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1Employee Benefits Guide2025
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 18 for more details.Contents3 Important Contacts4 Eligibility5 How to Enroll Online7 Medical Coverage9 Gravie Pay10 Telemedicine11 Gravie Value Adds12 Navigating Your Gravie ID Card13 Dental Coverage14 Vision Coverage15 Life and AD&D Insurance16 MASA Insurance17 Colonial Voluntary Benefits20 Employee Rates21 Benefit Summaries Flowcode22 Legal NoticesWe are pleasedto offer a full benefits package to you and your eligible dependents. Read this guide to know what benefits are available to you. You may only enroll for or make changes to your benefits during Open Enrollment or when you have a Qualifying Life Event.Availability Of Summary Health InformationYour plan offers medical coverage. To help you make an informed choice, review each plan’s Summary of Benefits and Coverage (SBC) available on the Flowcodeon page 17 or from Human Resources.Y O U R N E W B E N E F I T S B E G I NJanuary 1, 2025AND CONTINUE THROUGHDecember 31, 20252
3Program Provider Phone/Email Network WebsiteMedicalGravie 855-451-8365 Aetna www.gravie.comVirtual Visits by TeladocTeladoc 00-835-2362 www.teladoc.comDentalGuardian800-541-7846 DentalGuard Preferred www.guardiananytime.comVision877-814-8970 VSP www.vsp.comLife and AD&D800-525-4542 www.guardiananytime.comMedical TransportMASA 800-643-9023 www.masaaccess.comVoluntary Benefits: Accident, Disability, Critical IllnessColonial 830-968-0462 www.coloniallife.comHuman ResourcesPitts Oilfield Products & Services, LLC. Starla Shinn303-884-3392Starla@pittsoilfield.comwww.pittsoilfield.comBenefits SpecialistHigginbotham Penny Phillips903-434-4777pphillips@higginbotham.netwww.Higginbotham.comImportant Contacts
EligibilityYou have 30 days from the event to notify HR and complete your changes.You may need to provide documents to verify the change.Qualifying Life EventsCHANGING COVERAGE OUTSIDE OF OPEN ENROLLMENTYou may only change coverage during the plan year if you have a Qualifying Life Event, such as:4new 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 60 days of full-time employmentemployeewho is eligible• A regular, full-time employee working an average of 30 hours per weekwhen to enroll• Enroll during Open Enrollment (OE): December 6-13, 2024• When you have a Qualified Life Event (QLE): Ask Human Resourceswhen coverage starts• OE: January 1st, 2025• QLE: Ask Human Resourcesdependent(s)who is eligible• Your legal spouse• Child(ren) under age 26, regardless of student, dependency or marital status• 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• Enroll during OE: December 6-13, 2024• When you have a QLE: Ask Human Resources• When covering dependents, you must enroll for and be on the same planswhen coverage starts• Ask Human ResourcesMarriageDivorceLegal 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 Order
5Company Identifier: Pitts-Oilfield-Products--Services
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Medical CoverageThe medical plan options through Gravie protect you and your family from major financial hardship in the event of illness or injury. You have a choice of two plans:• Gravie HSA $3,300 Ded/$3,300 OOPM• Gravie ComfortFit $5,000 OOPM GXPreferred Provider Organization (PPO)A PPO allows you to see any provider when you need care. When you see in-network providers for care, you will pay less and get the highest level of benefits. You will pay more for care if you use non-network providers. When you see in-network providers, your office visits, urgent care, and prescription drugs are covered with a copay and most other network services are covered at the deductible and coinsurance level.7Find a Provider• Call 855-451-8365• Visit www.aetna.com/asa• Download the mobile app
881 What you pay after your Out-of-Pocket Maximum/Deductible is met.2 30-day supply versus 90-day supply.Medical Plan ComparisonGravie HSA $3,300 Ded/$3,300 OOPM Gravie ComfortFit $5,000 OOPM GXProvider NetworkAetna AetnaIn-Network Out-of-Network In-Network Out-of-NetworkDeductible• Individual• Family$3,300$6,600$10,000$20,000N/A N/A$10,000$20,000Out-of-Pocket Maximum• Individual• Family$3,300$6,600N/A$5,000$10,0000N/ALifetime Maximum BenefitUnlimited Unlimited Unlimited UnlimitedGeneral Level of Coverage100% 50% 100% 50%You Pay You PayPreventive CareN/A 50%1N/A 50%1TelemedicineN/A N/A N/A N/APrimary Care PhysicianN/A after deductible 50%1N/A 50%1SpecialistN/A after deductible 50%1N/A 50%1Diagnostic Lab and X-rayDeductible 50%1First $500 covered; then no cost after Out of Pocket Max50%1Complex ImagingDeductible 50%1First $500 covered; then no cost after Out of Pocket Max50%1Urgent CareDeductible 50%1N/A 50%1Emergency RoomDeductible $750 CopayInpatient Hospital ServicesDeductible 50%1Out of Pocket Max 50%1Outpatient ServicesDeductible 50%1Out of Pocket Max 50%1Prescription Drugs – Retail Up to 90-day supply• Generic• Preferred brand name• Non-preferred brand name• SpecialtyDeductible DeductibleDeductible$0 after deductible w/ PrudentRX-$01$751$1001 No cost w/ PrudentRX-Prescription Drugs – Mail Order90-day supply• Generic• Preferred brand name• Non-preferred brand name• SpecialtyDeductible DeductibleDeductibleDeductible-$0$150$200No cost w/ PrudentRX-Weekly Employee RatesEmployee$29.26 $41.93Employee + Spouse$129.99 $156.59Employee + Child(ren)$111.68 $135.74Employee + Family$230.72 $271.25
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TelemedicineYour medical coverage offers telemedicine services through Teladoc. Connect anytime day or night with a board-certified doctor via your mobile device or computer for free.While telemedicine does not replace your primary care physician, it is a convenient and cost-effective option when you need care and:• Have a non-emergency issue and are considering an after-hours health care clinic, urgent care clinic or emergency room for treatment• Are on a business trip, vacation or away from home• Are unable to see your primary care physician Registration is EasyRegister so you are ready to use this valuable service when and where you need it.• Online – www.teladoc.com• Phone – 800-835-2362• Mobile – Download the mobile app to your smartphone or mobile device.10• Mental health issues• Allergies• Fever• Urinary tract infectionsWhen to Use TelemedicineUse telehealth services for minor conditions such as:Do not use telemedicine for serious or life-threatening emergencies.• Sore throat• Headache• Stomachache• Cold/Flu
11Gravie Value Adds
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DentalGuard Preferred PlanIn-Network1Calendar Year Deductible• Individual• Family$50$150Calendar Year Benefit MaximumPer Individual$1,500You PayPreventive Care $0Basic Restorative Care 20% after deductibleMajor Restorative 50% after deductibleOrthodontia 50%Orthodontia Lifetime Maximum$1,500Weekly Employee RatesEmployee$10.50Employee + Spouse$21.88Employee + Child(ren)$23.58Employee + Family$36.811 See your plan for details about out-of-network coverage.Our dental plan helps you maintain good oral health through affordable options for preventive care, including regular checkups and other dental work. Coverage is provided through Guardian using the DentalGuardPreferred provider network.DPPO PlanTwo levels of benefits are available with the DPPO plan: in-network and out-of-network. You may see any dental provider for care, but you will pay less and get the highest level of benefits with in-network providers. You could pay more if you use an out-of-network provider.Dental Coverage13Find a Provider• Call 800-541-7846• Visit www.guardiananytime.com• Download the mobile app
14Our vision plan offers quality care to help preserve your health and eyesight. Regular exams can detect certain medical issues such as diabetes and high cholesterol, in addition to vision and eye problems. You may seek care from any vision provider, but the plan will pay the highest level of benefits when you see in-network providers. Coverage is provided through Guardian using the VSP provider network.Vision CoverageFull Feature Vision PlanIn-NetworkYou PayOut-of-NetworkReimbursementExam $10 Up to $39Lenses• Single Vision• Bifocals• Trifocals• Lenticular$10 copay$10 copay$10 copay$10 copayUp to $23 Up to $37 Up to $49 Up to $64Frames $150 allowance + 20% off balanceUp to $46ContactsIn lieu of frames and lenses• Elective• Medically NecessaryUp to $150$0Up to $100Up to $210Benefit FrequencyExam Once every 12 monthsLenses Once every 12 monthsFrames Once every 12 monthsContacts Once every 12 monthsWeekly Employee RatesEmployee$1.94Employee + Spouse$4.13Employee + Child(ren)$4.45Employee + Family$6.35Find a Provider• Call 877-814-8970• Visit www.vsp.com• Download the mobile app
15Life and AD&D InsuranceLife and Accidental Death and Dismemberment (AD&D) insurance through Guardian are important to your financial security, especially if others depend on you for support or vice versa. With Life insurance, you or your beneficiary(ies) can use the coverage to pay off debts, such as credit cards, loans, and bills. AD&D coverage provides specific benefits if an accident causes bodily harm or loss (e.g., the loss of a hand, foot, or eye). If death occurs from an accident, 100% of the AD&D benefit would be paid to you or your beneficiary(ies). Life and AD&D coverage amounts reduce by 35% at age 65 and 50% at age 70.Designating a BeneficiaryA beneficiary is the person or entity you elect toreceive the death benefits of your Life and AD&Dinsurance policies. You can name more than onebeneficiary and you can change beneficiaries atany time. If you name more than one beneficiary,you must identify how much each beneficiary willreceive (e.g., 50% or 25%).Voluntary Life and AD&DEmployee• Increments of $10,000 up to $300,000• Guaranteed Issue $100,000Spouse• Increments of $5,000 up to $250,0000 not to exceed 100% of employee amount• Guaranteed Issue $25,000Child(ren)• Birth to 14 days – $500• 14 days to age 26 – $10,000 increments up to $20,000 not to exceed 100% of employee amount• Guaranteed Issue $20,000Monthly Rates per $1,000Employee SpouseAge Rate Age Rate<30 $0.070 <30 $0.06030-34 $0.070 30-34 $0..07035-39 $0.090 35-39 $0.08040-44 $0.130 40-44 $0.11045-49 $0.200 45-49 $0.17050-54 $0.290 50-54 $0.25055-59 $0.420 55-59 $0.35060-64 $0.570 60-64 $0.57065-69 $1.010 65-69 $0.96070-74 $1.530 70-74 $1.55075-79 $2.450 75-79 $3.20080+ $4.380 80+ $4.560Child(ren)To age 26 $0.250Voluntary Life and AD&D You may buy more Life and AD&D insurance for you and your eligible dependents. If you do not elect Voluntary Life and AD&D insurance when first eligible or if you want to increase your benefit amount at a later date, you may need to show proof of good health. You must elect Voluntary Life and AD&D coverage for yourself before you may elect coverage for your spouse or children. If you leave the company, you may be able to take the insurance with you. Basic Life and AD&D Basic Life and AD&D insurance are provided at no cost to you. You are covered at $25,000 for each benefit.
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To learn more, contact:-DPLH3RSH409-782-1910jamie@colonialtx.comPitts Oilfield Services3-17 | NS-16028NS-16028Voluntary benefitsIndividual Disability– A short-term disability product that replaces a portion of income for on/o-job or o-job only disabilities. Optional features include psychiatric and psychological conditions benefits and waiver of elimination period for first day hospital confinement. Guaranteed-issue and simplified-issue options are available. Accident Insurance Individual Accident – A guaranteed-issue, composite-rated, guaranteed-renewableaccident product that oers several coverage levels to fit all budgets. Employer-optional benefits are available to customize the accident product oering. Additional employee-choice riders can create a comprehensive product package. Special Risk Insurance Individual Critical Illness– A critical illness product that provides a lump-sum benefit for the diagnosis of a critical illness. ColonialLife.comChoices to protect what you’ve worked so hard to buildEach individual’s lifestyle and needs are different from the next. Voluntary benefits from Colonial Life offer a broad range of financial protection options for employees and their families. Disability Insurance &RYHUDJHLVDYDLODEOHWRVSRXVHVDQGHOLJLEOHGHSHQGHQWFKLOGUHQ %HQHILWVDUHSDLGGLUHFWO\WRWKHLQVXUHGXQOHVVVSHFLILHGRWKHUZLVH (PSOR\HHVFDQFRQWLQXHFRYHUDJHZLWKQRLQFUHDVHLQSUHPLXPVLIWKH\UHWLUHRUFKDQJHMREV (PSOR\HHVPD\UHFHLYHEHQHILWVUHJDUGOHVVRIDQ\RWKHULQVXUDQFH 3UHPLXPVDUHSD\UROOGHGXFWHGIRUHDV\DGPLQLVWUDWLRQImportant coverage features:
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17Employee RatesYour BenefitCostsMedicalGravie ComfortFit $5,000 OOPM GX Gravie HSAA $3,300 Ded/$3,300 OOPMEmployee $41.93 $29.26$Employee + Spouse $156.59 $129.99Employee + Child(ren) $135.74 $111.68Employee + Family $271.25 $230.72DentalEmployee$10.50$Employee + Spouse$21.88Employee + Child(ren)$23.58Employee + Family$36.81VisionEmployee$1.94$Employee + Spouse$4.13Employee + Child(ren)$4.45Employee + Family$6.35Basic Life and AD&DEmployee OnlyPaid by Pitts Oilfield Products & Services LLC.$ 0Voluntary Life and AD&DEmployee See page 15 for rates $Spouse See page 15 for rates $Child(ren) See page 15 for rates $Supplemental BenefitsMASASee page 16 for rates$Your Total Benefit Cost$Summaries of BenefitsTo View Complete Carrier BenefitPlan Summaries Scan Flowcode Or Visit Linkhttps://page.higginbotham.com/pittsoilfield
18Women’s Health and Cancer Rights Act of 1998In October 1998, Congress enacted the Women’s Health and Cancer Rights Act of 1998. This notice explains some important provisions of the Act. Please review this information carefully.As specified in the Women’s Health and Cancer Rights Act, a plan participant or beneficiary who elects breast reconstruction in connection with a mastectomy is also entitled to the following benefits:• All stages of reconstruction of the breast on which the mastectomy was performed;• Surgery and reconstruction of 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 of a marriage, birth, adoption, or placement for adoption, 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:Pitts Oilfield Products & Services LLC. Human Resources1114 US Hwy 87 S.San Angelo, TX 76904 303-884-3392Your Prescription Drug Coverage and MedicarePlease read this notice carefully and keep it where you can find it. This notice has information about your current prescriptiondrug coverage with Pitts Oilfield Products & Services LLC. and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to enroll in a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.If neither you nor any of your covered dependents are eligible for or have Medicare, this notice does not apply to you or the dependents, as the case may be. However, you should still keep a copy of this notice in the event you or a dependent should qualify for coverage under Medicare in the future.Please note, however, that later notices might supersede this notice.1. Medicare prescription drug coverage became available in 2006 to 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. Pitts Oilfield Products & Services LLC. hasdetermined that the prescription drugcoverage offered by the Pitts Oilfield Products & Services LLC. medical plan is,on average for all plan participants,expected to pay out as much as thestandard Medicare prescription drugcoverage pays and is consideredCreditable Coverage.Because your existing coverage is, on average, at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay a higherpremium (a penalty) if you later decide to enroll in a Medicare prescription drug plan, as long as you later enroll within specific time periods.You can enroll in a Medicare prescription drug plan when you first become eligible for Medicare. If you decide to wait to enroll ina Medicare prescription drug plan, you may enroll later, during Medicare Part D’s annual enrollment period, which runs each year from October 15 through December 7 but as a general rule, if you delay your enrollment in Medicare Part D after first becoming eligible to enroll, you may have to pay a higher premium (a penalty).You should compare your current coverage, including which drugs are covered at what cost, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. See the Plan’s summary plan description for a summary of the Plan’s prescription drug coverage. If you don’t have a copy, you can get one by contacting Pitts Oilfield Products & Services LLC. at the phone number or address listed at the end of this section.If you choose to enroll in a Medicare prescription drug plan and cancel your current Pitts Oilfield Products & Services LLC. prescription drug coverage, be aware that you and your dependents may not be able to get this coverage back. To regain coverage, you would have to re-enroll in the Plan, pursuant to the Plan’s eligibility and enrollment rules. You should review the Plan’s summary plan description to determine if and when you are allowed to add coverage.If you cancel or lose your current coverage and do not have prescription drug coverage for 63 days or longer prior to enrolling in the Medicare prescription drug coverage, your monthly premium will be at least 1% per month greater for every month that you did not have coverage for as long as you have Medicare prescription drug coverage. For example, if nineteen months lapse without coverage, your premium will always be at least 19% higher than it would have been without the lapse in coverage.For more information about this notice or your current prescription drug coverage:Contact the Human Resources Department at303-884-3392.NOTE: You will receive this notice annually and at other times in the future, such as before the next period you can enroll in Medicare prescription drug coverage and if this coverage changes. You may also request a copy.Legal Notices
19For 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 will get a 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).01/01/2025 Pitts Oilfield Products & Services LLC.Human Resources 1114 US Hwy 87 S.San Angelo, TX 76904 303-884-3392Notice 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, 2013Pitts Oilfield Products & Services LLC.’s Plan isrequired by law to take reasonable steps toensure the privacy of your personallyidentifiable health information and to informyou 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 are not limited to quality assessment and improvement, reviewing competence or qualifications of health care professionals, underwriting, premium rating and other insurance activities relating to creating orrenewing insurance contracts. It also includes case management, conducting or arranging for medical review, legal services and auditing functions including fraud and abuse compliance programs, business planning and development, business management and general administrative activities. However, no genetic information can be used or disclosed for underwriting purposes.For example, the Plan may use information to project future benefit costs or audit the accuracy of its claims processing functions.Uses and disclosures that require that you be given 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 for your health care. Also, if you are not capable of agreeing or objecting to these disclosures because of, for instance, an emergency situation, the Plan will disclose protected health information (as the Plan determines) in your best interest. After the emergency, the Plan will give you the opportunity to object to future disclosures to family and friends.Uses and disclosures for which your consent, authorization or opportunity to object is not required.The Plan is allowed to use and disclose your PHI without your authorization under the following 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.
206. When required by law to report information about abuse, neglect or domestic violence to public authorities if there exists a reasonable belief that you may be a victim of abuse, neglect or domestic violence. In which case, the Plan will promptly inform you that such a disclosure has been or will be made unless that notice would cause a risk of serious harm. For the purpose ofreporting child abuse or neglect, it is not necessary to inform the minor that such a disclosure has been or will be made. Disclosure may generally be made to the minor’s parents or other representatives although there may be circumstances under federal or state law when the parents or other representatives may not be given access to the minor’s PHI.7. The Plan may disclose your PHI to a 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 or Medicaid fraud).8. The Plan may disclose your PHI when required for judicial or administrative proceedings. For example, your PHI may be disclosed in response to a subpoena or discovery request.9. When required for law enforcement purposes, including for the purpose of identifying 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 the individual agrees to the disclosure or the Plan is unable to obtain the individual’s agreement because of emergency circumstances. Furthermore, the law enforcement official must represent that the information is not intended to be used against the individual, the immediate law enforcement activity would be materially and adversely affected by waiting to obtain the individual’s agreement and disclosure is in the best interest of the individual as determined by the exercise of 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 and standards of ethical conduct if the Plan, in good faith, believes the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure 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 to specific conditions, the Plan will not use or disclose 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 to do so. You may revoke written authorizations at any time, so long as the revocation is in writing. 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 and Disclosures of PHIYou may request the Plan to restrict the uses and disclosures of your PHI. However, the Plan 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 of pocket).You or your personal representative will be required to submit a written request to exercise this right. Such requests should be made to the Plan’s Privacy Official.Right to Request Confidential CommunicationsThe Plan will accommodate reasonable requests to receive communications of PHI by alternative means or at alternative locations if necessary to prevent a disclosure that could endanger you.You or your personal representative will be required 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 the PHI. If the information you request is in an electronic designated record set, you may request 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 the Plan, regardless of form.Designated Record SetIncludes the medical records and billing records about individuals maintained by or for a covered health care provider; enrollment, payment, billing, claims adjudication and case or medical management recordsystems maintained by or for the Plan; or other information used in whole or in part by 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 the designated 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 is maintained 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 be required to submit a written request to request access to the PHI in your designated record set. Such requests should be made to the Plan’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 the Plan’s decision and a description of how you may 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 to amend your PHI or a record about you in your designated record set for as long as the PHI is maintained in the designated record set.The Plan has 60 days after the request is made to act on the request. A single 30-day extension is allowed if the Plan is unable to comply with the deadline. If the request is denied in whole or part, the Plan must provide you with a written denial that explains the basis for the denial. You or your personal representative may then submit a written statement disagreeing with the denial and have that statement included with any future disclosures of your PHI.
21Such requests should be made to the Plan’s Privacy Official.You or your personal representative will be required to submit a written request to request amendment of the PHI in your designated record set.Right to Receive an Accounting of PHI DisclosuresAt your request, the Plan will also provide you an accounting of disclosures by the Plan of your PHI during the six years prior to the date of your request. However, such accounting will not include PHI disclosures made: (1)to carry out treatment, payment or health care 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 and the Plan’s privacy practices. In addition, the Plan need not account for certain incidental disclosures.If the accounting cannot be provided within 60 days, an additional 30 days is allowed if the individual is given a written statement of the reasons for the delay and the date by which the accounting will be provided.If you request more than one accounting within a 12-month period, the Plan will charge 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 of this Notice. Such requests should be made to the Plan’s Privacy Official.A Note About Personal RepresentativesYou may exercise your rights through a personal 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 for you. Proof of such authority may take one of the 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 the privacy of PHI and to provide individuals (participants and beneficiaries) with notice of the Plan’s legal duties and privacy practices.This Notice is effective September 23, 2013, and the Plan is required to comply with the terms of this Notice. However, the Plan reserves the right to change its privacy practices and to apply the changes to any PHI received or maintained by the Plan prior to that date. If a privacy practice ischanged, a revised version of this Notice will be provided to all participants for whom the Plan still maintains PHI. The revised Notice will be distributed in the same manner as the initial 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 in the 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, the individual’s privacy rights, the duties of the Plan 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 the minimum amount of PHI necessary to accomplish the intended purpose of the use, 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 the intended 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 information that has been de-identified. De-identified information is information that does notidentify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual.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 the privacy of participants’ PHI and to provide individuals with notice of its legal duties and privacy practices. In the event of a breach of unsecured 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 have been 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 Secretary of the U.S. Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington, D.C. 20201. The Plan will not retaliate against you for filing a complaint.Section 5 – Whom to Contact at the Plan for More InformationIf you have any questions regarding this notice or the subjects addressed in it, you may contact the Plan’s Privacy Official. Such questions should be directed to the Plan’s Privacy Official at:Pitts Oilfield Products & Services LLC.Human Resources 1114 US Hwy 87 S.San Angelo, TX 76904 303-884-3392ConclusionPHI use and disclosure by the Plan is regulated by a federal law known as HIPAA (the Health Insurance Portability and Accountability Act). You may find these rules at 45 Code of Federal Regulations Parts 160 and 164. The Plan intends to comply with these regulations. This Notice attempts to summarize the regulations. The regulations will supersede any discrepancy between the information in this Notice and the regulations.
22Premium 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 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 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 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 for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment”opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of January 31, 2024. Contact your State for more information on eligibility.Alabama – MedicaidWebsite: http://www.myalhipp.com/ Phone: 1-855-692-5447Alaska – MedicaidThe AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: https://health.alaska.gov/ dpa/Pages/default.aspxArkansas – MedicaidWebsite: http://myarhipp.com/Phone: 1-855-MyARHIPP (855-692-7447)California– MedicaidHealth Insurance Premium Payment (HIPP) Program Website: http://dhcs.ca.gov/hipp Phone: 916-445-8322Fax: 916-440-5676Email: hipp@dhcs.ca.govColorado – Health First Colorado (Colorado’s Medicaid Program) and 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 711 CHP+: 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: 1-855-692-6442Florida – MedicaidWebsite: https://www.flmedicaidtplrecovery. com/flmedicaidtplrecovery.com/hipp/index. htmlPhone: 1-877-357-3268Georgia – MedicaidGA HIPP Website: https://medicaid.georgia. gov/health-insurance-premium-payment- program-hippPhone: 678-564-1162, Press 1GA CHIPRA Website: https://medicaid. georgia.gov/programs/third-party-liability/ childrens-health-insurance-program- reauthorization-act-2009-chipraPhone: 678-564-1162, Press 2Indiana – MedicaidHealthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/Phone: 1-877-438-4479All other MedicaidWebsite: https://www.in.gov/medicaid/ Phone 1-800-457-4584Iowa – Medicaid and CHIP (Hawki)Medicaid Website: https://dhs.iowa.gov/ime/ membersMedicaid Phone: 1-800-338-8366Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563HIPP Website: https://dhs.iowa.gov/ime/ members/medicaid-a-to-z/hippHIPP Phone: 1-888-346-9562Kansas – MedicaidWebsite: https://www.kancare.ks.gov/ Phone: 1-800-792-4884HIPP Phone: 1-800-967-4660Kentucky – MedicaidKentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/ member/Pages/kihipp.aspxPhone: 1-855-459-6328Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: https://kynect.ky.gov Phone: 1-877-524-4718Kentucky 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: 1-800-442-6003TTY: Maine relay 711Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications- formsPhone: 1-800-977-6740TTY: Maine Relay 711Massachusetts – Medicaid and CHIPWebsite: https://www.mass.gov/masshealth/pa Phone: 1-800-862-4840TTY: 711Email: masspremassistance@accenture.comMinnesota – MedicaidWebsite: https://mn.gov/dhs/people-we-serve/ children-and-families/health-care/health- care-programs/programs-and-services/other- insurance.jspPhone: 1-800-657-3739Missouri – MedicaidWebsite: http://www.dss.mo.gov/mhd/ participants/pages/hipp.htmPhone: 573-751-2005Montana – MedicaidWebsite: https://dphhs.mt.gov/ MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084Email: HHSHIPPProgram@mt.gov
23Nebraska – MedicaidWebsite: http://www.ACCESSNebraska. ne.govPhone: 1-855-632-7633Lincoln: 402-473-7000Omaha: 402-595-1178Nevada – MedicaidMedicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900New Hampshire – MedicaidWebsite: https://www.dhhs.nh.gov/programs- services/medicaid/health-insurance-premium- programPhone: 603-271-5218Toll free number for the HIPP program: 1-800- 852-3345 ext.5218New Jersey – Medicaid and CHIPMedicaid Website: http://www.state.nj.us/ humanservices/dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392CHIP Website: http://www.njfamilycare.org/ index.htmlCHIP Phone: 1-800-701-0710New York – MedicaidWebsite: https://www.health.ny.gov/health_ care/medicaid/Phone: 1-800-541-2831North Carolina – MedicaidWebsite: https://medicaid.ncdhhs.gov Phone: 919-855-4100North Dakota – MedicaidWebsite: https://www.hhs.nd.gov/healthcare Phone: 1-844-854-4825Oklahoma – Medicaid and CHIPWebsite: http://www.insureoklahoma.org Phone: 1-888-365-3742Oregon – MedicaidWebsite: https://healthcare.oregon.gov/Pages/ index.aspxPhone: 1-800-699-9075Pennsylvania – Medicaid and CHIPWebsite: https://www.dhs.pa.gov/Services/ Assistance/Pages/HIPP-Program.aspx Phone: 1-800-692-7462CHIP Website: https://www.dhs.pa.gov/CHIP/ Pages/CHIP.aspxCHIP Phone: 1-800-986-KIDS (5437)South Dakota - MedicaidWebsite: https://dss.sd.gov Phone: 1-888-828-0059Texas – MedicaidWebsite: https://www.hhs.texas.gov/services/ financial/health-insurance-premium-payment- hipp-programPhone: 1-800-440-0493Utah – Medicaid and CHIPMedicaid Website: https://medicaid.utah.gov CHIP Website: https://health.utah.gov/chip Phone: 1-877-543-7669Vermont– MedicaidWebsite: https://dvha.vermont.gov/members/ medicaid/hipp-programPhone: 1-800-250-8427Virginia – Medicaid and CHIPWebsite: https://coverva.dmas.virginia.gov/ learn/premium-assistance/famis-select https://coverva.dmas.virginia.gov/learn/ premium-assistance/health-insurance- premium-payment-hipp-programs Medicaid/CHIP Phone: 1-800-432-5924Washington – MedicaidWebsite: https://www.hca.wa.gov/ Phone: 1-800-562-3022West Virginia – Medicaid and CHIPWebsite: https://dhhr.wv.gov/bms/ http://mywvhipp.com/Medicaid Phone: 304-558-1700CHIP Toll-free phone: 1-855-MyWVHIPP (1- 855-699- 8447)Wisconsin – Medicaid and CHIPWebsite: https://www.dhs.wisconsin.gov/ badgercareplus/p-10095.htmPhone: 1-800-362-3002Wyoming – MedicaidWebsite: https://health.wyo.gov/healthcarefin/ medicaid/programs-and-eligibility/Phone: 1-800-251-1269To see if any other States have added a premium 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/ebsa 1-866-444-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 Pitts Oilfield Products & Services LLC. group health plan you and your eligible dependents may be entitled to continue your group health benefits coverage under the Pitts Oilfield Products & Services LLC. plan after you have left employment with the company. If you wish to elect COBRA coverage, contact your Human Resources Department for the applicable deadlines to elect coverage and pay the initial premium.Plan Contact InformationPitts Oilfield Products & Services LLC.Human Resources 1114 US Hwy 87 S.San Angelo, TX 76904 303-884-3392Your Rights and Protections Against Surprise Medical BillsWhen you get emergency care or get treated by 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 other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.“Out-of-network” describes providers and facilities 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 and the 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.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.gov Phone: 1-888-549-0820
24“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 payingyour share of the cost (like thecopayments, coinsurance, anddeductibles that you would pay if theprovider or facility was in-network). Yourhealth plan will pay out- of-networkproviders and facilities directly.• Your health plan generally must:» Cover emergency serviceswithout requiring you to getapproval for services in advance(prior authorization).» Cover emergency services by out-of- network providers.» Base what you owe the provideror facility (cost-sharing) on what it would pay an in-network provideror facility and show that amountin your explanation of benefits.» Count any amount you pay foremergency services or out-of-network services toward your deductible andout-of-pocket limit.If you believe you have been wrongly billed, you may contact your insurance provider. Visit www.cms.gov/nosurprises for more information about your rights under federal law.
This brochure highlights the main features of the Pitts Oilfield Products & Services LLC. employee benefits program. It does not include all plan rules, details, limitations, and exclusions. The terms of your benefit plans are governed by legal documents, including insurance contracts. Should there be an inconsistency between this brochure and the legal plan documents, the plan documents are the final authority. Pitts Oilfield Products & Services LLC. reserves the right to change or discontinue its employee benefits plans at any time.