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2 7 Eligibility & Enrollment We offer a variety of options to help you select the benefit plans that best suit you and your family’s needs. Consider factors such as spousal benefits, dependent eligibility and qualifying life events as you make your benefits selections. à Eligibility Regular full-time employees who work a minimum of 30 hours per week and their dependents are eligible for medical, dental and vision on the first day of the month following full time date of hire. Dependent children are covered on the medical, dental, vision plans up to age 26. à How and When to Enroll We are excited to make enrollment in your benefits simple! Open enrollment period runs from April 14, 2025 through April 18, 2025. The open enrollment benefits you elect will be in effective April 1, 2025 through March 31, 2026. à How to Access Additional Benefit Information Þ You can access additional benefit plan information by visiting www.employeenavigator.com You can view plan summaries, contact information, required notices and more! à Qualifying Life Events When one of the following events occurs, you have 30 days from the date of the event to notify the Benefits Department and/or request changes to your coverage. Your change in coverage must be consistent with your change in status. » Change in your legal marital status (marriage, divorce or legal separation) » Change in the number of your dependents (birth, death or adoption, or age) » Change in your spouse’s employment status (resulting in a loss or gain of coverage) » Change in your employment status from full-time to part-time, or part-time to full-time » Entitlement to Medicare or Medicaid » Change in your address or location that affects the plans for which you are eligible Plan Carrier Group Number Contact Number Website Medical UnitedHealthcare 1428453 800-650-5826 UHC.com Dental UnitedHealthcare 1428453 877-901-7321 Dentaltx.uhc.com Vision Ameritas 10-64242 800-487-5553 Ameritas.com Worksite Colonial TBD 800-325-4368 Coloniallife.com/individuals/policyholder-support
3 Medical Plan Option The chart below gives a summary of the 2025 plan year medical coverages provided by UnitedHealthcare. All covered services are subject to medical necessity as determined by the Plan. The informaon in this Employee Benefits Communicator is presented for illustrave purposes only. The text contained in this Guide was taken from various summary plan descripons and benefit informaon documents. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of dis-crepancy between the Benefit Enrollment Guide and the actual plan document will prevail. If you have any quesons about this summary, contact Human Resources. United Healthcare E3500i100LX21B Funding Type Level Funded Benefit items In-network Out-of-network Individual Deductible $3,500 N/A Family Deductible $7,000 N/A Individual Out-of-Pocket Max $6,000 N/A Family Out-of-Pocket Max $12,000 N/A Coinsurance (Policy Holder Portion) 0% After Ded. N/A Primary Care/Office $25 N/A Specialist Care $75 N/A Emergency Room $300 Copay + 0% After Ded. Urgent Care $50 N/A In-Network Prescription Coverage Tiers $10 / $35 / $75 /$250 Rx - Mail Order / Retail 2X for 90 day supply Monthly Rates Employee $0.00 + Spouse $426.57 + Child(ren) $349.02 + Family $814.37
4 Voluntary Dental Benefits P3305 MAC United Healthcare Benefit items In-network Individual Deductible $50 Calendar Year Max Benefit $1,200 Preventive Coinsurance 100% Basic Coinsurance 80% Major Coinsurance 50% Waiting Period - Major (No Waiting Period) Ortho Coinsurance N/A Periodontics / Endodontics Major Monthly Rates Employee $31.26 + Spouse $62.52 + Child(ren) $67.84 + Family $103.97 Our Dental Plan helps you maintain good dental health through affordable options for preventive care, including regular checkups and other dental work. When you receive services from a dentist in our network, your cost may be lower. Network dentists agree to lower their fees for dental services and not charge you the difference. You’ll have access to the UnitedHealthcare Plan Dental network which is one of the largest dental networks nation wide. Visit DentalTX.uhc.com to find a dentist or call 877-901-7321.
5 Voluntary Vision Benefits Vision benefits provide access to quality vision care. To ensure that you and your family get the care you need, we offer a comprehensive vision benefit provided by Ameritas. Þ Visit VSP.com to locate a VSP doctor close to you Þ Call 800-877-7195 Vision Plan Ameritas VSP Choice Network Benefit items In-Network Out-of-Network Exam Frequency Once every 12 months Lense Frequency Once every 12 months Frame Frequency Once every 24 months Exams $10 Up to $45 Single Lenses Covered in full Up to $30 Bifocal Lenses Covered in full Up to $50 Trifocal Lenses Covered in full Up to $65 Frames $130 Allowance Up to $70 Contacts - Medically Necessary Covered in full Up to $210 Contacts - Elective $130 Allowance Up to $105 Monthly Rates Employee $7.92 Employee + Spouse $16.96 Employee + Child(ren) $13.76 Employee + Family $22.80
Get more out of your health plan benefits with these 2 handy digital tools The UnitedHealthcare® app and myuhc.com®Whether on the go or online, you'll have access to resources designed to help you: • View benefit info, claim details and account balances • Search network providers and facilities for the type of care you may need • Quickly compare cost estimates before you get care • Learn about covered preventive care • Access your health plan ID card and add your plan details to your smartphone’s digital walletRegister once to access both toolsStart by downloading the UnitedHealthcare app or going to myuhc.com and then:• Tap Register Now on the app, or select Register on the website• Fill in the required fields and create your username and password • Enter your contact information and select SMS text or phone call for two-factor authentication — then, agree to the terms and conditions • Opt in to paperless delivery from your communication preferencesNow you're registered for — and connected to — the app and the website.Get connectedScan this code to download the app and register, or visit myuhc.comCertain preventive care items and services, including immunizations, are provided as specified by applicable law, including the Patient Protection and Affordable Care Act (ACA), with no cost-sharing to you. These services may be based on your age and other health factors. Other routine services may be covered under your plan, and some plans may require copayments, coinsurance or deductibles for these benefits. Always review your benefit plan documents to determine your specific coverage details.All UnitedHealthcare members can access a cost estimate online or on the mobile app. None of the cost estimates are intended to be a guarantee of your costs or benefits. Your actual costs may vary. When accessing a cost estimate, please refer to the Website or Mobile application terms of use under the Find Care & Costs section. Available only for insured plans and self-funded plans with Optum Rx integrated pharmacy benefits.The UnitedHealthcare® app is available for download for iPhone® or Android®. iPhone is a registered trademark of Apple, Inc. Android is a registered trademark of Google LLC. Health Plan coverage provided by or through a UnitedHealthcare company. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates.Administrative services provided by United HealthCare Services, Inc. or their affiliates, and UnitedHealthcare Service LLC in NY. Stop-loss insurance is underwritten by UnitedHealthcare Insurance Company or their affiliates, including UnitedHealthcare Life Insurance Company in NJ, and UnitedHealthcare Insurance Company of New York in NY.B2C EI232735050.0 12/23 © 2023 United HealthCare Services, Inc. All Rights Reserved. 23-2725605
Easily Manage Your Dental BenefitsHere’s what you can do now to get the most from your plan.Create your secure online member account today Additional plan benefits found in your secure member account1 Go online Visit ameritas.com/sign-in and select ‘Member Sign In’ under ‘Dental, Vision & Hearing.’ 2 Register Under first-time users, select ‘Register Now’ and complete the form. Log into your new account and complete the verification process.3 Authenticate Provide the personal information used at enrollment including name, date of birth and ZIP Code. Mark if you are the insured member and enter your member ID.Due to HIPAA regulations, only the primary member/policyholder has full account access. Learn more about access levels.Go paperless. Sign up to receive your explanation of benefits (EOB) statements online. To receive electronic EOBs instead of paper statements, select the go paperless option once you are logged in or when setting up your member account.GR 6122 4-24Additional savings Ameritas offers money-saving discounts to help with hearing, prescription and eyewear expenses. These savings arrangements are not insurance and are available to Ameritas plan members at no additional cost to the plan premium. Access savings cards using the QR code or through your secure account at ameritas.com.Worldwide supportAXA Assistance helps nd a provider and schedule an appointment if you have a dental or vision emergency while traveling outside the U.S. Save these numbers: 866-662-2731 (toll free) and 312-935-3727 (collect).Watch this short video to learn more about navigating your secure member account.Member account to-do list: Print out or save your ID card to your smartphone Review your plan details including maximum benefit, deductible amounts and your remaining benefits Check if your current provider is part of the Ameritas Dental Network Locate your claims status page so you can see how benefits are calculated and payments are processed
Evaluate your potential out-of-pocket costs• Located in your secure member account, the dental cost estimator lets you compare estimated procedure charges based on ZIP Code. You can search estimates for both in-network and out-of-network providers. • Ask your dentist to submit a pretreatment estimate for any dental work you consider expensive. Then Ameritas will let you know the amount insurance will cover so you can budget for the remainder. The pretreatment estimate is based on your plan benefits and submitted claims.Save moneyYou can use your dental benefits with any provider. The thing to consider is out-of-network dentists will charge you their regular rates, whereas Ameritas network providers have agreed to charge you 25-50% less. After your plan benefits are applied, you pay the remaining balance. Find out if your dentist is in the networkVisit ameritas.com, Find a Health Provider, to find a new dentist or see if your current provider is in the Ameritas Dental Network. For a list of providers that allow you to use your in-network benefits in Mexico, select Find a Contracted Provider in Mexico. Nominate your dentistIf your dentist is not in the network already, just go to ameritas.com, search for “nominate a provider” and complete the online form.Here to helpFor plan information any time, visit ameritas.com and sign in to your secure member account. Or download the Ameritas Benefits app available for iOS and Android. Log in with the same user ID and password you use for your secure member account. If you have questions about your plan benefits, use the chat feature located in your secure member account or call the Ameritas customer connections team. Claims, benefit and provider network questions: group@ameritas.com I 800-487-5553 Monday - Thursday, 7 a.m. - Midnight (CST) Friday, 7 a.m. - 6:30 p.m. (CST) 800-776-9446 ameritas.comThis is not a certificate of insurance or guarantee of coverage. Plan designs may not be available in all areas and are subject to individual state regulations. This piece is not for use in New Mexico. This information is provided by Ameritas Life Insurance Corp. (Ameritas Life). Dental, vision and hearing care products (9000 Rev. 03-16 for Group and 9000 Rev. 10-22 for Individual, dates may vary by state) are issued by Ameritas Life. The Dental and Vision Networks are not available in RI. In Texas, our dental network and plans are referred to as the Ameritas Dental Network. For WV residents, view the access plan as required by the Health Benefit Plan Network Access and Adequacy Act. Ameritas, the bison design and “fulfilling life” are service marks or registered service marks of Ameritas Life, affiliate Ameritas Holding Company or Ameritas Mutual Holding Company. © 2024 Ameritas Mutual Holding Company. Out-of-networkFilling(Type 2)Crown(Type 3)In-network$1,535$228$82$674For illustrative purposes only. Allowance and cost estimates are specific to ZIP Code 605XXX. The initial cost without insurance has been estimated. Actual charges may vary. Average dentist charges
Deductions per year: 12 These rates were prepared on 4/10/2025 and are valid for 90 days.Group Accident (GAC4100) for TXApplicable to policy forms GAC4100-P,GAC4100-ClAdditional Benefits:On/Off-Job Accident CoverageBENEFIT LEVEL AD&D BENEFIT LEVEL ISSUE AGE EMPLOYEE EMPLOYEE ANDSPOUSEEMPLOYEE ANDDEPENDENTCHILD(REN)EMPLOYEE, SPOUSEAND DEPENDENTCHILD(REN)Premier Not Included 17-99 $12.91 $19.77 $31.19 $38.20Premier Preferred 17-99 $15.10 $23.46 $34.20 $42.75Group Medical Bridge (GMB7000) for TXAge-BandedApplicable to Policy Forms GMB7000–P & GMB7000-ClWithout Wellbeing AssistanceHOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 2: $100017-49 $9.50 $17.10 $13.55 $21.1550-59 $12.30 $24.40 $16.35 $28.4560-64 $17.20 $35.80 $21.25 $39.8565-99 $24.10 $50.10 $28.15 $54.15HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 4: $200017-49 $18.90 $34.00 $26.95 $42.0550-59 $24.50 $48.60 $32.55 $56.6560-64 $34.30 $71.40 $42.35 $79.4565-99 $48.10 $100.00 $56.15 $108.05Group Critical Illness (GCI6000) for TXApplicable to policy forms GCI6000-P, GCI6000-C,R-GCI6000-CB, R-GCI6000-BB, R-GCI6000-HB,R-GCI6000-INF, R-GCI6000-PDlPlan 2 - Critical Illness & Cancer, Wellbeing Assistance Benefit - $50 BenefitNon-Tobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$15,000 17-24 $8.90 $13.05 $8.90 $13.0525-29 $11.45 $16.95 $11.45 $16.9530-34 $14.15 $20.85 $14.15 $20.8535-39 $20.15 $30.00 $20.15 $30.0040-44 $26.15 $39.00 $26.15 $39.0045-49 $36.05 $54.30 $36.05 $54.3050-54 $45.80 $69.60 $45.80 $69.6055-59 $59.30 $90.15 $59.30 $90.1560-64 $79.85 $121.35 $79.85 $121.3565-69 $97.25 $148.05 $97.25 $148.0570-74 $97.25 $148.05 $97.25 $148.05Page 1 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 3 for Important Notice
Group Critical Illness (GCI6000) for TXApplicable to policy forms GCI6000-P, GCI6000-C,R-GCI6000-CB, R-GCI6000-BB, R-GCI6000-HB,R-GCI6000-INF, R-GCI6000-PDlPlan 2 - Critical Illness & Cancer, Wellbeing Assistance Benefit - $50 BenefitNon-Tobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$30,000 17-24 $14.90 $21.60 $14.90 $21.6025-29 $20.00 $29.40 $20.00 $29.4030-34 $25.40 $37.20 $25.40 $37.2035-39 $37.40 $55.50 $37.40 $55.5040-44 $49.40 $73.50 $49.40 $73.5045-49 $69.20 $104.10 $69.20 $104.1050-54 $88.70 $134.70 $88.70 $134.7055-59 $115.70 $175.80 $115.70 $175.8060-64 $156.80 $238.20 $156.80 $238.2065-69 $191.60 $291.60 $191.60 $291.6070-74 $191.60 $291.60 $191.60 $291.60Tobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$15,000 17-24 $12.50 $18.15 $12.50 $18.1525-29 $16.70 $24.45 $16.70 $24.4530-34 $20.90 $30.75 $20.90 $30.7535-39 $30.50 $45.15 $30.50 $45.1540-44 $40.10 $59.70 $40.10 $59.7045-49 $55.85 $84.15 $55.85 $84.1550-54 $71.45 $108.60 $71.45 $108.6055-59 $93.05 $141.60 $93.05 $141.6060-64 $125.90 $191.55 $125.90 $191.5565-69 $153.80 $234.00 $153.80 $234.0070-74 $153.80 $234.00 $153.95 $234.15$30,000 17-24 $22.10 $31.80 $22.10 $31.8025-29 $30.50 $44.40 $30.50 $44.4030-34 $38.90 $57.00 $38.90 $57.0035-39 $58.10 $85.80 $58.10 $85.8040-44 $77.30 $114.90 $77.30 $114.9045-49 $108.80 $163.80 $108.80 $163.8050-54 $140.00 $212.70 $140.00 $212.7055-59 $183.20 $278.70 $183.20 $278.7060-64 $248.90 $378.60 $248.90 $378.6065-69 $304.70 $463.50 $304.70 $463.5070-74 $304.70 $463.50 $305.00 $463.80(Continued...)Page 2 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 3 for Important Notice
Term Life (ITL5000) for TXApplicable to policy form ITL5000l20-Year Term Base PlanNon-Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $6.71 $10.77 $10.54 $13.81 $17.0835 $7.69 $13.23 $11.58 $15.37 $19.1745 $9.68 $18.21 $21.79 $30.69 $39.5855 $18.06 $39.14 $46.33 $67.50 $88.6665 $41.00 $61.54 $119.08 $176.62 $234.16Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $10.48 $20.21 $18.21 $25.31 $32.4235 $11.72 $23.29 $20.62 $28.94 $37.2545 $15.89 $33.73 $45.46 $66.19 $86.9155 $33.93 $78.83 $106.04 $157.06 $208.0865 $70.14 $103.68 $203.37 $303.05 $402.7320-Year Spouse Term Life BenefitISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $2.36 $4.72 $7.07 $9.43 $11.7935 $2.81 $5.62 $8.42 $11.23 $14.0445 $6.56 $13.12 $19.67 $26.23 $32.79Children's Term Life BenefitISSUE AGE $10,000 $20,0000-18 $5.00 $10.00Important NoticeInsurance coverage has exclusions and limitations that may affect benefits payable. For a complete description of benefits, limitations and exclusions, please refer to anoutline of coverage, sample policy/certificate, proposal description or see your Colonial Life benefits counselor. Coverage type, benefits and rates vary by state. Coverage maynot be available in all states. Rates provided are illustrative and your actual premium may be different depending on your particular situation and plan choices.Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.© 2025 Colonial Life & Accident Insurance Company"Colonial Life," and the Colonial Life logo, separately and in combination, are service marks of Colonial Life & Accident Insurance Company. All rights reserved.(Continued...)Page 3 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 3 for Important Notice
6 Group Accident Insurance Premier Plan If you are in an accident, your focus should be on recovery, not how you’re going to pay your bills. Colonial Life accident insurance can pay benefits directly to you to use however you like—from medical costs to everyday expenses. Whether you’ve had a fall or a car accident, these benefits can offer financial support when you need it. Our coverage includes: Þ Benefits payable directly to you Þ No medical questions to qualify for coverage Þ Coverage for simple and complex injuries Þ Benefits payable regardless of other insurance Þ Worldwide coverage Þ Works alongside your Health Savings Account Please speak with a licensed benefit counselor for rates and see plan summary for additional details.
7 If you’re diagnosed with a covered critical illness or cancer, group critical illness insurance from Colonial Life can help with your expenses, so you can concentrate on what’s most important—your treatment, care and recovery. *The policy name is Critical Illness and Cancer Group Specified Disease Insurance. Face Amount: $15,000 & $30,000 Please speak with a licensed benefit counselor for rates and see plan summary for additional details.
8 Group Medical Bridge insurance can help with medical costs associated with a hospital stay that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children. Please speak with a licensed benefit counselor for rates and see plan summary for additional details, limitations and exclusions.
9 16 IMPORTANT NOTIFICATIONS WOMEN'S HEALTH AND CANCER RIGHTS ACT OF 1998 The federal law entled the Women's Health and Cancer Rights Act of 1998 requires group health plans and health insurers provide coverage for mastectomies to provide certain mastectomy-related benefits or services. Surge Technology Soluons, Inc. medical plan with United Healthcare provides coverage for these medical services. The following informaon is being provided to you as required by law. This noce is a summary, for informaon purposes only, and is not intended to be legal advice. The Women's Health and Cancer Rights Act of 1998 (The "ACT") was enacted as part of H.R. 4328, Federal Omnibus Consolidated and Emergency Supplemental Appropriaons Bill for 1999. The Act requires that group health plans and health insurance issuers, in the group or individual markets, that provide medical and surgical benefits with respect to mastectomy, must provide plan parcipants and plan beneficiaries who are receiving benefits in connecon with a mastectomy, and who elect breast reconstrucon in connecon with the mastectomy, coverage for the following: • reconstrucon of the breast on which the mastectomy has been performed; • surgery and reconstrucon of the other breast to produce a symmetrical appearance; • and prostheses and treatment of physical complicaon at all stages of mastectomy, including lymphedemas. Coverage for these benefits or services will be provided in a manner determined in consultaon with the aending physician and the paent. Coverage for the mastectomy-related services or benefits required under the Women's Health Law may be subject to the same deducbles and co-insurance or co-payment provisions that apply with respect to other established medical or surgical benefits under the group health plan or coverage. Insured plans, including large and small groups, individual coverage, associaon plans and self-funded plans, are subject to the law. The Act's requirements are effecve for plan years beginning on or aer October 21, 1998. In addion to the mandated coverage, the Act requires that group plans and health insurance issuers provide wrien noce of the availability of the coverage to plan parcipants and plan beneficiaries at the me of inial enrollments, and annually thereaer. The Act prohibits group health plans and health insurance issuers from: • denying eligibility or connuing eligibility; • not enrolling or non-renewing coverage under the terms of the plan solely for the purpose of avoiding compliance with the Act; • penalizing or otherwise reducing or liming the reimbursements of an aending health care provider; • providing incenves (monetary or otherwise) to an aending health care provider; or inducing a provider to provide care in a manner inconsistent with the Act. The summary above is an overview of the Women's Health and Cancer Rights Act of 1998. This is your legally required noficaon. If you have any quesons regarding the provisions of this law, please contact your plan's Member or Customer Service Department (the telephone number is on your health insurance ID card). Newborn’s & Mothers’ Protecons (Newborns’ Act) The Newborns’ and Mothers’ Health Protecon Act (Newborns’ Act) includes important protecons for mothers and their newborn children with regard to the length of the hospital stay following childbirth. The Newborns’ Act requires that group health plans that offer maternity coverage pay for at least a 48-hour hospital stay following childbirth (96-hour stay in the case of Cesarean secon).
10 COBRA LAW TEMPORARY EXTENSION OF HEALTH & DENTAL INSURANCE COVERAGE Pursuant to the Consolidated Omnibus Budget Reconciliaon Act (COBRA), Surge Technology Soluons, Inc. employees and their families the opportunity to obtain temporary extension of health coverage at the group rate in certain instances where coverage under the plan would otherwise end. An employee or an employee's dependent covered by a Surge Technology Soluons. Inc. insurance plan (medical or dental), may extend coverage for a period of eighteen (18) months if the employee’s/dependent's coverage is lost due to the occurrence of any of the following qualifying events and the employee or dependent is not covered by any other group health insurance plan: • voluntary terminaon of employment (i.e. resignaon or rerement); • involuntary terminaon of employment (other than for gross misconduct); • temporary disability leave; or • reducon in work hours. In the event of one of the above qualifying events, COBRA coverage is available for up to eighteen (18) months, but may be extended to a total of twenty-nine (29) months in certain cases of disability (see Disability Extension below). The employee and each covered dependent has an individual right to request COBRA coverage. A covered dependent may elect COBRA coverage for a period of up to thirty-six (36) months if coverage is lost due to one of the following qualifying events: • the employee's death; • divorce or legal separaon; • the employee becomes eligible for Medicare; • or the dependent child ceases to be dependent because of age, dependency status, or marriage. The cost for this extended coverage is 102% of the total premium (the amount Surge Technology Soluons, Inc. and you have been paying for health insurance coverage, plus a 2% administraon charge). If the cost for COBRA coverage changes during your parcipaon you will be nofied of the new premium in wring prior to its due date. The coverage may be terminated automacally if: (1) you fail to make a monthly premium payment, (2) obtain health coverage through a new employer, (3) Medicare coverage begins for a person benefing from the extension; (4) a spouse remarries and becomes eligible for coverage under another group health plan; or, (5) the plan itself is terminated. Both you and Surge Technology Soluons, Inc. have responsibilies when certain events occur which qualify you for connued coverage. You or a covered dependent have the responsibility to inform Surge Technology Soluons, Inc. a divorce, legal separaon, or a child losing dependent status under the group health plan within sixty (60) days of the qualifying event. Surge Technology Soluons Inc. will then nofy any other covered dependents that are affected by the event of their right to elect COBRA coverage. COBRA parcipants also have the responsibility of nofying Surge Technology Soluons, Inc. they experience addional COBRA qualifying events during their COBRA term that might qualify them for addional months of extended coverage. Legislave changes to COBRA coverage effecve January 1, 1997. Disability Extension - If you elect COBRA connuaon coverage based on terminaon of employment or reducon of hours, and you become disabled (as determined by Social Security) anyme within the first sixty (60) days of COBRA connuaon coverage, you and your covered family members may elect a special addional eleven (11)-month extension, for a total of twenty-nine (29) months of COBRA connuaon coverage. To elect the eleven (11)-month extension, you must nofy the Plan Administrator within sixty (60) days of the date Social Security determines that you or your family member is disabled and within the first eighteen (18) months of COBRA connuaon coverage. (The cost of COBRA coverage will increase from 102% to 150% of total premium during this addional eleven (11)-month extension period.) Newborn and Adopted Children - If you are entled to COBRA because you are a current or former employee of Surge Technology Soluons, Inc. a child is born to or adopted by you while you are on COBRA connuaon coverage, you can enroll your new child for COBRA connuaon coverage immediately. Also, your newborn or adopted child will aain "qualified beneficiary" status; in other words, he/she will have independent elecon rights and second qualifying event rights. Pre-exisng Condion Limitaon - COBRA coverage may be terminated when you become covered under another group health plan, but only if the other plan does not contain an exclusion or limitaon that affects a pre-exisng condion you have. If you do become covered under another group health plan and are affected by a pre-exisng condion limitaon, COBRA coverage may be canceled as soon as that pre-exisng condion limitaon is sasfied due to the new plan's creding toward the limitaon any prior coverage you had. If you have any quesons about the COBRA law, need premium informaon, or need to report a qualifying event, please contact Surge Technology Soluons, Inc.
11 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. OUR LEGAL DUTIES We are required by law to reasonably safeguard the privacy of your protected health informaon. We are also required to give you this noce about our legal dues and privacy pracces relang to protected health informaon. Protected health informaon is any individually idenfiable health informaon, whether oral or recorded in any medium, that is created or received by enes such as health care providers, health plans, or employers, and relates to the physical or mental health or condion of an individual, or to the payment for the provision of health care to an individual and that is maintained in a designated record set(s). We are required to abide by the terms of this noce currently in effect. We reserve the right to change our privacy pracces and the terms of this noce for all protected health informaon we maintain even if it was created or received before issuing the revised noce. If a material revision is made, we will distribute a copy of the revised noce. This noce takes effect on April 14, 2003, and remains in effect unl we replace it. You may request a copy of this noce at any me. For more informaon about our privacy pracces, or for addional copies of this noce, please contact the individual designated at the end of this noce. USES AND DISCLOSURES We may use and disclose your health informaon for treatment, payment, and healthcare operaons. For example: Treatment: We may use and disclose your protected health informaon to provide, coordinate, or manage your health care and any related services with a physician or other health care provider. Payment: We may use and disclose your protected health informaon to determine and to fulfill coverage responsibilies and to provide benefits under Surge Technology Soluons, Inc. health plan. We may also use and disclose your protected health informaon to obtain or provide reimbursement for benefits provided. Healthcare Operaons: We may use and disclose your protected health informaon for certain administrave, financial, legal, and quality improvement acvies necessary to run our business and to support the core funcons of treatment and payment. Such acvies include, but are not limited to, underwring and other acvies relang to the creaon, renewal, or replacement of a contract for health benefits. Such acvies also include sharing your protected health informaon with third party “business associates” that perform various acvies for us. In addion to treatment, payment and health care operaons purposes, we may use or disclose your protected health informaon for the following purposes: Family and Representaves: We must disclose your protected health informaon to you, as described in the Paent Rights secon of this noce. We may disclose your health informaon to a family member, friend or other person to the extent necessary for the proper provision or payment of healthcare. Persons Involved in Your Care: We may use or disclose protected health informaon to nofy, or assist in the noficaon of (including idenfying or locang) a family member, a personal representave of the individual, or another person responsible for the care of the individual of the individual’s locaon, general condion, or death. If you are present you will have the opportunity to object to such use or disclosure of your protected health informaon. If you are not present, or the opportunity to agree or object cannot be provided due to incapacity or emergency, we, in the exercise of professional judgment, may determine whether the disclosure is in your best interest. We may use professional judgment and our experience with common pracce to make reasonable inferences of your best interest in allowing a person to act on your behalf to pick up protected health informaon. Required by Law: We may use or disclose protected health informaon to the extent that such use or disclosure is required by federal, state or local law and the use or disclosure complies with & is limited to the relevant requirements of such law. Public Health Acvies and Related Purposes: We may disclose your protected health informaon to public health authories authorized by law to collect or receive such informaon for the purpose of prevenng or controlling disease, injury, disability, or child abuse or neglect. We may also disclose your protected health informaon to a person subject to the jurisdicon of the Food and Drug Administraon (FDA) with respect to an FDA-regulated product or acvity for which that person has certain responsibilies. Abuse or Neglect: We may disclose protected health informaon about an individual whom we reasonably believe to be a vicm of abuse, neglect, or domesc violence to a government authority, including a social service or protecve services agency, authorized by law to receive reports of such abuse, neglect, or domesc violence. Health Oversight Acvies: With certain excepons, we may disclose your protected health informaon to a health oversight agency for oversight acvies authorized by law, including audits; civil, administrave, or criminal invesgaons; inspecons; licensure or disciplinary acons; civil, administrave, or criminal proceedings or acons; or other acvies necessary for appropriate oversight of specified programs.
12 Judicial and Administrave Proceedings: We may disclose protected health informaon in the course of any judicial or administrave pro-ceeding: 1) in response to an order of a court or administrave tribunal, or 2) in response to a subpoena, discovery request, or other lawful process. Law Enforcement Purposes: We may disclose your protected health informaon for a law enforcement purpose to a law enforcement official as required or permied by law. Workers’ Compensaon: We may disclose protected health informaon as authorized by and to the extent necessary to comply with laws relang to workers’ compensaon or other similar programs that provide benefits for work-related injuries or illness without regard to fault. Health and Safety: We may, consistent with applicable law and standards of ethical conduct, use or disclose protected health informaon, if we, in good faith, believe the use or disclosure will avert a serious threat to health or safety of a person or the public. Plan Sponsor: We may disclose your protected health informaon to corporate officials as needed to fulfill our administrave responsibili-es relang to Surge Technology Soluons, Inc. Health Care Plan. Naonal Security: We may use and disclose the protected health informaon of individuals who are Armed Forces personnel for acvies deemed necessary by appropriate military command authories to assure the proper execuon of the military mission, if the appropriate military authority has published by noce the appropriate informaon. We may also disclose to authorized federal officials health infor-maon required for lawful intelligence, counterintelligence, and other naonal security acvies. We may disclose to a correconal instu-on or law enforcement official having lawful custody of an inmate or other individual protected health informaon about such inmate or individual upon a showing of necessity. INDIVIDUAL RIGHTS Access: You have a right of access to inspect and obtain a copy of protected health informaon about you, with limited excepons, for so long as we maintain the informaon. You may request the informaon in a format other than hard copies and we will comply with your request if praccable. You must make your wrien request for a copy to the contact person listed at the end of this noce. You will be charged a reasonable cost-based fee for expenses such as copies, labor, postage, and a summary of the health informaon if you request one. You may also request access by sending wrien noce to the contact person at the end of this noce. You have a right to request a review of certain denials of access. Restricon: You have the right to request addional restricons on the use and disclosure of your protected health informaon. We are not required to agree, but if we do, we are required to abide by the restricon. We must also accommodate reasonable wrien requests to receive communicaons of protected health informaon by alternave means or at alternave locaons, if you clearly state that the disclosure of all or part of that informaon could endanger you. Amendment: You have the right to request that we amend your protected health informaon. Your request must be in wring stang the reason for your request and must be provided to the contact person listed at the end of this noce. We have the right to deny such re-quests under certain circumstances. If your request is denied, you have a right to submit a wrien statement disagreeing with the denial. Accounng: You have a right to receive an accounng of disclosures of your protected health informaon made by us or our business asso-ciates for purposes other than treatment, payment or health care operaons and certain other acvies. The request may be for disclo-sures in the six years prior to the date on which the accounng is requested, but not before April 14, 2003. The first request for an ac-counng is provided free of charge. Addional requests within a 12-month period will be charged a reasonable cost-based fee. Authorizaon: The Plan will obtain your authorizaon for uses or disclosures that are not idenfied by this noce or permied by applica-ble law. You may revoke any authorizaon in wring at any me. Your revocaon will not affect any use or disclosure permied by your authorizaon while it was in effect. Electronic Noce: If you receive this noce electronically, you may sll obtain a paper copy upon request to the contact person listed at the end of this noce. QUESTIONS AND COMPLAINTS If you have quesons, concerns, or complaints about our privacy pracces please contact us. Soumya Madishey 832-930-8777 HR@surgetechinc.com If you believe that your privacy rights have been violated or you are concerned about a decision relang to access, restricon, amendment, accounng, or noce, you may file a grievance with the contact person listed below. You may also submit a wrien complaint to the Secre-tary of the U.S. Department of Health and Human Services at: Region VI, Office for Civil Rights, U.S. Department of Health and Human Ser-vices, 1301 Young Street, Suite 1169, Dallas, Texas 75202; or by e-mail at: OCRComplaint@hhs.gov. The privacy of your health informaon is important to us. We will not retaliate against you for filing a complaint.
13 Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free or Low-Cost Health Coverage to Children and Families If you are eligible for health coverage from your employer, but are unable to afford the premiums, many states, including Texas, have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP, you can contact the Texas State Medicaid or CHIP office to find out if premium assistance is available to you. 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, you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer- sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer’s health plan is required to permit you and your dependents to enroll in the plan – as long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. You may be eligible for assistance for paying your employer health plan premiums. To find out if you are you should contact the following department for addional informaon about eligibility. If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2014. Contact your State for more informaon on eligibility. 17 ALABAMA – Medicaid ALASKA – Medicaid Website: http://www.medicaid.alabama.gov Phone: 1-855-692-5447 Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529 ARIZONA – CHIP COLORADO – Medicaid Website: http://www.azahcccs.gov/applicants Phone (Outside of Maricopa County): 1-877-764-5437 Phone (Maricopa County): 602-417-5437 Website: http://www.colorado.gov/ Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943 FLORIDA – Medicaid GEORGIA – Medicaid Website: https://www.flmedicaidtplrecovery.com/ Phone: 1-877-357-3268 Website: http://dch.georgia.gov/ - Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: 1-800-869-1150 IDAHO – Medicaid INDIANA – Medicaid Medicaid Website: http://healthandwelfare.idaho.gov/Medical/Medicaid/PremiumAssist ance/tabid/1510/Default.aspx Medicaid Phone: 1-800-926-2588 Website: http://www.in.gov/fssa Phone: 1-800-889-9949 IOWA – Medicaid KANSAS – Medicaid Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 Website: http://www.kdheks.gov/hcf/ Phone: 1-800-792-4884 KENTUCKY – Medicaid LOUISIANA – Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570 Website: http://www.lahipp.dhh.louisiana.gov Phone: 1-888-695-2447 MAINE – Medicaid MASSACHUSETTS – Medicaid and CHIP Website: http://www.maine.gov/dhhs/ofi/public- assistance/index.html Phone: 1-800-977-6740 Website: http://www.mass.gov/MassHealth Phone: 1-800-462-1120 MINNESOTA – Medicaid MISSOURI – Medicaid Website: http://www.dhs.state.mn.us/ Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
14 To see if any other states have added a premium assistance program since July 31, 2014, or for more informaon on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administraon www.dol.gov/ebsa U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 18 MONTANA – Medicaid NEBRASKA – Medicaid Website: http://medicaidprovider.hhs.mt.gov Phone: 1-800-694-3084 Website: www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 NEVADA – Medicaid NEW HAMPSHIRE – Medicaid Website: http://dwss.nv.gov/ Phone: 1-800-992-0900 Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 NEW JERSEY – Medicaid and CHIP NEW YORK – Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA – Medicaid NORTH DAKOTA – Medicaid Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100 Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-755-2604 OKLAHOMA – Medicaid and CHIP OREGON – Medicaid Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 Website: http://www.oregonhealthykids.gov Phone: 1-800-699-9075 PENNSYLVANIA – Medicaid RHODE ISLAND – Medicaid Website: http://www.dpw.state.pa.us/hipp Phone: 1-800-692-7462 Website: www.ohhs.ri.gov Phone: 401-462-5300 SOUTH CAROLINA – Medicaid SOUTH DAKOTA – Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 Website: http://dss.sd.gov Phone: 1-888-828-0059 TEXAS – Medicaid UTAH – Medicaid and CHIP Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493 Website: http://health.utah.gov/upp Phone: 1-866-435-7414 VERMONT – Medicaid VIRGINA – Medicaid and CHIP Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427 Website: http://www.coverva.org/programs_premium_assistance.cfm Phone: 1-800-432-5924 WASHINGTON – Medicaid WEST VIRGINA – Medicaid Website: http://www.hca.wa.gov/medicaid/ Phone: 1-800-562-3022 ext. 15473 Website: www.dhhr.wv.gov/bms/ Phone: 1-877-598-5820, HMS Third Party Liability WISCONSIN – Medicaid WYOMING – Medicaid Website: http://www.badgercareplus.org/pubs/p-10095.htm Website: http://health.wyo.gov/healthcarefin/equalitycare
15 HIPAA NOTICE OF SPECIAL ENROLLMENT RIGHTS If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contribung towards your or your dependents’ other coverage). However, you must request enrollment within 30 days aer your or your dependents’ other coverage ends (or aer employer stops contribung towards the other coverage). In addion, if you have a new dependent as a result of marriage, birth, adopon, or placement for adopon, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days aer the marriage, birth, adopon, or placement for adopon. IMPORTANT NOTICE FROM Surge Technology Soluons, Inc. ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND MEDICARE Please read this noce carefully and keep it where you can find it. This noce has informaon about your current prescripon drug coverage with Surge Technology Soluons, Inc. and about your opons under Medicare’s prescripon drug coverage. This informaon can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescripon drug coverage in your area. Informaon about where you can get help to make decisions about your prescripon drug coverage is at the end of this noce. There are two important things you need to know about your current coverage and Medicare’s prescripon drug coverage: 1. Medicare prescripon drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescripon Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescripon drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Surge Technology Soluons, Inc. Services Corp. has determined that the prescripon drug coverage offered by the BlueCross BlueShield of Texas is, on average for all plan parcipants, expected to pay out as much as standard Medicare prescripon drug coverage pays and is therefore considered Creditable Coverage. Because your exisng coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescripon drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current BlueCross BlueShield of Texas coverage will [or will not] be affected. See pages 7- 9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance (available at hp://www.cms.hhs.gov/CreditableCoverage/), which outlines the prescripon drug plan provisions/opons that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D. If you do decide to join a Medicare drug plan and drop your current Surge Technology Soluons, Inc. coverage, be aware that you and your dependents will not be able to get this coverage back.
16 When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Surge Technology Solutions, Inc. and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For exam-ple, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare pre-scription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information: Soumya Madishetty 832-930-8777 Company Email: HR@surgetechinc.com NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Surge Technology Solutions, Inc. changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit www.medicare.gov Call your State Health Insurance Assistance Program for personalized help Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For infor-mation about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, there-fore, whether or not you are required to pay a higher premium (a penalty).