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Message EMPLOYEE BENEFITSGUIDE2024 - 2025An overview of the medical benefits provided byMellow Mushroom.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations and exclusions set forth in each insurance carrier's or provider's contract.Employee Benefits Guide2024 - 2025 Mellow MushroomAs an employee of Mellow Mushroom, enjoying your work and making valuable contributions to business are equally vital. The health, satisfaction and security of you and your family are important, not only to your well-being, but ultimately, in terms of achieving the goals of our organization.This benefits booklet is a summary description of your Mellow Mushroom benefit plans. If there is a discrepancy between these summaries and the written legal plan documents, the plan documents shall prevail. This booklet and plan summaries do not constitute a contract of employment.We hope this benefits booklet, along with our additional communication and decision-making tools, will help you make the best health care choices for you and your family.INTRODUCTIONEligibility & EnrollmentA full-time employee working at least 30+ hours/week on average, who has completed their measurement period, is eligible for benefits. Eligible employees will receive a link to enroll in benefits through the Employee Navigator online enrollment tool. You can enroll or make changes during our annual enrollment period or within 30 days if you experience a qualifying life event during the year. A Qualifying Life Event includes changes in marital status, employment status, birth or adoption of a child, death of a dependent, entitlement to Medicaid or Medicare, loss of other coverage or eligibility of dependents.Benefits Begin First of the month following date of eligibility Benefits End End of the month following terminationDependents Legal Spouses; Dependent children up to age 26
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations and exclusions set forth in each insurance carrier's or provider's contract.Employee Benefits Guide2024 - 2025 Mellow MushroomComparison of PlansCoverage Provided by AetnaIn-NetworkBase Plan: NC Connect 6750 Narrow NetworkBuy-Up Plan: HSA 3250Broad NetworkBenefit Period Plan Year: 12/1 – 11/30 Plan Year: 12/1 – 11/30Deductibles (Individual / Family) $6,750/$13,500Individual:$3,250Individual within a family: $6,500Family: $6,500Out-of-Pocket Max (Individual / Family)$8,750/$17,500Individual:$7,500Individual within a family: $7,500Family: $15,000Preventive Care No cost; covered at 100% No cost; covered at 100%Primary Care Visit $35 Copay 0% after deductibleSpecialist Visit $75 Copay after deductible 0% after deductibleTelehealth via Teladoc Via CVS Virtual CareCopay varies$0 Copay0% after deductible0% after deductibleUrgent Care $100 Copay 0% after deductibleEmergency Room $500 Copay after deductible $500 Copay after deductibleInpatient Visit $500 Copay after deductible 0% after deductibleOutpatient Procedure $250 Copay after deductible 0% after deductiblePharmacy / RX (30 Day Supply)Advanced Control FormularyGeneric: $3 or $10Brand and Specialty: After deductible $50/$80/20% up to $250 max/40% up to $500 maxAfter deductible:$3 or $10/$50/$80/20% up to $250 max/40% up to $500 max*Deductible waived for medicines on the Preventive Medicine listRoutine Eye Care 1 routine eye exam annually 1 routine eye exam annuallyMEDICALThe chart below is an overview of the In-Network benefits. Out-of-Network benefits are available; please review your Aetna plan documents for additional details.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations and exclusions set forth in each insurance carrier's or provider's contract.Employee Benefits Guide2024 - 2025 Mellow MushroomAnnual Deductible - The amount you must pay each year before the plan starts paying a portion of medical expenses. All family members’ expenses that count toward a health plan deductible accumulate together in the aggregate; however, each person also has a limit on their own individual accumulated expenses (the amount varies by plan).Copays and Coinsurance - These expenses are your share of cost paid for covered health care services. Copays are a fixed dollar amount and are usually due at the time you receive care. Coinsurance is your share of the allowed amount charged for a service and is generally billed to you after the health insurance company reconciles the bill with the provider.Out-of-Pocket Maximum - This is the total amount you can pay out of pocket each plan year before the plan pays 100 percent of covered expenses for the rest of the calendar year. Most expenses that meet provider network requirements count toward the annual out-of-pocket maximum, including expenses paid to the annual deductible, copays and coinsurance. MEDICAL PLAN INFORMATIONUnderstanding the full value of covered benefits allows you to take responsibility for maintaining good health and incorporating healthy habits into your lifestyle. Some examples include getting regular physical examinations, mammograms and immunizations. Through the plans offered by your employer, all covered individuals and family members are eligible to receive routine wellness services like these, at no cost; all copays, coinsurance, and deductibles are waived.Which Preventive Care Services Are Covered?The US Preventive Services Task Force maintains a regular list of recommended services that all Affordable Care Act (i.e., Health Care Reform) compliant insurance plans should cover at 100% for in-network providers. Below is a list of common services that are included in the plans offered this year:• Routine physical exam• Well baby and childcare• Well women visits• Immunizations• Routine bone density test• Routine breast exam• Routine gynecological exam• Screening for Gestational diabetes• Obesity screening and counseling• Routine digital rectal exam• Routine colonoscopy• Routine colorectal cancer screening• Routine prostate test• Routine lab procedures• Routine mammograms• Routine pap smear• Smoking cessation• Health education/counseling services• Health counseling for STDs and HIV • Testing for HPV and HIV• Screening/counseling for domestic violencePREVENTIVE CARE
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations and exclusions set forth in each insurance carrier's or provider's contract.Employee Benefits Guide2024 - 2025 Mellow MushroomA health savings account (HSA) is a health care account and savings account in one. HSA helps offset the cost of a HDHP while saving for your out-of-pocket eligible health care expenses. The HSA is your personal bank account and can be used for you and your dependents now and in the future.Why Is It A Good Idea To Have An HSA?HSAs benefit everyone who are eligible to have this account, including single individuals, families and soon-to-be retirees. You save money on taxes in three ways:• Tax-Free Deposits: The money you contribute to your HSA isn't taxed (up to the IRS annual limit)• Tax-Free Earnings: Your interest and any investment earnings grow tax-free• Tax-Free Withdrawals: The money used toward eligible health care expenses isn't taxed now or in the futureSetting aside pre-tax dollars into your HSA means you pay fewer taxes and increase your take-home pay by your tax savings. You save money on eligible expenses that you are paying for out of your pocket. The amount you save depends on your tax bracket. For example, if you are in the 30% tax bracket, you can save $30 on every $100 spent on eligible health care expenses.HSA funds roll over from year to year and accumulate in your account. There is no "use-it-or-lose-it" rule with HSAs, and you decide how and when to use your HSA funds, which can be used for eligible expenses you have now, in the future, or during retirement. Also, when you have a certain balance in your HSA, investment opportunities are available.Who is Eligible?You are eligible to contribute to an HSA if:• You are enrolled in a qualified HDHP• You are not enrolled in a copay plan such as a spouse’s non-HDHP, Medicare, Medicaid or Tri-Care• You or your spouse is not enrolled in a full purpose Health Care Flexible Spending AccountRefer to your HSA documentation for more information.HSA Contribution LimitsYou can contribute to your Inspira HSA on a pre-tax basis through payroll deductions up to the IRS statutory maximums. The IRS has established the following maximum HSA contributions:2024 Tax Year 2025 Tax Year$4,150 Individual / $8,300 Family $4,300 Individual / $8,550 FamilyIf you are age 55 and over, you may contribute an extra $1,000 catch-up contribution. HEALTH SAVINGS ACCOUNT (HSA)
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations and exclusions set forth in each insurance carrier's or provider's contract.Employee Benefits Guide2024 - 2025 Mellow MushroomEmployees and dependents enrolled in our medical plan have access to telemedicine through CVS Health Virtual Care AND Teladoc. Telehealth provides acute and behavioral care 24 hours a day via phone or video by board-certified doctors and behavioral health specialists. Telehealth is a good option for minor health problems when you can’t see your regular doctor. It is also a convenient choice when you want to speak to a counselor or therapist. Some providers will also offer telehealth appointments. Check with your provider on the availability and cost.How Does Telehealth Work?Your virtual visit will take place via phone, video call on a laptop, tablet or cellphone; or through an app. The provider will ask you the same questions you'd be asked at an in-person visit and may recommend treatment based on their findings.What Can’t Telehealth Be Used For?• Life-threatening or emergency situations • Situations in which diagnostic care (e.g., blood work, imaging or lab tests) are required• Situations of severe illness or complex conditionsHow Do I Access Telehealth?• Activate your virtual care benefit by visiting www.CVS.com/virtual-care • Create an account and confirm your details• Schedule a mental health appointment, or request on-demand care 24/7/365• Call Teladoc at:855-835-2362 or visit www.Teladoc.com/AetnaRefer to your plan documentation for more information.TELEHEALTHWhat Can Telemedicine Be Used For?General, non-life-threatening doctor's visits or consultations for acute care, such as:• Allergies• Cough, cold and flu• Diarrhea, nausea and vomiting• Ear problems• Insect bites• Sinus problems• Urinary problems• And moreMental health services for things such as:• Anxiety• Stress• Psychiatry services for medication managementDermatology is also available through Teladoc
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations and exclusions set forth in each insurance carrier's or provider's contract.Employee Benefits Guide2024 - 2025 Mellow MushroomWith your included MinuteClinic® benefit in your plan, healthier happens together. You get more options for where and when you get care. Plus, it’s a lower-cost alternative to the emergency room or urgent care.• More than 1,150 Minute Clinic locations in 35 states• $0 Copay on the NC Connect 6750 Base Plan• Discounted rate for members on the HSA 3250 Buy-Up Plan• Virtual Care options• Book an appointment onlineMinute Clinic Benefit through AetnaWhat Can Telemedicine Be Used For?Learn more about your Minute Clinic benefit:https://www.cvs.com/minuteclinic
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations and exclusions set forth in each insurance carrier's or provider's contract.Employee Benefits Guide2024 - 2025 Mellow MushroomSeeking medical care when an acute situation arises can be stressful. Knowing your options can save you time and money. Know Where To GoFind an Aetna provider/facility:Visit: www.myaetnawebsite.comScan the QR code to download the Mobile AppThis grid offers a general guide for seeking care. If you believe you are experiencing a medical emergency, go to your nearest emergency room or call 911.Where When WhyPrimary Care$Routine check-ups and screenings, preventive care, non-urgent treatment, chronic disease managementEstablishing a PCP is important for your overall wellbeingVirtual Visits$Allergies, cold, cough, flu, fever, sore throat, ear problems, diarrhea, pink eye, sinus infections, insect bites, behavioral healthAvailable 24 hours 7 days a weekMinute Clinic$Ear infections, sore throat, bronchitis, pink eye, rashes, flu shots, vaccines, screeningsWhen you can’t get into your doctor's officeUrgent Care$$Sprains and strains, small cuts, common infections, flu, fever, vomiting, sports injuries, insect bitesAfter Hours CareEmergency Room$$$Uncontrolled bleeding, shortness of breath, chest pains, stroke symptoms, major burns, head injuries, unconsciousness, poisoning, broken bonesLife Threatening Emergency
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations and exclusions set forth in each insurance carrier's or provider's contract.Employee Benefits Guide2024 - 2025 Mellow MushroomBase Plan: NC Connect 6750* Buy-Up Plan: HSA 3250Employee$111.43 $158.10Employee + Spouse$344.83 $513.64Employee + Child(ren)$309.81 $460.30Employee + Family$601.56 $904.74Your Cost Per Pay Period Carrier ResourcesBENEFIT CARRIER GROUP # PHONE NUMBER WEBSITEMedical Aetna 95725418 888-802-3862 www.myaetnawebsite.comHSA Inspira 855-384-8249https://inspirawallet.com/Page/HomeVirtual Care CVS Health Virtual Care 95725418Visit the website:www.CVS.com/virtual-care Telehealth Teladoc 95725418 855-835-2362 www.Teladoc.com/aetnaHow to access ID CardsBENEFIT CARRIER HOW TO ACCESSMedical AetnaMembers will receive an ID Card in the mail. Also accessible through the Aetna Portal Or Mobile App.*Due to ACA requirements, employees averaging under $20/hour may have a lower rate for the base plan. Please log into Employee Navigator to see your specific rates.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations and exclusions set forth in each insurance carrier's or provider's contract.Employee Benefits Guide2024 - 2025 Mellow MushroomENROLL IN YOUR BENEFITS: One step at atimeStep 1: Log InGo to www.employeenavigator.com and click Login• Returning users: Log in with the username and password you selected. 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.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 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”Step 4: Start EnrollmentsAfter clicking Start Enrollment, you’ll need to complete some personal& dependent information before moving to your benefit elections.T I PHave dependent details handy. To enroll a dependent in coverage you willneed their date of birth and Social Securitynumber.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations and exclusions set forth in each insurance carrier's or provider's contract.Employee Benefits Guide2024 - 2025 Mellow MushroomStep 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-down menu.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 the dependent’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.
HEALTH & WELFARE BENEFITS REQUIRED ANNUAL NOTICES Children’s Health Insurance Program (CHIP) Notice Women’s Health and Cancer Rights Act Notice Newborns’ Mother Health Protections Act Notice HIPAA Special Enrollment Rights Notice HIPAA Notice of Privacy Practice Notice of ExchangeMedicare Part D Creditable Coverage Notice Annual 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’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, 2024. Contact your State for more information on eligibility – ALABAMA – Medicaid Website: http://myalhipp.com/Phone: 1-855-692-5447 ALASKA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.comMedicaid Eligibility: https://health.alaska.gov/dpa/Pages/default.aspxARKANSAS – Medicaid Website: http://myarhipp.com/Phone: 1-855-MyARHIPP (855-692-7447) CALIFORNIA – Medicaid Health Insurance Premium Payment (HIPP) Program Website: http://dhcs.ca.gov/hippPhone: 916-445-8322 Fax: 916-440-5676 Email: hipp@dhcs.ca.govCOLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) Health First Colorado Website: https://www.healthfirstcolorado.com/Health First Colorado Member Contact Center: 1-800-221-3943/State Relay 711CHP+: https://hcpf.colorado.gov/child-health-plan-plusCHP+ Customer Service: 1-800-359-1991/State Relay 711Health Insurance Buy-In Program (HIBI):https://www.mycohibi.com/HIBI Customer Service: 1-855-692-6442 FLORIDA – Medicaid Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.htmlPhone: 1-877-357-3268
GEORGIA – MedicaidGA HIPP Website: https://medicaid.georgia.gov/health-insurance-premium-payment-program-hippPhone: 678-564-1162, Press 1 GA CHIPRA Website: https://medicaid.georgia.gov/programs/third-party-liability/childrens-health-insurance-program-reauthorization-act-2009-chipraPhone: 678-564-1162, Press 2 INDIANA – MedicaidHealth Insurance Premium Payment Program All other Medicaid Website: https://www.in.gov/medicaid/http://www.in.gov/fssa/dfr/Family and Social Services Administration Phone: 1-800-403-0864 Member Services Phone: 1-800-457-4584 IOWA – Medicaid and CHIP (Hawki)Medicaid Website: Iowa Medicaid | Health & Human ServicesMedicaid Phone: 1-800-338-8366 Hawki Website: Hawki - Healthy and Well Kids in Iowa | Health & Human ServicesHawki Phone: 1-800-257-8563 HIPP Website: Health Insurance Premium Payment (HIPP) | Health & Human Services (iowa.gov)HIPP Phone: 1-888-346-9562 KANSAS – MedicaidWebsite: https://www.kancare.ks.gov/Phone: 1-800-792-4884 HIPP Phone: 1-800-967-4660 KENTUCKY – MedicaidKentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspxPhone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.govKCHIP Website: https://kynect.ky.govPhone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov/agencies/dmsLOUISIANA – MedicaidWebsite: www.medicaid.la.gov or www.ldh.la.gov/lahippPhone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)MAINE – MedicaidEnrollment Website: https://www.mymaineconnection.gov/benefits/s/?language=en_USPhone: 1-800-442-6003 TTY: Maine relay 711 Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-formsPhone: 1-800-977-6740 TTY: Maine relay 711 MASSACHUSETTS – Medicaid and CHIPWebsite: https://www.mass.gov/masshealth/pa Phone: 1-800-862-4840 TTY: 711 Email: masspremassistance@accenture.comMINNESOTA – MedicaidWebsite: https://mn.gov/dhs/health-care-coverage/Phone: 1-800-657-3672 MISSOURI – MedicaidWebsite: http://www.dss.mo.gov/mhd/participants/pages/hipp.htmPhone: 573-751-2005
MONTANA – MedicaidWebsite: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084 Email: HHSHIPPProgram@mt.gov NEBRASKA – MedicaidWebsite: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178 NEVADA – MedicaidMedicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900 NEW HAMPSHIRE – MedicaidWebsite: https://www.dhhs.nh.gov/programs-services/medicaid/health-insurance-premium-programPhone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext. 15218 Email: DHHS.ThirdPartyLiabi@dhhs.nh.govNEW JERSEY – Medicaid and CHIPMedicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/Phone: 1-800-356-1561 CHIP Premium Assistance Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.htmlCHIP Phone: 1-800-701-0710 (TTY: 711) NEW YORK – MedicaidWebsite: https://www.health.ny.gov/health_care/medicaid/Phone: 1-800-541-2831 NORTH CAROLINA – MedicaidWebsite: https://medicaid.ncdhhs.gov/Phone: 919-855-4100 NORTH DAKOTA – MedicaidWebsite: https://www.hhs.nd.gov/healthcarePhone: 1-844-854-4825 OKLAHOMA – Medicaid and CHIPWebsite: http://www.insureoklahoma.orgPhone: 1-888-365-3742 OREGON – Medicaid and CHIPWebsite: http://healthcare.oregon.gov/Pages/index.aspxPhone: 1-800-699-9075 PENNSYLVANIA – Medicaid and CHIPWebsite: https://www.pa.gov/en/services/dhs/apply-for-medicaid-health-insurance-premium-payment-program-hipp.htmlPhone: 1-800-692-7462 CHIP Website: Children's Health Insurance Program (CHIP) (pa.gov)CHIP Phone: 1-800-986-KIDS (5437) RHODE ISLAND – Medicaid and CHIPWebsite: http://www.eohhs.ri.gov/Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)SOUTH CAROLINA – MedicaidWebsite: https://www.scdhhs.govPhone: 1-888-549-0820 SOUTH DAKOTA - MedicaidWebsite: http://dss.sd.govPhone: 1-888-828-0059
TEXAS – MedicaidWebsite: Health Insurance Premium Payment (HIPP) Program | Texas Health and Human ServicesPhone: 1-800-440-0493 UTAH – Medicaid and CHIPUtah’s Premium Partnership for Health Insurance (UPP) Website: https://medicaid.utah.gov/upp/Email: upp@utah.govPhone: 1-888-222-2542 Adult Expansion Website: https://medicaid.utah.gov/expansion/Utah Medicaid Buyout Program Website: https://medicaid.utah.gov/buyout-program/CHIP Website: https://chip.utah.gov/VERMONT– MedicaidWebsite: Health Insurance Premium Payment (HIPP) Program | Department of Vermont Health AccessPhone: 1-800-250-8427 VIRGINIA – Medicaid and CHIPWebsite: https://coverva.dmas.virginia.gov/learn/premium-assistance/famis-selecthttps://coverva.dmas.virginia.gov/learn/premium-assistance/health-insurance-premium-payment-hipp-programsMedicaid/CHIP Phone: 1-800-432-5924 WASHINGTON – MedicaidWebsite: https://www.hca.wa.gov/Phone: 1-800-562-3022 WEST VIRGINIA – Medicaid and CHIPWebsite: https://dhhr.wv.gov/bms/http://mywvhipp.com/Medicaid Phone: 304-558-1700 CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447) WISCONSIN – Medicaid and CHIPWebsite: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htmPhone: 1-800-362-3002 WYOMING – MedicaidWebsite: https://health.wyo.gov/healthcarefin/medicaid/programs-and-eligibility/Phone: 1-800-251-1269 To see if any other states have added a premium assistance program since July 31, 2024, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa1-866-444-EBSA (3272)U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov1-877-267-2323, Menu Option 4, Ext. 61565Paperwork 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.
Women’s Health and Cancer Rights Act Notice If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: All stages of reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; Prostheses; and Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. Therefore, the following deductibles and coinsurance apply: Base Plan: $6,750; 0% coinsurance HDHP: $3,250/$6,500; 0% coinsuranceIf you would like more information on WHCRA benefits, contact your plan administrator Katie Henderson at katie.lassiter@gmail.com. Newborns’ Mother Health Protections Act Notice Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). HIPAA Special Enrollment Notice If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. You must request enrollment within 30 days of the HIPAA qualifying event. To request special enrollment or obtain more information, contact: Katie Henderson, Accounting & Operations at katie.lassiter@gmail.com or 919.280.7061
Your Information. Your Rights. Our Responsibilities. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get a copy of health and claims records • You can ask to see or get a copy of your health and claims records and other health information we have aboutyou. Ask us how to do this.• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request.We may charge a reasonable, cost-based fee.Ask us to correct health and claims records • You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask ushow to do this.• We may say “no” to your request, but we’ll tell you why in writing within 60 days.Request confidential communications • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a differentaddress.• We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.Ask us to limit what we use or share • You can ask us not to use or share certain health information for treatment, payment, or our operations.• We are not required to agree to your request, and we may say “no” if it would affect your care.Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to thedate you ask, who we shared it with, and why.• We will include all the disclosures except for those about treatment, payment, and health care operations, andcertain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free butwill charge a reasonable, cost-based fee if you ask for another one within 12 months.Get a copy of this privacy notice • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the noticeelectronically. We will provide you with a paper copy promptly.Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person canexercise your rights and make choices about your health information.• We will make sure the person has this authority and can act for you before we take any action.File a complaint if you feel your rights are violated • You can complain if you feel we have violated your rights by contacting us using the information on page 1.• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights bysending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visitingwww.hhs.gov/ocr/privacy/hipaa/complaints/.• We will not retaliate against you for filing a complaint.
Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: • Share information with your family, close friends, or others involved in payment for your care• Share information in a disaster relief situationIf you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission: • Marketing purposes• Sale of your informationOur Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Help manage the health care treatment you receive We can use your health information and share it with professionals who are treating you. Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services. Run our organization • We can use and disclose your information to run our organization and contact you when necessary.• We are not allowed to use genetic information to decide whether we will give you coverage and the price of thatcoverage. This does not apply to long term care plans.Example: We use health information about you to develop better services for you. Pay for your health services We can use and disclose your health information as we pay for your health services. Example: We share information about you with your dental plan to coordinate payment for your dental work. Administer your plan We may disclose your health information to your health plan sponsor for plan administration. Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues We can share health information about you for certain situations such as: • Preventing disease• Helping with product recalls• Reporting adverse reactions to medications• Reporting suspected abuse, neglect, or domestic violence• Preventing or reducing a serious threat to anyone’s health or safety
Do research We can use or share your information for health research. Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Respond to organ and tissue donation requests and work with a medical examiner or funeral director • We can share health information about you with organ procurement organizations.• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you: • For workers’ compensation claims• For law enforcement purposes or with a law enforcement official• With health oversight agencies for activities authorized by law• For special government functions such as military, national security, and presidential protective servicesRespond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities • We are required by law to maintain the privacy and security of your protected health information.• We will let you know promptly if a breach occurs that may have compromised the privacy or security of yourinformation.• We must follow the duties and privacy practices described in this notice and give you a copy of it.• We will not use or share your information other than as described here unless you tell us we can in writing. Ifyou tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you. Effective Date of this Notice: 12/1/24Privacy contact: Katie Henderson, Accounting & Operations at katie.lassiter@gmail.com or 919.280.7061.
Beginning in 2014, there is a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace. 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. Each year, the open enrollment period for health insurance coverage through the Marketplace runs from Nov. 1 through Dec. 15 of the previous year. After Dec. 15, you can get coverage through the Marketplace only if you qualify for a special enrollment period or are applying for Medicaid or the Children’s Health Insurance Program (CHIP). 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 percent (as adjusted each year after 2014) 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. (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.) Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution—as well as your employee contribution to employer-offered coverage—is often excluded from income for federal and state income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact Katie Henderson, Accounting & Operations at katie.lassiter@gmail.com or 919.280.7061. 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, as well as an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area. New Health Insurance Marketplace Coverage Options and Your Health Coverage
Important Notice from Your Employer About YourPrescription 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 your Employer andabout your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone withMedicare. You can get this coverage if you join a Medicare Prescription Drug Planor join a Medicare Advantage Plan (like an HMO or PPO) that offers prescriptiondrug coverage. All Medicare drug plans provide at least a standard level ofcoverage set by Medicare. Some plans may also offer more coverage for a highermonthly premium.2. Your Employer has determined that the prescription drug coverage offered by theMedical Plan(s) is, on average for all plan participants, expected to pay out as muchas standard Medicare prescription drug coverage pays and is therefore consideredCreditable Coverage. Because your existing coverage is Creditable Coverage, youcan keep this coverage and not pay a higher premium (a penalty) if you later decideto 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, you will 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 as an active employee, your Employer's coverage will be the primary payer for your prescription drug benefit and Medicare will pay secondary.If you do decide to join a Medicare drug plan and drop your current Employer Sponsored coverage, be aware that you and your dependents 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 your Employer and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information. NOTE: You’ll get this notice eachyear. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through your Employer changes. You also may request a copy of this notice at anytime. For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: Name of Entity/Sender: Contact--Position/Office: Address: Phone Number: 12/1/24Mellow MushroomKatie Henderson, Accounting & Operations 601 W. Peace St, Raleigh, NC 27605919.280.7061
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