Act of 1990 the Genetic Information Nondiscrimination Act of 2008 and the Health Insurance Portability and Accountability Act as applicable among others If you choose to participate in the wellness program you may be asked to complete a voluntary health risk assessment or HRA that asks a series of questions about your health related activities and behaviors and whether you have or had certain medical conditions e g cancer diabetes or heart disease You may also be asked to complete a biometric screening which could include a blood test for certain medical conditions such as diabetes heart disease etc You are not required to complete the HRA or to participate in the blood test or other medical examinations However employees who choose to participate in the wellness program may qualify for an incentive Although you are not required to complete a HRA or biometric screening the wellness program may specify that only employees who do so will qualify for the incentive Additional incentives may be available for employees who participate in certain health related activities or achieve certain health outcomes If you are unable to participate in any of the health related activities or achieve any of the health outcomes required to earn an incentive you may be entitled to a reasonable accommodation or an alternative standard You may request a reasonable accommodation or an alternative standard by contacting your HR dept If you choose to participate in a HRA and or biometric screening information from your HRA and results from your biometric screening will be used to provide you with information to help you understand your current health potential risks may also be used to offer you services through the wellness program You also are encouraged to share your results or concerns with your own doctor Protections from Disclosure of Medical Information We are required by law to maintain the privacy and security of your personally identifiable health information Although the wellness program may use aggregate information it collects to design a program based on identified health risks in the workplace the wellness program will never disclose any of your personal information publicly or to the employer except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program or as expressly permitted by law Medical information that personally identifies you provided in connection with the wellness program will not be provided to your supervisors or managers may never be used to make decisions regarding your employment Your health information will not be sold exchanged transferred or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements In addition all medical information obtained through the wellness program will be maintained separate from your personnel records information stored electronically will be encrypted no information you provide as part of the wellness program will be used in making any employment decision Appropriate precautions will be taken to avoid any data breach and in the event a data breach occurs involving information you provide in connection with the wellness program we will notify you immediately You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program nor may you be subjected to retaliation if you choose not to participate If you have questions or concerns regarding this notice or about protections against discrimination and retaliation please contact Human Resources 3 Employer Name Ticknor Enterprises DBA Southern Cross Senior Care 5 Employer Address 1500 W Abram Street 4 Employer Identification Number EIN 46 0731932 6 Employer Phone Number 682 305 7152 7 City Arlington 8 State TX 9 Zip Code 76013 10 Who can we contact about employee health coverage at this job Jodie Ellis 11 Phone Number 682 305 7152 12 E Mail Address Jodie ellis ticknorenterprises com 1 An employer sponsored health plan meets the minimum value standard if the plan s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs 45
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This brochure highlights the main features of Ticknor Enterprises Employee Benefits Program It does not include all plan rules details limitations and exclusions The terms of your benefit plans are governed by legal documents including insurance contracts Should there be an inconsistency between this brochure and the legal plan documents the plan documents are the final authority Ticknor Enterprises reserves the right to change or discontinue its Prepared by Higginbotham Global Reach Local Touch Single Source 1610 Shadywood Ln Mount Pleasant TX 75455 Phone 800 256 1905 Fax 903 577 1467 www higginbotham net