Wathen Deshong Junker : simplebooklet.com

2Required NoticeIMPORTANT: A fixed indemnity policy, NOT health insuranceThis fixed indemnity policy may pay you a limited dollar amount if you’re sick or hospitalized. You’re still responsible for paying the cost of your care.The payment you get isn’t based on the size of your medical bill.There might be a limit on how much this policy will pay each year.This policy isn’t a substitute for comprehensive health insurance.Since this policy isn’t health insurance, it doesn’t have to include most federal consumer protections that apply to health insurance.Looking for comprehensive health insurance?Visit HealthCare.govor call1-800-318-2596(TTY: 1-855-889-4325) to find health coverage options.To find out if you can get health insurance through your job, or a family member’s job, contact the employer.Questions about this policy?For questions or complaints about this policy, contact your state Department of Insurance. Find their number on the National Association of Insurance Commissioners’ website (naic.org) under “Insurance Departments.”If you have this policy through your job, or a family member’s job, contact the employer.Availability of Summary Health Information Our Employee Benefits Program offers two health coverage options. To help you make an informed choice, a Summary of Benefits and Coverage (SBC) is available, which summarizes important information about your health coverage options in a standard format. The SBC is available on the web at www.bcbstx.com/employer.If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, federal law gives you more choices for your prescription drug coverage. Please see page 17 for more details.

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EligibilityYou have 30 days from the event to notify HR and complete your changes.You may need to provide documents to verify the change.new hirewho is eligible•A regular, full-time employee working an average of 30 hours per weekwhen to enroll•Enroll by the deadline given by Human Resourceswhen coverage starts•First of the month after completing 30 days of full-time employmentemployeewho is eligible•A regular, full-timeemployee working anaverage of 30 hours perweekwhen to enroll•Enroll during OE or when you have a QLEwhen coverage starts•OE: Start of the plan year•QLE: Ask Human Resourcesdependent(s)who is eligible•Your legal spouse•Child(ren) under age 26, regardlessof student, dependency or maritalstatus•Child(ren) over age 26 who are fullydependent on you for support due to amental or physical disability and who areindicated as such on your federal tax returnwhen to enroll•You must enroll the dependent(s) at OE orfor a QLE•When covering dependents, you must enroll for and be on the same planswhen coverage starts•Based on 2025 effective datesMarriageDivorceLegal separationAnnulmentDeathBirthAdoption/placement for adoptionChange in benefits eligibilityGain or loss of benefits coverageChange in employment status affecting benefitsSignificant change in cost of spouse’s coverageFMLA, COBRA event, court judgement or decreeBecoming eligible for Medicare, Medicaid, or TRICAREReceiving a Qualified Medical Child Support Order5Qualifying Life EventsCHANGING COVERAGE OUTSIDE OF OPEN ENROLLMENTYou may only change coverage during the plan year if you have a Qualifying Life Event, such as:

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Medical Plan Comparison7Base PPO S661CHC Buy-Up PPO S663CHCCarrier BlueCross BlueShield BlueCross BlueShieldProvider Network Blue Choice PPO Blue Choice PPOIn-Network Out-of-Network In-Network Out-of-NetworkDeductible•Individual•Family$3,650$10,950$7,300$21,900$3,100$9,200$6,200$18,400Out-of-Pocket Maximum•Individual•Family$9,200$18,400UnlimitedUnlimited$9,200$18,400UnlimitedUnlimitedLifetime Maximum BenefitUnlimited Unlimited Unlimited UnlimitedGeneral Level of Coverage70% 50% 70% 50%You Pay You PayPreventive Care No Charge 50% + Ded No Charge 50% + DedTelemedicine $55 50% + Ded $50 50% + DedPrimary Care Physician $55 50% + Ded $50 50% + DedSpecialist $100 50% + Ded $100 50% + DedDiagnostic Lab &X-ray30% + Ded$150 + 30% + Ded50% + Ded 30% + Ded 50% + DedComplex Imaging $250 + 30% + Ded 50% + Ded $250 + 30% + Ded 50% + DedUrgent Care $100 50% + Ded $100 50% + DedEmergency Room $750 + 30% + Deductible $600 + 30% + DeductibleInpatient Hospital Services $350 + 30% + Ded $400 + 50% + Ded $350 + 30% + Ded $400 + 50% + DedOutpatient Services $300 + 30% + Ded $350 + 50% + Ded $300 + 30% + Ded $350 + 50% + DedPrescription Drugs1Preferred Non-Preferred Preferred Non-PreferredUp to 30-day supply•Generic•Non-preferred Generic•Preferred brand name•Non-preferred brand name•Specialty$5$10$50$100N/A$10$20$70$120$150 / $250$5$10$50$100N/A$10$20$70$120$150 / $250•Mail Order – 90 Day Supply3x copay (Tier I – Tier IV) 3x copay (Tier I – Tier IV)CVS & Target are OUT-OF-NETWORK pharmacies1In-network preferred pharmacy copay versus in-network non-preferred pharmacy copay.

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99Blue Access for MembersBlue Access for Members (BAM) is the secure BCBSTX member website where you can:• Check claim status or history• Confirm dependent eligibility• Sign up for electronic Explanation of Benefits • Locate in-network providers• Print or request an ID card• Review your benefits • Get tips to live and eat healthierTo get started, log on to www.bcbstx.com and use the information on your BCBSTX ID card to complete the registration process.Mobile AppThe BCBSTX mobile app can help you stay organized and in control of your health anytime, anywhere. Log in from your mobile device to access your BAM account, including:• Track account balances and deductibles• Access ID card information• Find doctors, dentists, and pharmaciesNurselineCall 800-581-0368 for immediate access to registered nurses who can answer general health questions, make appointments with your doctor and help determine where to go for immediate or emergency health care services. You can also access an audio library of more than 1,000 health-related topics in both English and Spanish.Member RewardsSometimes it is hard to maintain a healthy lifestyle, and you may need a little motivation. The Blue Points program serves as motivation to help you get on track – and stay on track – to reach your wellness goals. Access www.wellontarget.com to find all the interactive tools and resources you need to start racking up Blue Points. Keep yourself motivated to earn more points by viewing the online shopping mall and checking out all the rewards you can earn for adopting – and continuing – healthy habits.BCBSTX ResourcesBlue 365Blue365 can help you save money on health and wellness products and services not covered by insurance. There are no claims to file, and you do not need a referral or preauthorization. Sign up for Blue365 at www.blue365deals.com/bcbstx to receive weekly Featured Deals by email. Discount categories include:• Apparel and footwear• Fitness• Hearing and vision• Home and family• Nutrition• Personal care How to Find a Doctor or Hospital1. Go to the following website:https://www.bcbstx.com/find-a-doctor-or-hospital2. Login as a member or search as guest3. If searching as a guest, you will need to provide the following information:• City, State or Zip• Plan / Network – Select “Blue Choice PPO”4. Next you may search by the doctor, facility or specialty

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10Hinge HealthIf you suffer from constant back and joint pain, Hinge Health can help without drugs or surgery. Get personal therapy, unlimited support, a computer tablet, and wearable sensors — all for free! Average results show 60% pain reduction and two out of three surgeries avoided. Your remote care may be done in the comfort of your own home. You will begin with a 12-week intensive phase, followed by an ongoing program that builds on what you have learned. Learn more and apply at www. hingehealth.com/bcbstx.OmadaIf you are at risk of diabetes and/or high blood pressure, Omada helps you change the habits that put you most at risk for developing a chronic condition. A virtual care team will work with you to create a program to reduceyour risk and build healthy habits. You will receive weekly support and connect with a small group of peers, all from the comfort of your own home. If you have any health claims that show you may be at risk for diabetes or high blood pressure, Omada will reach out to you directly. Visit www.omadahealth.com/bcbstx for more information.WondrIf you would like to lose weight and change how your bodystores and uses energy, Wondr may be right for you.Wondr is a 100% digital weight loss program that teachesyou how to eat your favorite foods and still lose weight,have energy, stress less, and sleep better. Wondr is not adiet plan. There are no points, plans, or calories to count. It teaches you skills to know how and when you eat and improve your long-term health. Learn more and enroll at https://wondrhealth.com/bcbstx.LivongoLivongo offers digital solution programs to help you manage chronic diabetes and high blood pressure (hypertension). Participation is FREE and available to you and your family members.Diabetes Management ProgramManage Type 1 and Type 2 diabetes by using:•Livongo’s advanced blood glucose meter – Get immediate feedback and alert loved ones in real time (using a cellular connection) when your blood glucose is too high or low•Unlimited strips and lancets – Livongo ships supplies directly to you at NO COST•Real-time tips and support – Get 24/7 support if your glucose is not in range or if you want tips on diabetes managementHigh Blood Pressure Management ProgramLivongo offers personal support by monitoring your blood pressure using:•A wireless, connected blood pressure cuff•Support and coaching with licensed professionals 24/7•Notifications and reminders for high blood pressure readings•Blood pressure reading reportsParticipation in Livongo is Easy!•800-945-4355•https://get.livongo.com/txhealth/register•Text GO TXHEALTH to 85240 to download the app to your smartphone or mobile deviceUse registration code TXHEALTH when prompted.Chronic Medical Care

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Non-Emergency CareTelehealthAllergiesAccess to care via phone, online video or mobile app whether you are home, work or traveling; medications can be prescribed. 24 hours a day, 7days a weekCough/cold/flu Rash Stomachache$2-5minutesDoctor’s OfficeInfectionsGenerally, the best place forroutine preventive care; established relationship; able to treat based on medical history. Office hours varySore and strep throatVaccinationsMinor injuries/sprains/strains$15-20minutesRetail ClinicCommon infectionsUsually lower out-of-pocket costthan urgent care; when you can’t see your doctor; located in stores and pharmacies. Hours vary based on store hours.Minor injuries Pregnancy tests Vaccinations$15minutesUrgent CareWhen you need immediate attention; walk-in basis is usually accepted.Generally includes evening, weekend and holiday hoursSprains and strains Minor broken bonesSmall cuts that may require stitchesMinor burns and infections$$15-30minutesEmergency CareHospital ERLife-threatening or critical conditions; trauma treatment; multiple bills for doctor and facility. 24 hours a day, 7 days a weekChest pain Difficulty breathing Severe bleedingBlurred or sudden loss of vision Major broken bones$$$$4+hoursFreestanding ERServices do not include trauma care; can look similar to an urgent care center, but medical bills may be 10 times higher. 24 hours a day, 7 days aweekMost major injuries except trauma Severe pain$$$$$variesBecoming familiar with your options for medical care can save you time and money.Note: Examples of symptoms are not inclusive of all health issues. Wait times described are only estimates. This information is not intended asmedical advice. If you have questions, please call the phone number on the back of your medical ID card.Health Care Options11

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16Voluntary Colonial BenefitsWe are pleased to announce that we are adding the following optional insurance through Colonial Life. These policies pay money directly to you to assist with the out-of-pocket expenses that health insurance doesn’t cover. Life Insurance—Enables you to choose different coverage amounts to provide financial security for your family members.Accident Insurance—Helps offset medical expenses such as emergency room fees, deductibles and co-payments that can result from accidental injury.Cancer Insurance—Helps with the out-of-pocket medical expenses related to cancer that most medical plans don’t cover and has an annual wellness benefit to encourage regular checkups.Critical Illness Insurance—Provides a large, lump sum benefit for various serious illnesses such as heart attack and stroke and has a wellness benefit similar to cancer plan.Hospital Confinement Insurances—Provides lump sum payments for hospitalization, outpatient surgery and other common treatments to assist with the out-of-pocket expenses due to deductibles and co-payments.Disability Insurance—Our ability to earn an income may be one of our greatest assets. Colonial Life’s voluntary disability provides employees off-job disability for a covered accident or sickness, and includes partial disability.*During the enrollment, a Colonial Life representative will be available to give you detailed information on the benefits and rates for each product and assist you with the enrollment should you elect to participate in these coverages.

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17Women’s Health and Cancer Rights Act of 1998In October 1998, Congress enacted theWomen’s Health and Cancer Rights Act of1998. This notice explains some important provisions of the Act. Please review this information carefully.As specified in the Women’s Health andCancer Rights Act, a plan participant orbeneficiary who elects breast reconstruction inconnection with a mastectomy is also entitledto the following benefits:•All stages of reconstruction of the breast on which the mastectomy was performed;•Surgery and reconstruction of theother breast to produce a symmetrical appearance; and•Prostheses and treatment of physical complications of the mastectomy, including lymphedema.Health plans must determine the manner ofcoverage in consultation with the attending physician and the patient. Coverage for breast reconstruction and related services maybe subject to deductibles and coinsurance amounts that are consistent with those that apply to other benefits under the plan.Special Enrollment RightsThis 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 oryour dependents because of other health insurance or group health plan coverage, you may be able to later enroll yourself andyour dependents in this plan if you or your dependents lose eligibility for that othercoverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must enroll within31 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 undera Medicaid plan or CHIP, or if you or your dependents become eligible for a subsidyunder Medicaid or CHIP, you may be able toenroll yourself and your dependents in thisplan. You must provide notification within 60days after you or your dependent is terminated from, or determined to be eligible for, such assistance.Marriage, Birth or AdoptionIf you have a new dependent as a result ofa marriage, birth, adoption, or placement foradoption, you may be able to enroll yourself and your dependents. However, you mustenroll within 31 days after the marriage, birth, or placement for adoption.For More Information or AssistanceTo request special enrollment or obtain more information, contact:Wathen, DeShong & Juncker, LLPHuman Resources4140 Gladys Avenue, Suite 101Beaumont, TX 77706409-838-1605Your Prescription Drug Coverage and MedicarePlease read this notice carefully and keepit where you can find it. This notice hasinformation about your current prescriptiondrug coverage with Wathen, DeShong & Juncker, LLP and about your options underMedicare’s prescription drug coverage. Thisinformation can help you decide whether ornot you want to enroll in a Medicare drug plan.Information about where you can get help tomake decisions about your prescription drugcoverage 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 thedependents, as the case may be. However, you should still keep a copy of this notice inthe 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 everyonewith Medicare. You can get this coverage through a Medicare Prescription DrugPlan or a Medicare Advantage Plan that offers prescription drug coverage. AllMedicare prescription drug plans provideat least a standard level of coverage set byMedicare. Some plans may also offer more coverage for a higher monthly premium.2. Wathen, DeShong & Juncker, LLP hasdetermined that the prescription drugcoverage offered by the Wathen, DeShong& Juncker, LLP medical plan is, on averagefor all plan participants, expected to payout as much as the standard Medicare prescription drug coverage pays and isconsidered Creditable Coverage.Because your existing coverage is, onaverage, at least as good as standard Medicare prescription drug coverage, youcan keep this coverage and not pay a higherpremium (a penalty) if you later decide to enroll in a Medicare prescription drug plan, as longas you later enroll within specific time periods.You can enroll in a Medicare prescription drug plan when you first become eligible forMedicare. If you decide to wait to enroll ina Medicare prescription drug plan, you mayenroll later, during Medicare Part D’s annual enrollment period, which runs each year from October 15 through December 7 but as ageneral rule, if you delay your enrollment inMedicare Part D after first becoming eligible toenroll, you may have to pay a higher premium (a penalty).You should compare your current coverage, including which drugs are covered at whatcost, with the coverage and cost of the plans offering Medicare prescription drug coveragein your area. See the Plan’s summary plan description for a summary of the Plan’s prescription drug coverage. If you don’t have acopy, you can get one by contacting Wathen, DeShong & Juncker, LLP at the phone numberor address listed at the end of this section.If you choose to enroll in a Medicare prescription drug plan and cancel your current Wathen, DeShong & Juncker, LLP prescriptiondrug coverage, be aware that you and yourdependents may not be able to get thiscoverage back. To regain coverage, you wouldhave to re-enroll in the Plan, pursuant to thePlan’s eligibility and enrollment rules. Youshould review the Plan’s summary plandescription to determine if and when you areallowed to add coverage.If you cancel or lose your current coverageand do not have prescription drug coveragefor 63 days or longer prior to enrolling in theMedicare 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, ifnineteen months lapse without coverage, your premium will always be at least 19% higherthan it would have been without the lapse incoverage.For more information about this notice or your current prescription drug coverage:Contact the Human Resources Department at409-838-1605.NOTE: You will receive this notice annually and at other times in the future, such asbefore the next period you can enroll inMedicare prescription drug coverage and ifthis coverage changes. You may also request a copy.Legal Notices

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18For more information about your options under Medicare prescription drug coverage:More detailed information about Medicareplans that offer prescription drug coverage isin the “Medicare & You” handbook. You will geta copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare prescription drugplans. For more information about Medicare prescription drug coverage:•Visit www.medicare.gov.•Call your State Health InsuranceAssistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) forpersonalized 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 extra help is available from the Social Security Administration (SSA) online at www. socialsecurity.gov, or you can call them at800-772-1213. TTY users should call 800-325-0778.Remember: Keep this Creditable Coverage 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 requiredto pay a higher premium (a penalty).01/01/2025Wathen, DeShong & Juncker, LLPHuman Resources4140 Gladys Ave, Suite 101 Beaumont, TX 77706409-838-1605Notice of HIPAA Privacy PracticesThis notice describes how medical information about you may be used anddisclosed and how you can get access tothis information. Please review it carefully.Effective Date of Notice: September 23, 2013Wathen, DeShong & Juncker’s Plan is requiredby law to take reasonable steps to ensure theprivacy of your personally identifiable healthinformation and to inform you about:1. the Plan’s uses and disclosures ofProtected Health Information (PHI);2. your privacy rights with respect to your PHI;3. the Plan’s duties with respect to your PHI;4. your right to file a complaint with thePlan and to the Secretary of the U.S. Department of Health and Human Services; and5. the person or office to contact for further information about the Plan’s privacy practices.The term “Protected Health Information”(PHI) includes all individually identifiable health information transmitted or maintained by the Plan, regardless of form (oral,written, electronic).Section 1 – Notice of PHI Usesand DisclosuresRequired PHI Uses and DisclosuresUpon your request, the Plan is required togive you access to your PHI in order toinspect and copy it.Use and disclosure of your PHI may berequired by the Secretary of the Department of Health and Human Services toinvestigate or determine the Plan’scompliance with the privacy regulations.Uses and disclosures to carry outtreatment, payment and health careoperations.The Plan and its business associates will use PHI without your authorization tocarry out treatment, payment and healthcare operations. The Plan and its businessassociates (and any health insurersproviding benefits to Plan participants) mayalso disclose the following to the Plan’sBoard of Trustees: (1) PHI for purposesrelated to Plan administration (payment andhealth care operations); (2) summary healthinformation for purposes of health or stoploss insurance underwriting or for purposesof modifying the Plan; and (3) enrollmentinformation (whether an individual is eligiblefor benefits under the Plan). The Trusteeshave amended the Plan to protect your PHIas required by federal law.Treatment is the provision, coordinationor management of health care andrelated services. It also includes but isnot limited to consultations and referralsbetween one or more of your providers.For example, the Plan may disclose to atreating physician the name of your treating radiologist so that the physician may askfor your X-rays from the treating radiologist.Payment includes but is not limited toactions to make coverage determinationsand payment (including billing, claimsprocessing, subrogation, reviews for medicalnecessity and appropriateness of care,utilization review and preauthorizations).For example, the Plan may tell a treating doctor whether you are eligible forcoverage or what percentage of the bill willbe paid by the Plan.Health care operations include but arenot limited to quality assessment andimprovement, reviewing competence orqualifications of health care professionals, underwriting, premium rating and other insurance activities relating to creating orrenewing insurance contracts. It also includes case management, conducting or arrangingfor medical review, legal services andauditing functions including fraud and abuse compliance programs, business planning anddevelopment, business management andgeneral administrative activities. However, nogenetic information can be used or disclosed for underwriting purposes.For example, the Plan may use information to project future benefit costs or audit theaccuracy of its claims processing functions.Uses and disclosures that require that you begiven an opportunity to agree or disagree prior to the use or release.Unless you object, the Plan may provide relevant portions of your protected health information to a family member, friend or other person you indicate is involved in your health care or in helping you receive payment foryour health care. Also, if you are not capableof agreeing or objecting to these disclosures because of, for instance, an emergency situation, the Plan will disclose protectedhealth information (as the Plan determines) inyour best interest. After the emergency, thePlan will give you the opportunity to object tofuture disclosures to family and friends.Uses and disclosures for which your consent, authorization or opportunity to object is notrequired.The Plan is allowed to use and disclose your PHI without your authorization under thefollowing circumstances:1. For treatment, payment and health care operations.2. Enrollment information can be provided tothe Trustees.3. Summary health information can beprovided to the Trustees for the purposes designated above.4. When required by law.5. When permitted for purposes of public health activities, including when necessary to report product defects andto permit product recalls. PHI may alsobe disclosed if you have been exposedto a communicable disease or are at risk of spreading a disease or condition, ifrequired by law.

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196. When required by law to report information about abuse, neglect ordomestic violence to public authoritiesif there exists a reasonable belief that you may be a victim of abuse, neglector domestic violence. In which case,the Plan will promptly inform you that such a disclosure has been or will bemade unless that notice would cause arisk of serious harm. For the purpose ofreporting child abuse or neglect, it is notnecessary to inform the minor that sucha disclosure has been or will be made. Disclosure may generally be made to theminor’s parents or other representatives although there may be circumstances under federal or state law when theparents or other representatives may notbe given access to the minor’s PHI.7. The Plan may disclose your PHI toa public health oversight agency foroversight activities required by law. This includes uses or disclosures in civil, administrative or criminal investigations; inspections; licensure or disciplinary actions (for example, to investigate complaints against providers); and other activities necessary for appropriate oversight of government benefit programs (for example, to investigate Medicare orMedicaid fraud).8. The Plan may disclose your PHI when required for judicial or administrative proceedings. For example, your PHI maybe disclosed in response to a subpoenaor discovery request.9. When required for law enforcement purposes, including for the purpose ofidentifying or locating a suspect, fugitive, material witness or missing person.Also, when disclosing information about an individual who is or is suspectedto be a victim of a crime but only if theindividual agrees to the disclosure or thePlan is unable to obtain the individual’s agreement because of emergency circumstances. Furthermore, the lawenforcement official must represent that the information is not intended to be used against the individual, the immediate lawenforcement activity would be materially and adversely affected by waiting toobtain the individual’s agreement anddisclosure is in the best interest of theindividual as determined by the exerciseof the Plan’s best judgment.10. When required to be given to a coroner or medical examiner for the purposeof identifying a deceased person, determining a cause of death or other duties as authorized by law. Also, disclosure is permitted to funeraldirectors, consistent with applicable law, as necessary to carry out their duties with respect to the decedent.11. When consistent with applicable law andstandards of ethical conduct if the Plan, ingood faith, believes the use or disclosureis necessary to prevent or lessen aserious and imminent threat to the health or safety of a person or the public and thedisclosure is to a person reasonably able to prevent or lessen the threat, including the target of the threat.12. When authorized by and to the extent necessary to comply with workers’ compensation or other similar programs established by law.Except as otherwise indicated in this notice, uses and disclosures will be made only with your written authorization subject to your right to revoke such authorization.Uses and disclosures that require your written authorization.Other uses or disclosures of your protected health information not described above will only be made with your written authorization. For example, in general and subject tospecific conditions, the Plan will not use ordisclose your psychiatric notes; the Plan will not use or disclose your protected health information for marketing; and the Plan will not sell your protected health information, unless you provide a written authorization todo so. You may revoke written authorizations at any time, so long as the revocation is inwriting. Once the Plan receives your written revocation, it will only be effective for future uses and disclosures. It will not be effective for any information that may have been used or disclosed in reliance upon the written authorization and prior to receiving your written revocation.Section 2 – Rights of IndividualsRight to Request Restrictions on Uses andDisclosures of PHIYou may request the Plan to restrict the uses and disclosures of your PHI. However, thePlan is not required to agree to your request (except that the Plan must comply withyour request to restrict a disclosure of your confidential information for payment or health care operations if you paid for the servicesto which the information relates in full, out ofpocket).You or your personal representative will berequired to submit a written request to exercise this right. Such requests should be made tothe Plan’s Privacy Official.Right to Request Confidential CommunicationsThe Plan will accommodate reasonable requests to receive communications of PHI byalternative means or at alternative locations ifnecessary to prevent a disclosure that could endanger you.You or your personal representative will berequired to submit a written request to exercise this right.Such requests should be made to the Plan’s Privacy Official.Right to Inspect and Copy PHIYou have a right to inspect and obtain a copy of your PHI contained in a “designated record set,” for as long as the Plan maintains thePHI. If the information you request is in anelectronic designated record set, you mayrequest that these records be transmitted electronically to yourself or a designated individual.Protected Health Information (PHI)Includes all individually identifiable health information transmitted or maintained by thePlan, regardless of form.Designated Record SetIncludes the medical records and billing records about individuals maintained by or fora covered health care provider; enrollment, payment, billing, claims adjudication andcase or medical management recordsystems maintained by or for the Plan; orother information used in whole or in partby or for the Plan to make decisions aboutindividuals. Information used for quality control or peer review analyses and not used tomake decisions about individuals is not in thedesignated record set.The requested information will be provided within 30 days if the information is maintained on site or within 60 days if the information ismaintained off site. A single 30-day extension is allowed if the Plan is unable to comply with the deadline.You or your personal representative will berequired to submit a written request to request access to the PHI in your designated record set. Such requests should be made to thePlan’s Privacy Official.If access is denied, you or your personal representative will be provided with a written denial, setting forth the basis for the denial,a description of how you may appeal thePlan’s decision and a description of how youmay complain to the Secretary of the U.S. Department of Health and Human Services.The Plan may charge a reasonable, cost-based fee for copying records at your request.Right to Amend PHIYou have the right to request the Plan toamend your PHI or a record about you in your designated record set for as long as the PHI ismaintained in the designated record set.The Plan has 60 days after the request ismade to act on the request. A single 30-dayextension is allowed if the Plan is unable tocomply with the deadline. If the request isdenied in whole or part, the Plan must provide you with a written denial that explains thebasis for the denial. You or your personal representative may then submit a written statement disagreeing with the denial andhave that statement included with any future disclosures of your PHI.

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20Such requests should be made to the Plan’s Privacy Official.You or your personal representative will berequired to submit a written request to request amendment of the PHI in your designated record set.Right to Receive an Accounting of PHIDisclosuresAt your request, the Plan will also provide youan accounting of disclosures by the Plan ofyour PHI during the six years prior to the date of your request. However, such accountingwill not include PHI disclosures made: (1)to carry out treatment, payment or healthcare operations; (2) to individuals about their own PHI; (3) pursuant to your authorization;(4) prior to April 14, 2003; and (5) where otherwise permissible under the law andthe Plan’s privacy practices. In addition, thePlan need not account for certain incidental disclosures.If the accounting cannot be provided within 60days, an additional 30 days is allowed if theindividual is given a written statement of thereasons for the delay and the date by whichthe accounting will be provided.If you request more than one accountingwithin a 12-month period, the Plan willcharge a reasonable, cost-based fee for each subsequent accounting.Such requests should be made to the Plan’s Privacy Official.Right to Receive a Paper Copy of This Notice Upon RequestYou have the right to obtain a paper copy ofthis Notice. Such requests should be made tothe Plan’s Privacy Official.A Note About Personal RepresentativesYou may exercise your rights through apersonal representative. Your personal representative will be required to produce evidence of his/her authority to act on your behalf before that person will be given access to your PHI or allowed to take any action foryou. Proof of such authority may take one ofthe following forms:1. a power of attorney for health care purposes;2. a court order of appointment of theperson as the conservator or guardianof the individual; or3. an individual who is the parent of anunemancipated minor child may generally act as the child’s personal representative (subject to state law).The Plan retains discretion to deny accessto your PHI by a personal representative toprovide protection to those vulnerable peoplewho depend on others to exercise their rightsunder these rules and who may be subject toabuse or neglect.Section 3 – The Plan’s DutiesThe Plan is required by law to maintain theprivacy of PHI and to provide individuals (participants and beneficiaries) with notice ofthe Plan’s legal duties and privacy practices.This Notice is effective September 23,2013, and the Plan is required to complywith the terms of this Notice. However, thePlan reserves the right to change its privacy practices and to apply the changes to anyPHI received or maintained by the Planprior to that date. If a privacy practice ischanged, a revised version of this Notice will be provided to all participants for whom thePlan still maintains PHI. The revised Notice will be distributed in the same manner as theinitial Notice was provided or in any other permissible manner.If the revised version of this Notice is posted, you will also receive a copy of the Noticeor information about any material change and how to receive a copy of the Notice inthe Plan’s next annual mailing. Otherwise, the revised version of this Notice will bedistributed within 60 days of the effective date of any material change to the Plan’s policies regarding the uses or disclosures of PHI, theindividual’s privacy rights, the duties of thePlan or other privacy practices stated in this Notice.Minimum Necessary StandardWhen using or disclosing PHI or when requesting PHI from another covered entity, the Plan will make reasonable efforts notto use, disclose or request more than theminimum amount of PHI necessary toaccomplish the intended purpose of theuse, disclosure or request, taking into consideration practical and technological limitations. When required by law, the Planwill restrict disclosures to the limited data set, or otherwise as necessary, to the minimum necessary information to accomplish theintended purpose.However, the minimum necessary standard will not apply in the following situations:1. disclosures to or requests by a health care provider for treatment;2. uses or disclosures made to theindividual;3. disclosures made to the Secretary of theU.S. Department of Health and Human Services;4. uses or disclosures that are required bylaw; and5. uses or disclosures that are required for the Plan’s compliance with legal regulations.De-Identified InformationThis notice does not apply to informationthat has been de-identified. De-identifiedinformation is information that does notidentify an individual and with respect to which there is no reasonable basis to believe thatthe information can be used to identify anindividual.Summary Health InformationThe Plan may disclose “summary health information” to the Trustees for obtaining insurance premium bids or modifying, amending or terminating the Plan. “Summary health information” summarizes the claims history, claims expenses or type of claims experienced by participants and excludes identifying information in accordance with HIPAA.Notification of BreachThe Plan is required by law to maintain theprivacy of participants’ PHI and to provide individuals with notice of its legal duties andprivacy practices. In the event of a breach ofunsecured PHI, the Plan will notify affected individuals of the breach.Section 4 – Your Right to File a Complaint With the Plan or the HHS SecretaryIf you believe that your privacy rights havebeen violated, you may complain to the Plan. Such complaints should be made to the Plan’s Privacy Official.You may file a complaint with the Secretaryof the U.S. Department of Health and Human Services, Hubert H. Humphrey Building, 200Independence Avenue SW, Washington, D.C. 20201. The Plan will not retaliate against youfor filing a complaint.Section 5 – Whom to Contact at the Plan forMore InformationIf you have any questions regarding this notice or the subjects addressed in it, youmay contact the Plan’s Privacy Official. Such questions should be directed to the Plan’s Privacy Official at:Wathen, DeShong & Juncker, LLPHuman Resources4140 Gladys Avenue, Suite 101Beaumont, TX 77706409-838-1605ConclusionPHI use and disclosure by the Plan isregulated by a federal law known as HIPAA (the Health Insurance Portability andAccountability Act). You may find these rules at 45 Code of Federal Regulations Parts 160and 164. The Plan intends to comply with these regulations. This Notice attempts tosummarize the regulations. The regulationswill supersede any discrepancy between theinformation in this Notice and the regulations.

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21Premium 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 apremium assistance program that can helppay 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 tobuy individual insurance coverage throughthe 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 orCHIP office to find out if premium assistanceis available.If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might beeligible for either of these programs, contact your State Medicaid or CHIP office or dial1-877-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 forpremium assistance under Medicaid orCHIP, as well as eligible under your employer plan, your employer must allow you to enrollin 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 determinedeligible for premium assistance. If you have questions about enrolling in your employerplan, contact the Department of Labor atwww.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. Thefollowing list of States is current as ofJanuary 31, 2024. Contact your State formore information on eligibility.Louisiana – MedicaidWebsite: www.medicaid.la.gov or www.ldh. la.gov/lahippPhone: 1-888-342-6207 (Medicaid hotline) or1-855-618-5488 (LaHIPP)Texas – MedicaidWebsite: https://www.hhs.texas.gov/services/financial/health-insurance-premium-payment-hipp-programPhone: 1-800-440-0493To see if any other States have added apremium assistance program since January 31, 2024, or for more information on special enrollment rights, you can contact either:U.S. Department of Labor Employee Benefits Security Administrationwww.dol.gov/agencies/ebsa1-866-444-EBSA (3272)U.S. Department of Health and Human ServicesCenters for Medicare & Medicaid Serviceswww.cms.hhs.gov1-877-267-2323, Menu Option 4, Ext. 61565Continuation of Coverage Rights Under COBRAUnder the Federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA),if you are covered under the Wathen, DeShong & Juncker, LLP group health planyou and your eligible dependents may beentitled to continue your group healthbenefits coverage under the Wathen, DeShong & Juncker, LLP plan after you haveleft employment withthe company. If you wish to elect COBRA coverage, contact your Human Resources Department for the applicable deadlines toelect coverage and pay the initial premium.Plan Contact InformationWathen, DeShong & Juncker, LLPHuman Resources / Jennifer Shaw4140 Gladys AveBeaumont, TX 77706409-838-1605Your Rights and Protections Against Surprise Medical BillsWhen you get emergency care or get treatedby an out-of-network provider at an in-network hospital or ambulatory surgical center, youare protected from surprise billing or balance billing.What is “balance billing” (sometimes called “surprise billing”)?When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have othercosts or have to pay the entire bill if you see aprovider or visit a health care facility that isn’t in your health plan’s network.“Out-of-network” describes providers andfacilities that have not signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay andthe full amount charged for a service.This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visitat an in- network facility but are unexpectedly treated by an out-of-network provider.You are protected from balance billing for:•Emergency services – If you have anemergency medical condition and getemergency services from an out-of-network provider or facility, the most theprovider or facility may bill you is your plan’s in- network cost-sharing amount (such as copayments and coinsurance). You cannot be balance billed for these emergency services. This includes services you may get after you are instable condition, unless you give written consent and give up your protections notto be balanced billed for these post-stabilization services.•Certain services at an in-network hospital or ambulatory surgical center – When youget services from an in-network hospitalor ambulatory surgical center, certain providers there may be out-of-network.In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cannot balance bill you and maynot ask you to give up your protections notto be balance billed.If you get other services at these in-network facilities, out-of-network providers cannot balance bill you, unless you give written consent and give up your protections.You are never required to give up your protections from balance billing. You also arenot required to get care out-of-network. Youcan choose a provider or facility in your plan’s network.When balance billing is not allowed, you also have the following protections:•You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that youwould pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilitiesdirectly.•Your health plan generally must:»Cover emergency services without requiring you to get approval forservices in advance (prior authorization)

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