Aztec Chevrolet Benefits Guide : simplebooklet.com

Table of ContentsCoastal Bend offers a competitive total rewards package that includes valuable and comprehensive benefits plans. Our goal is to provide employees with tools and resources to help with your decision-making and assist you in accessing care when you need it. Key to our commitment is our Benefits Concierge, Maria Clinkscales. She is available to answer benefits questions and to help direct you to the right resources.Maria can help with questions about the enrollment process, qualified life events, lost ID cards or claims.Maria Clinkscales,Benefits ConciergeBenefits@BrightlineDealer.com888-727-8124Mon – Fri, 8:30 AM – 5:00 PM CSTABOUT THE BENEFITS GUIDEThis Benefits Guide describes the highlights of the program in non-technical language. Your specific rights to benefits under the plan are governed solely, and in every respect, by the official Plan Documents, and not information in the Guide. If there is any discrepancy between the description of the program elements as contained in this Guide and the official Plan Documents, the language of the official Plan Documents shall prevail as accurate. Some or all elements of the benefits program may be modified in the future, at any time, to meet required regulations or otherwise as decided by the employer.If you and/or your dependent(s) have Medicare or will become eligible for Medicare in the next 12 months, a federal law gives you more choices about your prescription drug coverage. Please see REQUIRED NOTICES for more details.1Welcome2Terms & Definitions3Eligibility & Enrollment4Medical and Rx5Mobile App6Virtual Visits – MD Live8Health Reimbursement HRA10freshbenies Health Advocate11SIS Gap Insurance13Dental14Vision15Basic & Voluntary Life16Supplemental Benefits17Steps to Enroll in Benefits19Required Notices26ContactsWelcome To Your 2024-2025 Benefits

Page 3

Terms and DefinitionsBenefits ConciergeA resource for employees to answer questions related to enrollment, benefits, ID cards or logging into the insurance portals.Always a good starting point when employees need assistance. If more in-depth service related to claims, billing, or providers is needed, the Concierge will enlist assistance for the member from the Health Advocate.CoinsuranceYour share of the costs of a covered medical service (typically after the deductible is met) calculated as a percent of the allowed amount for the service. For example, if your plan has a 30% coinsurance rate, the Carrier will pay 70% of the allowed amount while you pay 30% until you reach the Out-of-Pocket Maximum.CopaymentA fixed amount that you pay at the time of service. Copays are most common for doctor office visits, urgent care visits, emergency room, and prescription drugs. In some cases, you may be responsible for paying a copay as well as percentage of the remaining charges.DeductibleThe amount you pay before the insurance carrier starts sharing the expense of your medical care. Major medical expenses such as inpatient/outpatient surgeries, MRIs, and CT scans typically apply to the deductible.Explanation of Benefits (EOB)Commonly referred to as an "EOB". The EOB is an extremely useful document as it explains how the insurance carrier processed your claim. It shows the billed charges from the provider, the network discount applied, and what the resulting Negotiated Rate is. ( Provider Charge - Network Discount = Negotiated Rate ) It also shows whether the service was applied to your deductible or paid as a copay. It is not a bill, but merely an explanation of how the insurance carrier paid your claim.Health Maintenance Organization (HMO) A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. In-Network ProviderA provider who has a contract with your health insurer or plan to provide services to you at a discount and have agreed to accept reduced fees for services provided to plan members. Using in-network providers will cost you less money. Negotiated/Contracted RateWhen a Provider (doctor, facility, pharmacy or hospital ) contracts with an insurance carrier, they are considered In-Network. Part of the contract states that the provider will accept a lower payment (lower than what they normally charge) from the insurance carrier as payment in full. This lower payment is the Negotiated Rate.Out-of-Pocket MaximumThe most you will pay for covered medical expenses during your deductible period and then coverage is 100% for the remainder of the year.Preferred Provider Organization (PPO)A PPO is a type of insurance network where you may choose to obtain care in or out of your network. If you choose to visit a “Preferred” or “In-Network” provider, your out-of-pocket expenses will be significantly less than if you visit a provider outside your network. Preventive CareMedical treatments performed with the intention of preventing a health issue. For example, vaccinations and age-appropriate screenings are typically considered to be preventive.

Page 4

Who is Eligible?Full-time employees who work 30 hours or more per week are eligible to enroll in the benefits outlined in this Guide. In addition, the following family members are eligible to participate:Your legal spouseYour eligible child(ren) up to age 26 for medical, dental or vision coverage (natural children, stepchildren, legally-adopted children, and child(ren) for whom you are the court-appointed guardian); other coverage may have different age limits.Physically or mentally disabled children of any age who are incapable of self-support. Proof of disability may be requested.Qualified Life Events include:• Marriage, Divorce, Legal Separation• Birth or adoption of a child• Change in child’s dependent status• Death of a spouse, child or other qualified dependent• Change in employment status or a change in coverage under another employer-sponsored plan• Dependent loses eligibility due to age New hires: You will become eligible for benefits the 1st day of the month following 60 days of employment. The benefits elected will be effective through August 31, 2025. Current employees:Open Enrollment occurs each year, this is the time for you to make any changes. Benefits elected during Open Enrollment will be effective September 1, 2024 – August 31, 2025. How to Make Changes:Your elections are intended to remain in place until the next open enrollment. If you experience a qualified life event, you must contact Human Resources within 30 days of the event. Eligibility & EnrollmentCoastal Bend employees will make their elections on Employee Navigator. All eligible employees need to login to submit, whether or not they are electing benefits. Before beginning enrollment, please have all pertinent information available for both yourself and any dependent(s) you want to enroll. Information such as, dates of birth, and social security numbers, will be required along with beneficiary designations. During the enrollment process, you will have an opportunity to add the dependents you want to be covered. Each benefit election is independent, meaning you can enroll dependents in certain benefits and not enroll them in other benefits.Please remember that the elections you make must stay in place through the entire plan year unless you experience a Qualified Life Event.How to Enroll:

Page 5

MedicalSummary of Benefits and Coverage documents are available upon request to the Human Resources department.Medical benefits are offered through BlueCross BlueShield of Texas. FIND A NETWORK PROVIDER: https://www.bcbstx.com/star/getting-care/find-a-provider All benefits accumulate on a calendar year basis and start over each January 1stCoverage LevelMTBAB044 – LOW PLAN (HMO)Rates per Bi-Weekly Pay PeriodMTBCB044 – HIGH PLAN (PPO)Rates per Bi-Weekly Pay PeriodEmployee Only$54.71 $88.55Employee/Spouse$261.13 $343.72Employee/Child(ren)$175.53 $237.90Employee/Family$381.96 $493.08Plan MTBAB044 – LOW PLAN MTBCB044 – HIGH PLANNetwork Blue Advantage - HMO Blue Choice - PPO(You Pay) (You Pay)Calendar Year Deductible(Individual | Family)$6,000 | $15,800 $6,000 | $15,800Coinsurance Percentage 20% 20%Out-of-Pocket Maximum(Individual | Family)Includes deductible and copays$8,150 | $16,300then plan pays 100%$8,150 | $16,300then plan pays 100%Preventive Care No charge No chargePrimary Care Office Visit $40 copay $40 copaySpecialist Office Visit $80 copay $80 copayTelehealth Visit $0 copay $0 copayLabs and Imaging 20% after deductible 20% after deductibleEmergency Room $500 copay + 20% after deductible $500 copay + 20% after deductibleUrgent Care $75 copay $75 copayOutpatient Care 20% after deductible 20% after deductibleInpatient Care 20% after deductible 20% after deductibleTier 1 – Generic Preferred Rx $0 copay $0 copayTier 2 – Generic Non-Preferred Rx $10 copay $10 copayTier 3 – Brand Preferred Rx $50 copay $50 copayTier 4 – Brand Non-Preferred Rx $100 copay $100 copayTier 5 – Specialty Preferred Rx $150 copay $150 copayTier 6 – Specialty Non-Preferred Rx $250 copay $250 copayOut-of-Network BenefitsCalendar Year Deductible(Individual | Family)Not Covered $10,000 | $20,000Coinsurance Percentage Not Covered 50%Out-of-Pocket Maximum(Individual | Family)Not Covered Unlimited

Page 6

* Availability varies by device.**Message and data rates may apply. Terms and conditions and privacy policy at bcbstx.com/member/account-access/mobile/text-messaging.Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation,a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield AssociationWe’re with you wherever you go727545.0523Download the Blue Cross and Blue Shield of Texas (BCBSTX) App to manage your health wherever you are.• Find an in-network doctor, hospital or urgent care facility• Access your claims, coverage and deductible information• View or print your member ID card• Log in securely with your fingerprint or face recognition*• View your Explanation of BenefitsThen, Manage YourPreferencesIn the BCBSTXApp:• Update your profile with your mobile number.• Set your notification preferences to text.Choose the messages and information you want to get:• Claims, prior authorization or referral updates• New documents to review• Secure message notifications• Find out about new benefits and servicesAvailable in SpanishReady to get started? Text BCBSTXAPP to 33633**to get the app.

Page 7

Page 8

Why Virtual Visits?The Virtual Visits benefit is a convenient alternative fortreatment of more than 80 health conditions, including:• 24/7 access to an independentlycontracted, board-certified doctor or therapistAccess via phone, online video or mobile app from almost anywhereAverage wait time of less than20 minutesDoctors can send e-prescriptions to your local pharmacy•••AllergiesCold/FluFever•••HeadachesNauseaSinus infections•Virtual Visits sessions with licensed behavioral healththerapists are available by appointment. Get virtual care for:•••••DepressionEating disordersADHD•••Substance use disordersTrauma and PTSDAutism spectrum disorderFirst, call your doctor’s office; they may also offer telehealth consultations by phone or online video.If you have any questions about this or any other BCBSTX benefit, please call the number on the back of your ID card.Activate your VirtualVisits account today:••••Call 888-680-8646Go to MDLIVE.com/bcbstxText BCBSTX to 635-483Download the app

Page 9

Page 10

Page 11

Page 12

Page 13

Page 14

.DentalHIGH PLAN(In network, you pay:)LOW PLAN(In network, you pay:)Calendar Year Deductible (Individual/Family)$50 / $150 $50 / $150Calendar Year Maximum Benefit (per person)$2,000 $1,500TYPE A - Preventive Services Exams, cleanings, sealants0% - no deductible 0% - no deductibleTYPE B - Basic Services Fillings, extractions20% after deductible 20% after deductibleTYPE C - Major Services Crowns, dentures50% after deductible 50% after deductibleTYPE D - OrthodontiaBraces – child only to age 1950% after deductible to $2,000 Lifetime Maximum Benefit50% after deductible to $1,000 Lifetime Maximum BenefitPeriodontics / Endodontics Basic / Basic Major / MajorDental benefits will be offered through Dental Select. The PPO plan lets you choose any provider you want, however, when you use an in-network dentist your out-of-pocket expenses will be less. FIND A DENTIST: DentalSelect Providers then select the PLATINUM network.Rates per Bi-Weekly Pay PeriodPlat 1HIGH PLANPlat 2LOW PLANEmployee Only$13.03 $9.60Employee/Spouse$27.19 $20.00Employee/Child(ren)$29.39 $21.45Employee/Family$45.82 $33.48Dental RatesAll benefits accumulate on a calendar year basis and start over each January 1st.

Page 15

.VisionIn-Network(you pay)Out-of-Network(reimbursement)Schedule for Exams (frequency) Once every 12 months Once every 12 monthsPayment Amount for Exams $10 copay Up to $35Schedule for Lenses or Contact Lenses (frequency)Once every 12 months Once every 12 monthsPayment Amount for LensesSingleBifocalTrifocalStandard Progressive$10 copay$10 copay$10 copay$75 copayUp to $25Up to $40Up to $55Up to $40Contact Lenses (in lieu of glasses)ConventionalDisposableMedically NecessaryApplies to individuals whose vision cannot be corrected with glasses.$0 copay, $120 allowance15% off balance over $120$0 copay, $120 allowance$0 Copay – Paid in FullUp to $100Up to $100Up to $200Frames$0 copay$100 allowance + 20% off balance over $100Up to $50Schedule for Frames (frequency) Once every 12 Months Once every 12 MonthsVision RatesVision coverage is available through DentalSelect, utilizing the VSP network. With the Vision Plan, you can receive care from any licensed eye care professional. However, if you seek treatment from an in-network provider, you receive a higher level of benefits and there are no claim forms to file. Click here to https://www.dentalselect.com/find-a-provider/#/ or call 800-999-9789.All benefits accumulate on a 12 months basis from date of service.Rates per Bi-Weekly Pay PeriodEmployee Only$4.12Employee/Spouse$8.82Employee/Child(ren)$9.51Employee/Family$13.58

Page 16

Basic Life and AD&DCoastal Bend provides all full-time employees with Basic Life and Accidental Death & Dismemberment coverage at no cost. Coverage amount is shown below and reduces by 35% at age 65 and by 50% at Age 70.Voluntary Life and AD&D You may purchase Voluntary Life and AD&D for yourself, your spouse and/or your dependent children. You must elect coverage for yourself in order to elect for any dependents. Optional Life is paid for via payroll deductions on an after-tax basis.During your new-hire enrollment period, you may elect Voluntary Life and AD&D up to the Guaranteed Issueamount without having to submit proof of good health. If you do not elect during your initial enrollment,any future enrollment requests will be subject to proof of good health (medical underwriting) and youmay or may not be approved.For employees currently enrolled, you may increase your amount up to the Guarantee Issue amount duringyour annual open enrollment period without medical underwriting.Voluntary Lifeand AD&DEmployee Spouse Child(ren)Benefit Increments $10,000 $5,000Birth to 15 days: $100Age 15 days to 6 months: $100Age 6 months to 26 years: $5,000 or $10,000Guarantee Issue $100,000 $25,000 Full BenefitMaximum Benefit $500,000$250,000Cannot exceed 50% of Employee Amount$10,000Age ReductionBy 35% at age 65 By 35% at age 65N/ABy 50% at age 70By 50% at age 70If the loss of life is the result of an accident, your beneficiary will receive double payment under this policy. The dismemberment provision provides a scheduled payment of benefits to you for bodily dismemberment, such as loss of an arm or foot, loss of the sight of an eye, loss of hearing, etc.Basic Life Benefit AmountEmployee Flat $25,000Beneficiary Designation:Your beneficiary is the person who will receive your Life and AD&D insurance benefits in the event of your death. It is important that your beneficiary designation be clear so that there will be no questions as to your meaning. You can change your beneficiaries at any time during the year. You are automatically the beneficiary for spouse and child coverages.

Page 17

Page 18

STEPS TO ENROLL IN YOUR BENEFITSStep 1: LogInGo to www.employeenavigator.com and click Login• Returning users: Log in with the username and password youselected. Click Reset a forgotten password.• First time users: Click on your Registration Link in the email sent toyou by your admin or Register as a new user. Create an account and create your own username and password.Step 2: Welcome!After you login click Let’s Begin to complete your required tasks.Step 4: Start EnrollmentsAfter clicking Start Enrollment, you’ll need to complete some personal& dependent information before moving to your benefitelections.T I PHave dependent details handy. To enroll a dependent in coverage you willneed their date of birth and Social Securitynumber.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 Pif you hit “Dismiss, complete later” you’ll be taken to your Home Page. You’ll still be able to start enrollments again by clicking “StartEnrollments”Company ID: AztChe2022

Page 19

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!You can login to review your benefits 24/7Step 7: Review & Confirm ElectionsReview the benefits you selected on the enrollment summarypageto 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 PIf you miss a step, you’ll see Enrollment Not Complete inthe progress bar with the incomplete steps highlighted. Click on any incomplete steps to complete them.Click Save & Continue at the bottom of each screen to save yourelections.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-downmenu.Step 6: FormsIf 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 thosedetails.Step 5: Benefit ElectionsTo enroll dependents in a benefit, click the checkbox next to thedependent’sname 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.

Page 20

Required NoticesThe Benefits Guide contains required notices for all participants in a group-sponsored health plan. The following notices are included in this Guide. Please review each notice to see how it may affect coverage for your or your family.Premium Conversion Plan – Illustrates how participation in this tax-savings plan can result in lower premiums deducted from pay for employee benefits.Medicare Part D Notice – Provides information about how your current prescription drug coverage under the health care plan is affected and your options for coverage once you become eligible for Medicare.Newborn and Mothers Health Protection Notice – Describes federal laws that govern benefits for hospital stays for mothers following the birth of a child. Women’s Health and Cancer Rights – Summarizes benefits available under your medical plan if you had or are going to have a mastectomy. Notice of Special Enrollment Rights – Explains when you can enroll in the healthcare plan due to special circumstances. 60-Day Special Enrollment Period - Describes a special 60-day timeframe to elect or discontinue coverage. CHIP Notice – Provides information about Premium Assistance under Medicaid and the Children’s Health Insurance Program.

Page 21

Premium Conversion – Pre-Tax DeductionsThe purpose of the Premium Conversion Plan is to allow you to purchase coverage with pre-tax dollars.The advantage of this plan is that you pay no federal taxes on the contributions you make. This means ahigher take home pay for you than if you purchased these same benefits with after-tax dollars. You are automatically enrolled in this plan for applicable payroll deductionsHere is an example of the annual savings from a Premium Conversion Plan:SAMPLEWITH PRE-TAX WITHOUT PRE-TAXGross Annual SalaryGross Monthly Salary$50,000$4,167$50,000$4,167Pre-Tax Family Medical Plan Monthly Contributions- $1,026 $0Pre-Tax Family Dental PPO Contributions- $91 $0Taxable MonthlyIncome $3,050 $4,167FICA Tax (at 7.65%) - $233 - $319Federal Income Tax (at 15%) - $458 - $625NetIncome $2,359 $3,223After Tax Family Medical Contributions $0 - $1,026After Tax Family Dental Contributions $0 - $91Take HomePay $2,359 $2,106MonthlyDiﬀerence: $253AnnualSavings: $3,036Premium Conversion Participation RulesWith pre-tax contributions, you are required by the IRS to make all enrollment elections prospectively for the plan year and cannot change the elections until the following enrollment period unless you experience a qualiﬁed “life event” such as:• Change in employee’s legal marital status (marriage, divorce).• Change in number of tax dependents (birth, adoption, placement for adoption).• Termination or commencement of employment by the employee, spouse or dependent.• Change in the employee’s, spouse’s or dependent’s work schedule that would impact the individual’s eligibility for coverage.• Dependent satisﬁes or ceases to satisfy dependent eligibility requirements.• Change in residence or worksite of employee, spouse or dependent that would impact theindividual’s eligibility for coverage.• Signiﬁcant change in the health care cost for the employee or spouse attributable to the spouse’semployment.• HIPAA special enrollment rights (acquisition of new dependents or loss of other coverage).• Mid-year eligibility for, or loss of, Medicare or Medicaid.• Commencing or returning from unpaid leave, such as FMLA.• Spouse and Employee “mismatched” enrollment period.

Page 22

Required NoticesMedicare Part D NoticeImportant Notice from Coastal Bend About Your Prescription Drug Coverage and MedicareThis Notice Applies to You (or Dependent) ONLY if such person is (1) enrolled in a group medical plan offered byCoastal Bend AND (2) eligible for Medicare.Please read this notice carefully and keep it where you can find it. This notice has information about yourcurrent prescription drug coverage with Coastal Bend and about your options under Medicare’sprescription drug coverage. This information can help you decide whether or not you want to join aMedicare drug plan. If you are considering joining, you should compare your current coverage, includingwhich drugs are covered at what cost, with the coverage and costs of the plans offering Medicareprescription drug coverage in your area. Information about where you can get help to make decisionsabout your prescription drug coverage is at the end of this notice.There are two importantthings you need to know about your currentcoverage and Medicare’s prescriptiondrug coverage:1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can getthis coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMOor PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level ofcoverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.2. Coastal Bend has determined that the prescription drug coverage offered by the Coastal Bend EmployerHealth Plan is, on average for all plan participants, expected to pay out as much as standard Medicareprescription drug coverage pays and is therefore considered Creditable Coverage. Because your existingcoverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) ifyou later decide to join a Medicare drug plan.When Can You Join A Medicare Drug Plan?You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.However, if you lose your current creditable prescription drug coverage, through no fault of your own, youwill also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?If you decide to join a Medicare drug plan, your Coastal Bend coverage will not be affected. IF you dodecide to join a Medicare drug plan and drop your current Coastal Bend coverage, be aware that you andyour dependent(s) may not be able to get this coverage back.When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?You should also know that if you drop or lose your current coverage with Coastal Bend and don’t join aMedicare drug plan within 63 continuous days after your current coverage ends, you may pay a higherpremium (a penalty) to join a Medicare drug plan later.If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premiummay go up by at least 1% of the Medicare base beneficiary premium per month for every month that you didnot have that coverage. For example, if you go nineteen months without creditable coverage, your premium

Page 23

Required Noticesmay consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to paythis higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, youmay have to wait until the following October to join.For More Information About This Notice or Your Current Prescription Drug CoverageContact the person listed below for further information. NOTE: You’ll get this notice each year. You will alsoget it before the next period you can join a Medicare drug plan, and if this coverage through Coastal Bend changes. You also may request a copy of this notice at any time.For More Information About Your Options Under Medicare Prescription Drug CoverageMore detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also becontacted directly by Medicare drug plans.For more information about Medicare prescription drug coverage:• Visit www.medicare.gov• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the“Medicare & You” handbook for their telephone number) for personalized help• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.If you have limited income and resources, extra help paying for Medicare prescription drug coverage isavailable. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov,or call them at 1-800-772-1213 (TTY 1-800-325-0778).Remember: Keep this Creditable Coverage notice. If you decide to join one of theMedicare drug plans, you may be required to provide a copy of this notice when you jointo show whether or not you have maintained creditable coverage and, therefore,whether or not you are required to pay a higher premium (a penalty).Date:Name of Entity/Sender: Contact--Position/Office:Address:Phone Number:September 1, 2024Aztec ChevroletSusan Dobra772 Hwy 181 N, Beeville, TX 78102361-358-1681

Page 24

Required NoticesNEWBORN AND MOTHER HEALTH PROTECTION ACT NOTICEGroup health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospitallength of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginaldelivery, or less than 96 hours following a cesarean section.However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with themother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plansand issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuerfor prescribing a length of stay not in excess of 48 hours (or 96 hours).WOMEN’S HEALTH AND CANCER RIGHTS ACTIf you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Healthand Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be providedin a manner determined in consultation with the attending physician and the patient, for:• All stages of reconstruction of the breast on which the mastectomy wasperformed;• Surgery and reconstruction of the other breast to produce a symmetrical appearance;• Prostheses; and• Treatment of physical complications of the mastectomy, including lymphedema.These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgicalbenefits provided under this plan.NOTICE OF SPECIAL ENROLLMENT RIGHTSIf you are declining enrollment for yourself or your dependents (including your spouse) because of other health insuranceor group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or yourdependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverageends (or after the employer stops contributing toward the other coverage).In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may beable to enroll yourself and your dependents in Coastal Bend medical coverage by contacting the Benefits Specialist torequest enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.60-DAY SPECIAL ENROLLMENT PERIODIf you are declining enrollment for yourself or your dependents (including your spouse) while coverage under Medicaid ora state Children’s Health Insurance Program (CHIP) is in effect, you may be able to enroll yourself and your dependents inthis plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within60 days after your or your dependents’ Medicaid or CHIP coverage ends. If you or your dependents (including your spouse)become eligible for a state premium assistance subsidy from Medicaid or a CHIP program with respect to coverage underthis plan, you may be able to enroll yourself and your dependents (including your spouse) in this plan. However, you mustrequest enrollment within 60 days after you or your dependents become eligible for the premium assistance.

Page 25

Required Notices – CHIP Notice Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). __________________________________________________________________________________________________________________________________ If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2023. Contact your State for more information on eligibility – ALABAMA – Medicaid, http://www.myalhipp.com Phone: 1‐855‐692‐5447 ALASKA – Medicaid, http://dhss.alaska.gov/dpa/Pages/medicaid/default.as px, 1-866-251-4861, Customer Service@MyAKHIPP.com ARKANSAS – Medicaid, http://myarhipp.com/, 1-855-692-7447 CALIFORNIA – Medicaid, http://dhca.gov/hipp, 916-445-8322, hipp@dhcs.ca.gov COLORADO – Medicaid and CHP+ , https://www.healthfirstcolorado.com/, 1-800-221-3943, https://www.colorado.gov/hcpf/child- health-plan-plus, 1-800-359-1991 FLORIDA – Medicaid, https://www.flmedicaidtplrecovery.com/hipp/index.html, 1‐877‐357‐3268 GEORGIA – Medicaid, https://medicaid.georgia.gov/health- insurance-premium-payment-program-hipp 678-564-1162 4 INDIANA – Medicaid, http://www.in.gov/fssa/hip/, 877-438-4479 or https://www.in.gov/medicaid/, 800-457-4584 IOWA – Medicaid and CHIP, https://dhs.iowa.gov/ime/members : 1-800-338-8366 , Hawki: http://dhs.iowa.gov/Hawki, 1-800-257-8563 HIPP https://dhs.iowa.gov/ime/members/medicaid-a-to- z/hipp, 1-888-346-9562 KANSAS – Medicaid, https://www.kancare.ks.gov/ , 1-800-792-4884 KENTUCKY – Medicaid https://chfs.ky.gov/agencies/dms/member/Pages/kihi pp.aspx, 1-855-459-6328, KIHIPP.PROGRAM@ky.gov, : 1-877-524-4718, https://chfs.ky.gov LOUISIANA – Medicaid www.medicaid.la.gov or www.ldh.la.gov/lahipp, : 1-888-342-6207 or 1-855-618-5488 (LaHIPP) MAINE – Medicaid, https://www.maine.gov/dhhs/ofi/applications-forms, or 1‐800‐442‐6003 TTY: Maine relay 711 MASSACHUSETTS ‐ Medicaid and CHIP http://www.mass.gov/MassHealth, or 1‐800‐462‐1120 MINNESOTA – Medicaid: https://mn.gov/dhs/people-we-serve/children-and- families/health-care/health-care-programs/programs-and- services/other-insurance or 1‐800‐657‐3739 MISSOURI – Medicaid, http://www.dss.mo.gov/mhd/participants/pages/hipp.htm or 573‐751‐2005

Page 26

MONTANA – Medicaid, http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP or 1‐800‐694‐3084 NEBRASKA – Medicaid, http://www.ACCESSNebraska.ne.gov or 1‐855‐632‐7633 Omaha 402-595-1178 NEVADA – Medicaid, http://dwss.nv.gov/, Medicaid 1‐800‐992‐0900 NEW HAMPSHIRE – Medicaid, https://www.dhhs.nh.gov/oii/hipp.htm or 603‐271‐5218 NEW JERSEY ‐ Medicaid and CHIP, Medicaid http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid 1‐609‐631‐2392, CHIP http://www.njfamilycare.org/index.html or 1‐800‐701‐0710 NEW YORK – Medicaid https://www.health.ny.gov/health_care/medicaid/ or 1‐800‐541‐2831 NORTH CAROLINA ‐ Medicaid http://www.ncdhhs.gov/dma or 919‐855‐4100 NORTH DAKOTA – Medicaid, http://www.nd.gov/dhs/services/medicalserv/medicaid/ or 1‐844‐854‐4825 OKLAHOMA ‐ Medicaid and CHIP http://www.insureoklahoma.org or: 1‐888‐365‐3742 OREGON –Medicaid http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html :or 1‐800‐699‐9075 PENNSYLVANIA ‐ Medicaid, https://www.dhs.pa.gov/Services/Assistance/Pages/HIPP- Program.aspx or 1‐800‐692‐7462 RHODE ISLAND ‐ Medicaid and CHIP, www.eohhs.ri.gov or 401‐462‐5300 SOUTH CAROLINA ‐ Medicaid http://www.scdhhs.gov or 1‐888‐549‐0820 SOUTH DAKOTA ‐ Medicaid http://dss.sd.gov or 1‐888‐828‐0059 TEXAS – Medicaid, http://www.gethipptexas.com/ 1‐800‐440‐0493 UTAH ‐ Medicaid and CHIP, Medicaid https://medicaid.utah.gov/, CHIP http://health.utah.gov/chip 1‐877‐543‐7669 VERMONT‐ Medicaid, http://www.greenmountaincare.org/, Phone: 1‐800‐250‐8427 VIRGINIA ‐ Medicaid and CHIP, https://www.coverva.org/en/famis-select . https://www.coverva.org/en/hipp or Medicaid 1-800-432-5924, CHIP 1-800-432-5924 WASHINGTON ‐ Medicaid, https://www.hca.wa.gov/ 1-800-562-3022 WEST VIRGINIA-Medicaid and CHIP, https://dhhr.wv.gov/bms/ http://mywvhipp.com/ Medicaid 304-558-1700, CHIP 1-855-MyWVHIPP (1-855-699- 8447) WISCONSIN – Medicaid and CHIP, https://www.dhs.wisconsin.gov/badgercareplus/p- 10095.htm or 1‐800‐362‐3002 WYOMING – Medicaid, https://health.wyo.gov/healthcarefin/medicaid/programs-and-eligibility/ or 1-800-251-1269 To see if any other states have added a premium assistance program since July 31, 2023, or for more information on special enrollment rights, contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137. OMB Control Number 1210-0137 (expires 1/31/2026) Required Notices – CHIP Notice

Page 27

Below is contact information for our benefits carriers and vendors. If needed, feel free to contact them directlyor our Benefits Concierge, Maria Clinkscales. She is available to help with any questions or concerns.ContactsBenefits ConciergeMaria ClinkscalesBenefits@BrightlineDealer.com888-727-8124freshbenies Health Advocacy with AlightHealth Advocatefreshbenies@alight.com877-412-3108MedicalBlueCross BlueShield of Texaswww.bcbstx.com 800-531-4456HRA – Health Reimbursement ArrangementD.K. Youngwww.dkyoung.com210-558-0999Dental & VisionDentalSelectwww.dentalselect.com800-999-9789Basic and Voluntary Life and AD&DDearbornwww.dearbornnational.com800-778-2281Supplemental InsuranceColonialwww.colonial.com800-325-4368SIS Gap InsuranceSpecial Insurance ServicesFax 800-767-6811800-767-6811Human ResourcesSusan Dobraaztec0507@yahoo.com361-358-1681

Aztec Chevrolet Benefits Guide

Page 1

Page 2