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Annual Enrollment Effective September 1, 20242024-2025Employee Benefits Guide

2Important NoticeThe Fay School has made every attempt to ensure the accuracy of the information described in this enrollment guide. This guide is not an official plan document and does not provide a complete description of your benefit plans. Any discrepancy between this guide and the insurance contracts, summary plan descriptions (SPDs) or any other legal documents that govern the plans of benefits described in this enrollment guide will be resolved according to those documents. The Fay School reserves the right to amend or discontinue the benefits described in this enrollment guide in the future, as well as change how eligible employees and The Fay School share plan costs at any time. This enrollment guide creates neither an employment agreement of any kind nor a guarantee of continued employment with The Fay School.Table of Contents3 Welcome4 Eligibility5 Employee Contributions6 Medical Plan Options7 Prescription Drug Benefits8 Where to Go for Care9 Dental Benefits10 Vision Benefits11 Flexible Spending Accounts (FSA)12 Life Insurance13 Voluntary Life Rates14 Income Protection Benefits15 Additional Benefits16 Voluntary Benefits17 Key Contacts18 Important Notices

Welcome3OPEN ENROLLMENT is from August 12th through August 21st At The Fay School, we truly value the dedication that goes into your work every day. We’re proud of our talented employees and understand that our success is because of you. That’s why as a Fay School employee, you have access to a quality, comprehensive benefits package that offers flexibility and security for you and your family.2024 Open EnrollmentStarting August 12th , 2024, you will have the opportunity to make changes to your health care coverage that will become effective September 1, 2024. All benefit elections must be made by August 21st .All eligible employees must participate in Open Enrollment in which you can do any or all of the following: • Make changes to your medical, dental, or vision coverage for the upcoming plan year• Contribute to a Health Care and/or Dependent Care Flexible Spending Account (FSA)• Make changes to your income protection benefitsThis is an active enrollment. You must complete your elections in order to have coverage in 2024. You must participate in Open Enrollment even if you are waiving all coverage as all eligible employees are enrolled in certain employer sponsored products.Review this guide to choose which benefits are right for you. If after reading this guide you need more information, please contact LaSonya Fleming at HR@thefayschool.org or by calling the school at 713-681-8300.DURING OPEN ENROLLMENTYou can make changes to your benefits each year during the annual open enrollment period (normally held in August) for benefits effective September 1–August 31 of the following year. 2QUALIFYING LIFE EVENTSYour 2024 elections will remain in effect throughout the plan year unless you experience a change in status that affects eligibility for benefits or another qualifying life event (in accordance with Internal Revenue Code rules). You must request an election change within 30 days and may need to provide supporting documentation (such as a marriage license or birth certificate).3AS A NEW HIREYou can enroll in benefits effective the first of the month following date of hire. If you miss this initial enrollment window, your next opportunity to enroll will be the annual open enrollment period.1Enrolling in Benefits There are three opportunities to enroll in or make changes to your benefits:

Eligibility4Full-time employees (working a minimum of 30 hours per week) and their eligible dependents can participate in The Fay School benefits. Eligible dependents include: • Your legal spouse or domestic partner ¹ • Child(ren) up to age 26 • Child(ren) of any age if you support the child and he or she is incapable of self-support due to mental or physical disability Enrolling in BenefitsIf you’re eligible for The Fay School benefits you can enroll thru Employee Navigator by visiting www.employeenavigator.com. Once you’ve accessed the page, log in with the username and password you selected. If after reading this guide you have enrollment questions, please reach out toLaSonya Fleming at hr@thefayschool.org.Proof of Dependent Eligibility You may be required to provide proof of eligibility for your dependents. Note that attempting to enroll an ineligible dependent could lead to discipline and possible termination of employment. If your dependent becomes ineligible for coverage during the year, you must contact Human Resources within 30 days. Failure to provide notification may lead to discipline, termination of coverage and possible termination of employment. Qualifying Life EventsOnce you enroll in your benefit plan, your elections remain in effect for the remainder of the plan year. The only exception is if you have a qualifying change in status. Any benefit changes resulting from a Qualifying Life Event must be requested by the employee within 30 days of the event. These qualifying events include:• Marriage, divorce or legal separation• Birth, adoption, placement for adoption or custody of a child• The death of a dependent• A change in your spouse’s employment that affects your benefits eligibility (starting a new job, leaving a job, starting or returning from an unpaid leave of absence or changing from part-time to full-time status, etc.)• A change in your dependent’s eligibility for benefits• A change in you or your dependent’s residence that affects eligibility for coverage• Receiving a court order, such as a Qualified Medical Child Support Order1Due to federal and state tax regulations, benefits provided to domestic partners are generally taxable and therefore deducted from your pay on an after-tax basis. Additionally, any premium contributions made by The Fay School on behalf of your domestic partner are generally considered taxable income to you. Contact The Fay School if you believe your domestic partner is exempt from federal or state taxes.

Employee Contributions5The values below indicate how much you’re responsible for contributing towards coverage. Amounts are taken directly from your paycheck.Contribution SummarySemi-monthlySemi-monthlyBenefitEmployee OnlyEmployee + SpouseEmployee + Child(ren)Employee + FamilyKelsey Charter Plan$16.78 $188.96 $157.66 $329.84Base Choice Plan$38.39 $211.66 $178.19 $362.26Buy Up Choice Plus Plan$46.61 $220.28 $185.99 $374.59Dental High/Low Plan$0 $10.65 $17.77 $31.94Vision Plan$0 $1.30 $1.17 $2.58Basic Life AD&DEmployee SponsoredSupplemental Life AD&DSee page 13 for rate sheetSupplemental Long-Term Disability (LTD)Employee SponsoredBenefitEmployee OnlyEmployee + SpouseEmployee + Child(ren)Employee + FamilyKelsey Charter Plan$33.56 $377.92 $315.31 $659.68Base Choice Plan$76.78 $423.31 $356.37 $724.51Buy Up Choice Plus Plan$93.21 $440.56 $371.98 $749.17Dental High/Low Plan$0 $21.30 $35.55 $63.87Vision Plan$0 $2.60 $2.34 $5.17Monthly

Medical Plan Options6You have the choice of several quality and comprehensive medical plans through United Healthcare. When choosing your plan, consider your budget, any planned procedures and other potential healthcare needs.To find a network provider sign in to myuhc.com> Find Care & Costs to find a network PCP, clinic, hospital or lab based on location, specialty, availability, hours of operation and more. You can even see patient ratings and estimate the cost of care before you choose a provider. If you would like more information about a provider's qualifications, call the member phone number on your ID card.Medical Plans Summary Key FeaturesKelsey Charter PlanBase Choice PlanBuy Up Choice Plus PlanIn-Network In-Network In-Network Out-of-NetworkCalendar Year DeductibleIndividual / Family$1,000 / $2,000 $1,500 / $3,000 $1,500 / $3,000 $3,000 / $6,000Out-of-Pocket Maximum (includes deductible)Individual / Family$3,500 / $7,000 $5,000 / $10,000 $5,000 / $10,000 $10,000 / $20,000Lifetime MaximumNo Limit No Limit No LimitCoinsurance (portion you pay)0% 20% 20% 50%Preventive CareCovered 100% Covered 100% Covered 100% 50% after DedPhysician ServicesOffice Visit / Specialist Visit$25 / $75 $25 / $75 $25 / $75 50% after DedSpecialist – Referral RequiredYes No No NoUrgent Care Copay$50 $50 $50 50% after DedEmergency Room Copay(waived if admitted)$300 copay + Ded $300 copay + Ded + Coins$300 copay + Ded + Coins$300 copay + Ded + CoinsInpatient Hospital (per admission)0% 20% after Ded 20% after Ded 20% after DedLab and X-Ray Services (Physician Office)0% 20% after Ded 20% after Ded 20% after Ded

Prescription Drug Benefits7Medical plan options include prescription drug coverage from Optum RX through United Health Care. When you log into myuhc.com. Pharmacies & Prescriptions you can: Find and compare medication costs, locate a network pharmacy and see if your medications have any requirements before filling them. Optum Rx pharmacy services help make it easier to save on medications and keep track of them, too—whether you're online or on the go.Ways to Save on Your PrescriptionsThere are many ways to save on prescriptions! Keep these in mind the next time your provider prescribes a new medication.Order by MailFor maintenance medications, you can save time and money by using a mail-order service. Instead of a 30-day supply, you can have a 90-day supply shipped directly to you.Compare PharmaciesLess expensive prescriptions may be offered by some pharmacies, such as those at warehouse clubs or discount stores. Call ahead to determine which has the most competitive price.Check Over-The-Counter OptionsOver-the-counter drugs can be an inexpensive alternative for some common ailments. Ask your pharmacist if they have any suggestions for options that serve the same purpose for less.Key FeaturesKelsey Charter Plan Base EPO PlanBuy Up PPO PlanIn-NetworkIn-Network In-NetworkOut-of-NetworkRETAIL PRESCRIPTIONS (30-DAY SUPPLY)Tier 1 $10 $10 $10$10Tier 2 $35 $35 $35$35Tier 3 $75 $75 $75$75Tier 4 $250 $250 $250$250MAIL-ORDER PRESCRIPTIONS (90-DAY SUPPLY)Tier 1 $25 $25 $25N/ATier 2 $87.50 $87.50 $87.50N/ATier 3 $187.50 $187.50 $187.50N/ATier 4 $625 $625 $625N/A

Where to Go for Care8With so many options for care, how do you know which is best for the flu, a broken bone or physical exam?Depending upon where you receive medical attention, the cost can vary immensely. Here’s a general guideline that can help you save on health care expenses and your time.Location of Care Cost Common Conditions Time InvestmentTelemedicine$0No Charge by a Designated Virtual Network Provider.• Cough/cold/sinus/flu• Earaches/stomach pain/diarrhea• Rashes/allergies/• insect bites• Urinary tract infections• Pink eyeAppointments typically available within an hourNo need to leave homePrimary Care Physician or Retail Clinic$25In-network Provider• Checkups• Preventive services• Vaccinations and screenings• General health management• Sick visits for minor conditionsUsually need appointmentShort wait timesUrgent Care$50In-network Provider• Severe Fever and flu symptoms• Sprains and strains• Stitches• Minor burns• Minor infections• Minor broken bonesNo appointment neededTypically, have extended hoursEmergency Room$300• Chest pain • Heavy bleeding• Large open wounds• Spinal or head injuries• Major broken bones• Severe cuts/burns• Numbness or weakness• Sudden vision changeOpen 24/7No appointment neededWait times can be up to several hours

Dental Benefits9The Mutual of Omaha dental plans are designed to keep you smiling year after year. Good dental health can have an impact on you as a whole and can be the first sign of a more serious health issue. Take advantage of our comprehensive plan options and keep up with your preventive dental care. The Fay School offers you the ability to choose from two different dental PPO options. You may notice the premiums for both plans are the same low rate. If you remain in network for most of your dental claims, the High Plan will offer better coverage. However, if you choose to seek services out of network, you may consider the low plan.High and Low PPO dental plans utilize the: Mutually Preferred Dental Network.To find a participating Mutual of Omaha dental provider, visit www.mutualofomaha.com/dental-insurance or call 1-866-480-7566Key FeaturesHigh PPO Low PPOIn-Network Only In-NetworkCalendar Year Deductible (Individual / Family)$50 / $150 $50 / $150Preventive Services (no deductible)100% 100%Basic Services100% 80%Major Services60% 50%Orthodontics (children up to age 19)50% 50%Orthodontics Lifetime Maximum$2,000 $2,000Annual Calendar Year Maximum$2,000 $2,000Plan Plan FeaturesPPO• Allows you to receive care from a dentist in the network or outside the network• Pays a portion of your expenses after you meet your annual deductible, except for preventive care which is covered at 100% Dental Plans Summary

Vision Benefits10You and your dependents have access to vision coverage through Mutual of Omaha. The plan pays benefits for both in-network and out-of-network services. When you visit an in-network provider through the EyeMed Insight Network pays for eligible expenses at a higher level. If you receive care outside the network, you will need to pay the full cost upfront and file a claim to be reimbursed for a portion of the costs.To find a participating Mutual of Omaha provider, visit www.mutualofomaha.com/vision-insurance or call 1-833-279-4358Vision Plans Summary Key Features In-Network Out-of-Network Frequency Exam$10 N/A Every 12 monthsLenses• Single Vision• Lined Bifocal• Lined Trifocal• LenticularCovered at 100% after copay• Up to $20• Up to $36• Up to $64• Up to $64Every 12 monthsFramesUp to $13020% Discount on remaining balanceUp to $58 Every 24 monthsContact Lenses (instead of glasses)Elective: Up to $130 allowanceMedically Necessary: Covered 100%Up to $104Up to $210Every 12 months10

Flexible Spending Accounts (FSA)11Flexible Spending Accounts (FSAs) allow you to save money from your paycheck to pay Health Care expenses with tax-free dollars. When you contribute to FSAs, your pretax contributions reduce your taxable income.Account What it can be used for:Most you can contribute in 2024:Health Care FSATo pay medical, dental, vision, and hearing expenses not covered by your health care plans, such as deductibles, coinsurance and copayments.$3,200Healthcare FSAThe Healthcare FSA lets you set aside up to $3,200 (2024 IRS limit) from your paycheck for eligible medical, dental and vision expenses. Use-It or Lose-It – if your plan has a carry over feature, any funds over $640 will be lost at the end of the plan year. Make sure to use it, all funds over $610 do not roll-over!Determine how much you want to saveEnroll to have that amount taken out, divided equally per checkUse your FSA debit card or submit receipts for qualifying expensesHow the FSAs Work• Before you enroll you should estimate your annual health care expenses in 2024.• Your contributions are deducted from your paycheck on a pretax basis in equal amounts throughout the year. Your entire account balance is available as of September 1, 2024.• If you enroll in the Health Care FSA, you will receive a debit card that you can use to pay for eligible health care expenses at the point of service. Otherwise, you can pay for expenses out-of-pocket and submit a claim for reimbursement online or by mail.• You choose how much to put into the account, up to the IRS limit each year (IRS 502 Publicationor the IRS 503 Publication for full details) • FSA elections do not automatically roll over from one year to the next. You must re-enroll each year to participate.• For a complete list of eligible Health Care expenses and to manage your account through Healthy Equity/Wage Works please visit www.healthequity.com/wageworksor call 1-877-924-3967

Life Insurance12Basic Life and AD&D The Fay School provides you with Basic Life and AD&D insurance in the amount of $30,000. You are automatically enrolled and there is no cost to you. If your death is the result of an accident, you will receive an additional Accidental Death & Dismemberment (AD&D) benefit. If you lose a limb or your eyesight as the result of an accident, the AD&D plan will pay a percentage of your AD&D benefit amount. Supplemental Life and AD&D You have the option to supplement your company-paid coverage by purchasing additional Life and AD&D insurance for yourself, your spouse and your children. You are required to purchase coverage for yourself in order to enroll your family members. You pay the full cost of this coverage on an after-tax basis. The cost varies depending on your age and the amount of coverage you choose. This chart shows the coverage amounts you can choose. Please note: Evidence of insurability may be required if you enroll after your initial eligibility period or if you elect amounts over the policy's Guarantee Issue amount.Voluntary Life Employee Spouse ChildrenBenefit Amount $10,000 increments minimum $10,000 and and cannot exceed 5 times your basic annual salary or $500,000. AD&D benefit amount is equal to the life insurance benefit amount elected.Employee coverage terminates upon retirement.$5,000 incrementsup to 50% of the employee’s benefit amount up to $250,000.(whichever is less)AD&D benefit amount is equal to the life insurance benefit amount elected. Spouse coverage terminates at age 70.$1,000 increments with a minimum benefit amount of $2,000 and a max benefit amount of $10,000AD&D benefit amount is equal to the life insurance benefit amount elected.Child coverage cannot exceed 50% of the employee coverage and is only guaranteed if employee coverage is placed.Guaranteed Issue Amount $100,000 during initial enrollment only$50,000during initial enrollment only$10,000during initial enrollment only

Voluntary Life Rates13To calculate your premium, do the following:1. Select your benefit amount.2. Locate the benefit amount you want from the top row of the employee premium table. Your benefit amount must be in anincrement of $10,000. Refer to the Coverage Guidelines section for minimums and maximums, if needed.3. Find your age bracket in the far left column.4. Your premium amount is found in the box where the row (your age) and the column (benefit amount) intersect.Follow the method described above to select a benefit amount and calculate premiums for optional dependent spouseand/or child(ren) coverage. Your spouse’s rate is based on your age, so find your age bracket in the far left column ofthe Spouse Premium Table. Your spouse’s premium amount is found in the box where the row (the age) and the column(benefit amount) intersect. Your spouse’s benefit amount must be in an increment of $5,000. Refer to the CoverageGuidelines section for minimums and maximums, if needed.SPOUSE PREMIUM TABLE (24 PAYROLL DEDUCTIONS PER YEAR)Age $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,0000 - 29$0.17 $0.33 $0.49 $0.65 $0.82 $0.98 $1.14 $1.30 $1.47 $1.6330 - 34$0.19 $0.38 $0.57 $0.75 $0.94 $1.13 $1.32 $1.50 $1.69 $1.8835 - 39$0.27 $0.53 $0.79 $1.05 $1.32 $1.58 $1.84 $2.10 $2.37 $2.6340 - 44$0.42 $0.83 $1.24 $1.65 $2.07 $2.48 $2.89 $3.30 $3.72 $4.1345 - 49$0.57 $1.13 $1.69 $2.25 $2.82 $3.38 $3.94 $4.50 $5.07 $5.6350 - 54$1.09 $2.18 $3.27 $4.35 $5.44 $6.53 $7.62 $8.70 $9.79 $10.8855 - 59$1.64 $3.28 $4.92 $6.55 $8.19 $9.83 $11.47 $13.10 $14.74 $16.3860 - 64$1.69 $3.38 $5.07 $6.75 $8.44 $10.13 $11.82 $13.50 $15.19 $16.8865 - 69$2.99 $5.98 $8.97 $11.95 $14.94 $17.93 $20.92 $23.90 $26.89 $29.88ALL CHILDREN PREMIUM TABLE (24 PAYROLL DEDUCTIONS PER YEAR)*$2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000$0.23 $0.34 $0.45 $0.57 $0.68 $0.79 $0.90 $1.02 $1.13*Regardless of how many children you have, they are included in the "All Children" premium amounts listed in the tableabove.

Income Protection Benefits14DisabilityThe Fay School offers Long-Term Disability (LTD) through Mutual of Omaha. A disability income insurance policy can help provide security when you need it most. It pays you cash benefits when you’re sick or hurt and can’t work. You must be actively working a minimum of 30 hours per week to be eligible for coverage. The premiums for this insurance are paid in full by The Fay School, there is no cost to you.Plan Long-Term DisabilityWhen Benefits Begin 90 days after illness or accidentWhen Benefits End Benefits continue until you are no longer disabled or until you reach Social Security Normal Retirement Age, whichever comes first.Benefits Paid You receive 60% of your pay, up to a maximum benefit of $6,000 per month. Survivor Benefit If you pass away while receiving disability benefits, a lump sum equal to 3 times your monthly benefit will be paid to your eligible survivor

Additional Benefits15Employee Assistance Program (EAP) The Fay School provides you with a no-cost EAP program through Mutual of Omaha. All EAP services are 100% confidential and no information is shared with The Fay School the EAP offers you and your family information, referrals and short-term counseling. The EAP offers 24/7 telephone access to licensed professionals who can help with concerns regarding marriage and relationships, depression, anxiety, stress, grief, substance abuse, childcare, elder care, work-related issues, and much more. The EAP may refer you to a local counselor who can address your concerns in person. The program also gives you access to:• Childcare and elder care resources• Financial and legal consultations and information• Identity theft prevention and recoveryTo take advantage of the services and resources available through the EAP, call 1-800-316-2796. You can also access valuable information online at mutualofomaha.com/eapHEARING DISCOUNT PROGRAMIn addition to your hearing care benefit, you will have access to complimentary aftercare, including:• Custom hearing solutions — wide choice of products from the industry’s leading brands• Risk-free trial — find your right fit by trying your hearing aids for 60 days• Follow-up care — ensures a smooth transition to your new hearing aids• Battery support — battery supply or charging station to keep your hearing aids powered• Warranty — 3-year coverage for loss, repairs, or damageTo learn more visit amplifonusa.com/mutualofomahaIDENTITY THEFT ASSISTANCEIf your identity is compromised, the most important thing to do is respond quickly. Identity Theft Assistance, provided by AXA Assistance, helps you and your dependents understand the risks of identity theft, learn how to prevent it, and most importantly, assist you if your information is compromised.Access ID Theft Assistance services by calling AXA Assistance toll-free at (800) 856-9947WORLDWIDE TRAVEL ASSISTANCETravel Assistance Travels With You Experiencing an emergency while traveling can be especially difficult. Knowing who to call for medical problems, currency exchange issues or lost luggage is critical. Take comfort in knowing that Travel Assistance travels with you worldwide, offering access to a network of professionals who can help you with local medical referrals or provide other emergency assistance services in foreign locations.Services available for business and personal travel 24 hours a day, seven days a week. For inquiries within the U.S. call toll free: 1-800-856-9947 Outside the U.S. call collect: (312) 935-3658WILL PREPARATIONNo one likes to think about what happens when they’re gone. But it’s important for you to have a plan and one of the best ways to plan is to make a will.To create your will, visit www.willprepservices.com and use the code MUTUALWILLS to register. Once registered, you can get started drafting your will.

Voluntary Benefits16Voluntary benefits provide cash reimbursement during your time of need. Unlike traditional insurance, which covers medical costs, these benefits provide you with a cash benefit should you become ill with a critical illness, experience an accident, are hospitalized or need legal assistance. These benefits can help pay for out-of-pocket expenses not covered by other plans. You can enroll yourself and your eligible family members. Coverage for the voluntary plans is 100% employee-paid. For more information on voluntary benefits plans through Colonial Life call 1-800-325-4368Accident InsuranceAccident Insurance helps cover the cost of emergency medical care, physical therapy and other unexpected expenses that result from an accidental injury. Covered injuries and expenses may include:• Broken bones, burns and torn ligaments• Cuts requiring stitches• Concussions• Emergency room treatment and hospitalization• Outpatient surgery• Chiropractic care and physical therapyCritical IllnessCritical Illness Insurance pays a benefit if you are diagnosed with a serious illness covered by the plan. The benefit is paid to you and can be used to pay medical costs or living expenses such as child care or mortgage payments. Covered illnesses may include:• Heart attack or coronary artery disease • Stroke• Benign brain tumor• Major organ failure• Kidney failure• CancerMedical Bridge Gap InsuranceWith medical costs on the rise, you may be faced with having to pay more for things that your health insurance won't cover. (GAP) insurance can help fill those gaps.Cancer Assist InsuranceHelps pay some of the direct and indirect costs related to cancer diagnosis and treatment. Benefits can be used to help fill the gaps in deductibles and coinsurance and help pay unexpected expenses.Term Life InsuranceProvides financial protection for your family when you or a loved one passes away. If something happened to you, the last thing your family should have to worry about is financial burdens, funeral expenses, medical bills, taxes and the ongoing cost of living. Protect your family with life additional life coverage.Short Term Disability Insurance (STD)insurance is protection for the thing that matters most—your ability to earn an income. Sometimes referred to as paycheck protection, this insurance can replace a portion of your income if you are unable to work because of the birth of a new child, any covered injury or an illness.PRODUCT FEATURES:Payroll Deduction: Premiums are paid through theconvenience of payroll deduction.Pre-Tax: Most plans can be paid for pre-tax through aSection 125 plan.Pays In Addition To Other Insurance: Benefits are paidin addition to any other insurance coverage you may have.Pays Policyholder: Benefits are paid directly to you unlessassigned to a health care provider.Portable: These policies are individually owned andportable so you may convert your policy to a direct payment method with no increase in premium if youremployment is terminated.Guaranteed Renewable: The plans are guaranteedrenewable for the life of the policy as long as premium payments are maintained.

Key Contacts17For Questions About CarrierPlan/Group IDPhone Number Website/EmailMedical & Prescription Drug United Healthcare 5400023725 1-877-797-8812 www.myuhc.comDental Mutual of Omaha G000BRMR 1-800-927-9197www.mutualofomaha.com/dentalVision Mutual of Omaha G000BRMR 1-833-279-4358www.mutualofomaha.com/visionHealth Care Spending Accounts (FSAs)Health Equity/Wage Works54157 1-877-924-3967www.healthequity.com/wageworksLife and AD&D Insurance Mutual of Omaha G000BRMR1-800-377-9000www.mutualofomaha.com/lifeLong-Term Disability (LTD) Mutual of Omaha G000BRMR1-800-877-5176www.mutualofomaha.com/disabilityEmployee Assistance Program (EAP)Mutual of Omaha G000BRMR1-800-316-2796www.mutualofomaha.com/eapVoluntary Benefits Colonial Life1-800-325-4368www.coloniallife.comThe Fay School Business OfficeJeff Fountain713-681-8300jfountain@thefayschool.orgThe Fay School Human ResourcesLaSonya Fleming713-681-8300hr@thefayschool.orgEPIC Brokers & Consultants Tanya Henry469-217-7681tanya.henry@epicbrokers.com17

Important Notice Information18The following legal notices for participants in group health plans, sponsored by The Fay School, are required to be distributed on an annual basis. While no action is required on your part in relation to these notices, these areprovided to you for informational purposes and you should take time to familiarize yourself with their content.Please note, all the listed compliance notices below can be found in your Enrollment / Compliance Booklet.• United Healthcare Level Funded Charter Medical Plan SBC• United Healthcare Level Funded Choice Medical Plan SBC• United Healthcare Level Funded Choice Plus Medical Plan SBC• Health Insurance Marketplace Coverage Notice (Exchange Notice)• HIPAA Special Enrollment Rights Notice• Medicaid and The Children’s Health Insurance Program (CHIP)• Michelle’s Law• Women’s Health and Cancer Rights Act of 1998• Medicare Part D Eligible Employees and Dependents• COBRA Initial Rights Notice• Employee Rights Under The Family Medical Leave Act (FMLA)• Patient Protection Disclosures• Newborns and Mothers’ Health Protection Act• Notice of Privacy Practices

Health Plan NoticesThe Fay School Health Plan NoticesSeptember 1, 2024Included in This Packet:• Medicare Notice of Creditable Coverage• Patient Protection Notice• Notice of Special Enrollment Rights• Newborns and Mothers’ Health Protection Act Notice• Women’s Health and Cancer Rights Act Notice• Notice of HIPAA Privacy Practices

Prepared ByHealth Plan NoticesMEDICARE NOTICE OF CREDITABLE COVERAGEImportant Notice AboutYour Prescription Drug Coverage and MedicareNotice of Creditable CoverageThis Notice applies only if you and/or your dependent(s) are enrolled in a The Fay Schoolmedical plan and you are eligible for Medicare. If this does not apply to you, you mayignore this notice.Please read this notice carefully and keep it where you can find it. This notice has information about your prescription drug coverage with The Fay School and your optionsunder Medicare’s prescription drug coverage. This information can help you decidewhether or not you want to join a Medicare drug plan. If you are considering joining, youshould compare your employer coverage, including which drugs are covered at what cost,with the coverage and costs of the plans offering Medicare prescription drug coverage inyour area. Information about where you can get help to make decisions about yourprescription drug coverage is at the end of this notice.There are two important things you need to know about your employer coverage andMedicare’s prescription drug coverage:1. Medicare prescription drug coverage became available in 2006 to everyone withMedicare. You can get this coverage if you join a Medicare Prescription Drug Plan orjoin a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drugcoverage. All Medicare drug plans provide at least a standard level of coverage set byMedicare. Some plans may also offer more coverage for a higher monthly premium.2. The Fay School has determined that the prescription drug coverage offered underthe The Fay School plan(s) are, on average for all plan participants, expected to payout as much as standard Medicare prescription drug coverage pays and is thereforeconsidered Creditable Coverage. Because your coverage is Creditable Coverage, youcan keep this coverage and not pay a higher premium (a penalty) if you later decideto join a Medicare drug plan.

Prepared ByHealth Plan NoticesWhen 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 creditable prescription drug coverage through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.What Happens To Your Employer Coverage If You Decide to Join A Medicare Drug Plan?Your health plan coverage pays for other health expenses in addition to prescription drug. If you enroll in a Medicare prescription drug plan, you and your eligible dependents will be eligible to receive all of your current health and prescription drug benefits.If you do decide to join a Medicare drug plan and drop your employer coverage, be aware that you and your dependents will beeligible to receive health and prescription drug benefitsin the future.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 employer coverage and don’t join aMedicare drug plan within 63 continuous days after the coverage ends, you may pay ahigher premium (a penalty) to join a Medicare drug plan later.If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.For More Information About This Notice Or Your Employer Prescription Drug Coverage…Contact the person listed below for further information. NOTE: You’ll get this noticeeach year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage changes. You also may request a copy of this notice at any time.

Prepared ByHealth Plan NoticesFor More Information About Your Options Under Medicare Prescription Drug Coverage…More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.For More Information about Medicare prescription drug coverage: Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web atwww.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).September 1, 2024 The Fay SchoolLaSonya Fleming, Human Resources Officer105 N. Post Oak LnHouston, TX 77024(713) 681-8300 x 8911

Prepared ByHealth Plan NoticesPatient Protection NoticeYour health plan may require or allow for the designation of a primary care provider. If so, you have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members, including a pediatrician, as the primary care provider. Until you make this designation, the health plan may designate one for you.You do not need prior authorization from the health plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan or procedures for making referrals.For information on how to select a primary care provider, a list of participating primary care providers, or a list of health care professionals who specialize in obstetrics or gynecology, contact your health plan.Notice of HIPAA Special Enrollment RightsIf an eligible employee declines enrollment in a group health plan for the employee or the employee’s spouse or dependents because of other health insurance or group health plan coverage, the eligible employee may be able to enroll him/herself and eligible dependents in this plan if eligibility is lost for the other coverage (or because the employer stopscontributing toward this other coverage). However, the eligibleemployee must request enrollment within 30 days after the other coverage ends (orafter the employer ceases contributions for the coverage).In addition, if an eligible employee acquires a new dependent as a result of marriage, birth, adoption or placement for adoption, the eligible employee may be able to enroll him/herself and any eligible dependents, provided that the eligible employee requests enrollment within 30 daysafter the marriage, birth, adoption, or placement for adoption.Furthermore, eligible employees and their eligible dependents who are eligible for coverage but not enrolled, shall be eligible to enroll for coverage within 60 days after becoming ineligible for coverage under a Medicaid or Children’s Health Insurance Plan (CHIP) plan or being determined to be eligible for financial assistance under a Medicaid, CHIP, or state plan with respect to coverage under the plan.To request special enrollment or obtain more information, contact your health plan.

Prepared ByHealth Plan NoticesNewborns’ and Mothers’ Health Protection Act NoticeGroup health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for themother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours asapplicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). If you would like moreinformation on maternity benefits, contact your health plan.Women’s Health and Cancer Rights Act NoticeIf you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: All stages of reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; Prostheses; and Treatment of physical complications of the mastectomy, including lymphedema.These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more information on WHCRA benefits, contact your health plan.

Prepared ByHealth Plan NoticesNotice of HIPAA Privacy PracticesTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.This Notice of Privacy Practices (the "Notice") describes the legal obligations of the The Fay School HealthPlan (the "Plan") sponsored by The Fay School (“Plan Sponsor”) and your legal rights regarding your protected health information held by the Plan under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Health Information Technology for Economic and Clinical Health Act (HITECH Act) and subsequent amending regulations (“HIPAA Privacy Rule”). Among other things, this Notice describes how your protected health information may be used or disclosed to carry out treatment, payment, or health care operations, or for any other purposes that are permitted or required by law. We are required to provide this HIPAA Privacy Noticeto you pursuant to HIPAA.The HIPAA Privacy Rule protects only certain medical information known as "protected health information." Generally, protected health information is health information, including demographic information, collected from you or created or received by a health care provider, a health care clearinghouse, a health plan, or your employer on behalf of a group health plan, from which it is possible to individually identify you and that relates to: Your past, present, or future physical or mental health or condition; The provision of health care to you; or The past, present, or future payment for the provision of health care to you.If you have any questions about this Notice or about our privacy practices, please contact the individual listed at the end of this notice.Our ResponsibilitiesThe Fay School is required by law to:• Maintain the privacy of your protected health information;• Provide you with certain rights with respect to your protected health information;• Provide you with a copy of this Notice of our legal duties and privacy practices with respect to your Protected health information; and• Follow the terms of the Notice that is currently in effect.We reserve the right to change the terms of this Notice and to make new provisions regarding your protected health information that we maintain, as allowed or required by law. If we make any material change to this Notice, we will provide you with a copy of our revised HIPAA Privacy Notice electronically or by first class mail to the last known address on file.

Prepared ByHealth Plan NoticesHow We May Use and Disclose Your Protected Health InformationUnder the law, we may use or disclose your protected health information under certain circumstances without your permission. The following categories describe the different ways that we may use and disclose your protected health information. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.For Treatment. We may use or disclose your protected health information to facilitate medical treatment or services by providers. We may disclose medical information about you to providers, including doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of you. For example, we might disclose information about your prior prescriptions to a pharmacist to determine if prior prescriptions contraindicate a pending prescription.For Payment. We may use or disclose your protected health information to determine your eligibility for Plan benefits, to facilitate payment for the treatment and services you receive from health care providers, to determine benefit responsibility under the Plan, or to coordinate Plan coverage. For example, we may tell your health care provider about your medical history to determine whether a particular treatment is experimental, investigational, or medically necessary, or to determine whether the Plan will cover the treatment. We may also share your protected health information with a utilization review or precertification service provider. We mayshare or discuss your PHI with your family members or others involved in your care or payment for your care, unless you object in writing and provide the objection to the Plan’s HIPAA contact listed at the end of this Notice.Likewise, we may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments.In any of these cases, we will disclose only the information necessary to resolve the issue at hand.For Health Care Operations. We may use and disclose your protected health information for other Plan operations. These uses and disclosures are necessary to run the Plan. For example, we may use medical information in connection with conducting quality assessment and improvement activities; underwriting, premium rating, and other activities relating to Plan coverage; submitting claims for stop-loss (or excess-loss) coverage; conducting or arranging for medical review, legal services, audit services,and fraud and abuse detection programs; business planning and development such as cost management; and business management and general Plan administrativeactivities. However, we will not use your genetic information for underwriting purposes.Treatment Alternatives or Health-Related Benefits and Services. We may use and disclose your protected health information to send you information about treatment alternatives or other health-related benefits and services that might be of interest to you.

Prepared ByHealth Plan NoticesTo Business Associates. We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services. In order to perform these functions or to provide these services, Business Associates will receive, create, maintain, transmit, use, and/or disclose your protected health information, but only after they agree in writing with us to implement appropriate safeguards regarding your protected health information. For example, we may disclose your protected health information to a Business Associate to process your claims for Plan benefits or to provide support services, such as utilization management, pharmacy benefit management, or subrogation, but only after the Business Associate enters into a Business Associate contract with us.As Required by Law. We will disclose your protected health information when required to do so by federal, state, or local law. For example, we may disclose your protected health information when required by national security laws or public health disclosure laws.To Avert a Serious Threat to Health or Safety. We may use and disclose your protected health information when necessary to prevent a serious threat to your health and safety, or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. For example, we may disclose your protected health information in a proceeding regarding the licensure of a physician.To Plan Sponsors. For the purpose of administering the plan, we may disclose to certain employees of the Employer protected health information. However, those employees will only use or disclose that information as necessary to perform plan administration functions or as otherwise required by HIPAA, unless you have authorized further disclosures. Your protected health information cannot be used for employment purposes without your specific authorization.Special SituationsIn addition to the above, the following categories describe other possible ways that we may use and disclose your protected health information without your specific authorization. For each category of uses or disclosures, we will explain what we mean and present some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.Organ and Tissue Donation. If you are an organ donor, we may release your protected health information after your death to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Prepared ByHealth Plan NoticesMilitary. If you are a member of the armed forces, we may release your protected health information as required by military command authorities. We may also release protected health information about foreign military personnel to the appropriate foreign military authority.Workers' Compensation. We may release your protected health information for workers' compensation or similar programs, but only as authorized by, and to the extent necessary to comply with, laws relating to workers' compensation and similar programs that provide benefits for work-related injuries or illness.Public Health Risks. We may disclose your protected health information for public health activities. These activities generally include the following:• to prevent or control disease, injury, or disability;• to report births and deaths;• to report child abuse or neglect;• to report reactions to medications or problems with products;• to notify people of recalls of products they may be using;• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;• to notify the appropriate government authority if we believe that a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree, or when required or authorized by law.Health Oversight Activities. We may disclose your protected health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose your protected health information in response to a court or administrative order. We may also disclose your protected health information in response to a subpoena, discovery request, or other lawful process by someone involved in a legal dispute, but only ifefforts have been made to tell you about the request or to obtain a court oradministrative order protecting the information requested.Law Enforcement. We may disclose your protected health information if asked to do so by a law-enforcement official:• in response to a court order, subpoena, warrant, summons, or similar process;• to identify or locate a suspect, fugitive, material witness, or missing person;• about the victim of a crime if, under certain limited circumstances, we are unable to obtain the victim's agreement;• about a death that we believe may be the result of criminal conduct; and• about criminal conduct.

Prepared ByHealth Plan NoticesCoroners, Medical Examiners, and Funeral Directors. We may release protected health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients to funeral directors, as necessary to carry out their duties.National Security and Intelligence Activities. We may release your protected healthinformation to authorized federal officials for intelligence, counterintelligence, and othernational security activities authorized by law.Inmates. If you are an inmate of a correctional institution or are in the custody of a law-enforcement official, we may disclose your protected health information to the correctional institution or law-enforcement official if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.Research. We may disclose your protected health information to researchers when: the individual identifiers have been removed; or when an institutional review board or privacy board has reviewed the research proposal and established protocols to ensure the privacy of the requested information, and approves the research.Required DisclosuresThe following is a description of disclosures of your protected health information we arerequired to make.Government Audits. We are required to disclose your protected health information to the Secretary of the United States Department of Health and Human Services when the Secretary is investigating or determining our compliance with the HIPAA privacy rule.Disclosures to You. When you request, we are required to disclose to you the portion of your protected health information that contains medical records, billing records, and any other records used to make decisions regarding your health care benefits. We are also required, when requested, to provide you with an accounting of most disclosures of your protected health information if the disclosure was for reasons other than for payment, treatment, or health care operations, and if the protected health information was not disclosed pursuant to your individual authorization.Other DisclosuresPersonal Representatives. We will disclose your protected health information to individuals authorized by you, or to an individual designated as your personal representative, attorney-in-fact, etc., so long as you provide us with a written notice/authorization and any supporting documents (i.e., power of attorney). Note: Under the HIPAA privacy rule, we do not have to disclose information to a personal

Prepared ByHealth Plan Noticesrepresentative if we have a reasonable belief that: you have been, or may be, subjected to domestic violence, abuse, or neglect by such person; or treating such person as your personal representative could endanger you; and in the exercise of professional judgment, it is not in your best interest to treat the person as your personal representative.Spouses and Other Family Members. With only limited exceptions, we will send allmail to the employee. This includes mail relating to the employee's spouse and other family members who are covered under the Plan, and includes mail with information on the use of Plan benefits by the employee's spouse and other family members and information on the denial of any Plan benefits to the employee's spouse and other family members. If a person covered under the Plan has requested Restrictions or Confidential Communications (see below under "Your Rights"), and if we have agreed to therequest, we will send mail as provided by the request for Restrictions or Confidential Communications.Authorizations. 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, we will not use or disclose your psychiatric notes; we will not use or disclose your protected health information for marketing; and we will not sell your protected health information, unless you give us a written authorization. You may revoke written authorizations at any time, so long as the revocation is in writing. Once we receive 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.Your RightsYou have the following rights with respect to your protected health information:Right to Inspect and Copy. You have the right to inspect and copy certain protected health information that may be used to make decisions about your Plan benefits. If the information you request is maintained electronically, and you request an electroniccopy, we will provide a copy in the electronic form and format you request, if the information can be readily produced in that form and format; if the information cannot be readily produced in that form and format, we will work with you to come to an agreement on form and format. If we cannot agree on an electronic form and format, we will provide you with a paper copy.To inspect and copy your protected health information, you must submit your request in writing to the individual listed at the end of this Notice. If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy

Prepared ByHealth Plan Noticesin certain very limited circumstances. If you are denied access to your medical information, you may request that the denial be reviewed by submitting a written request to the individual listed at the end of this Notice.Right to Amend. If you feel that the protected health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Plan. To request an amendment, your request must be made in writing and submitted to the individual listed at the end of this Notice. You must provide a reason that supports your request.We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:• is not part of the medical information kept by or for the Plan;• was not created by us, unless the person or entity that created the information is no longer available to make the amendment;• is not part of the information that you would be permitted to inspect and copy; or• is already accurate and complete.If we deny your request, you have the right to file a statement of disagreement with us and any future disclosures of the disputed information will include your statement.Right to an Accounting of Disclosures. You have the right to request an "accounting" of certain disclosures of your protected health information. The accounting will not include (1) disclosures for purposes of treatment, payment, or health care operations;(2) disclosures made to you; (3) disclosures made pursuant to your authorization; (4) disclosures made to friends or family in your presence or because of an emergency; (5) disclosures for national security purposes; and (6) disclosures incidental to otherwise permissible disclosures.To request this list or accounting of disclosures, you must submit it in writing to the individual listed at the end of this Notice. Your request must state the time period you want the accounting to cover, which may not be longer than six years before the date of the request. Your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a 12-month period will be provided free of charge. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.Right to Request Restrictions. You have the right to request a restriction or limitation on your protected health information that we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on your protected health information that we disclose to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we not use or disclose information about a surgery that you had. Except as provided in the next paragraph, we are not required to agree to your request. However,

Prepared ByHealth Plan Noticesif we do agree to the request, we will honor the restriction until you revoke it or we notify you.We will comply with any restriction request if (1) except as otherwise required by law, thedisclosure is to a health plan for purposes of carrying out payment or health care operations (and is not for purposes of carrying out treatment); and (2) the protected healthinformation pertains solely to a health care item or service for which the health careprovider involved has been paid in full by you or another person. To request restrictions,you must send your request in writing the individual listed at the end of this notice.In your request, you must tell us (1) what information you want to limit; (2) whether youwant to limit our use, disclosure, or both; and (3) to whom you want the limits to apply- forexample, disclosures to your spouse.Right to Request Confidential Communications. You have the right to request that wecommunicate with you about medical matters in a certain way or at a certain location.For example, you can ask that we only contact you at work or by mail. To requestconfidential communications, you must make your request in writing the individual listedat the end of this notice. We will not ask you the reason for your request. Your requestmust specify how or where you wish to be contacted. We will accommodate allreasonable requests.Right to Be Notified of a Breach. You have the right to be notified in the event that we (ora Business Associate) discover a breach of unsecured protected health information.Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.ComplaintsIf you believe that your privacy rights have been violated, you may file a complaint with the Plan or with thesssss Office for Civil Rights of the United States Department of Healthand Human Services. To file a complaint with the Plan, contact to the individual listedbelow. All complaints must be submitted in writing.You will not be penalized, or in any other way retaliated against, for filing a complaint with the Office for Civil Rights or with us.HIPAA ContactLaSonya FlemingHuman Resources Officer105 N. Post Oak LnHouston, TX 77024(713) 681-8300 x 8911

Prepared ByPremium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer,your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visitwww.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.govto 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 iscalled 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 Laboratwww.askebsa.dol.govor 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 – Medicaid ALASKA – MedicaidWebsite: http://myalhipp.com/Phone: 1-855-692-5447The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/Phone: 1-866-251-4861Email:CustomerService@MyAKHIPP.comMedicaid Eligibility: https://health.alaska.gov/dpa/Pages/default.aspxARKANSAS – Medicaid CALIFORNIA – MedicaidWebsite: http://myarhipp.com/Phone: 1-855-MyARHIPP (855-692-7447)Health Insurance Premium Payment (HIPP) Program Website:http://dhcs.ca.gov/hippPhone: 916-445-8322Fax: 916-440-5676Email:hipp@dhcs.ca.govCOLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+)FLORIDA – MedicaidHealth First Colorado Website: https://www.healthfirstcolorado.com/Health First Colorado Member Contact Center:1-800-221-3943/State Relay 711CHP+:https://hcpf.colorado.gov/child-health-plan-plusCHP+ Customer Service: 1-800-359-1991/State Relay 711 Health Insurance Buy-In Program (HIBI): https://www.mycohibi.com/HIBI Customer Service: 1-855-692-6442Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.htmlPhone: 1-877-357-326833

Prepared ByGEORGIA – Medicaid INDIANA – 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 2Healthy 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)KANSAS – MedicaidMedicaid Website: https://dhs.iowa.gov/ime/membersMedicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/HawkiHawki Phone: 1-800-257-8563HIPP Website:https://dhs.iowa.gov/ime/members/medicaid-a-to-z/hippHIPP Phone: 1-888-346-9562Website:https://www.kancare.ks.gov/Phone: 1-800-792-4884HIPP Phone: 1-800-967-4660KENTUCKY – Medicaid LOUISIANA – 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.govKCHIP Website: https://kynect.ky.govPhone: 1-877-524-4718Kentucky Medicaid Website: https://chfs.ky.gov/agencies/dmsWebsite: www.medicaid.la.gov or www.ldh.la.gov/lahippPhone: 1-888-342-6207 (Medicaid hotline) or1-855-618-5488 (LaHIPP)MAINE – Medicaid MASSACHUSETTS – Medicaid and CHIPEnrollment 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 711Website: https://www.mass.gov/masshealth/paPhone: 1-800-862-4840TTY: 711Email:masspremassistance@accenture.comMINNESOTA – Medicaid MISSOURI – MedicaidWebsite:https://mn.gov/dhs/people-we-serve/children-and-families/health-care/health-care-programs/programs-and-services/other-insurance.jspPhone: 1-800-657-3739Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htmPhone: 573-751-2005MONTANA – Medicaid NEBRASKA – MedicaidWebsite: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPPPhone: 1-800-694-3084Email:HHSHIPPProgram@mt.govWebsite: http://www.ACCESSNebraska.ne.govPhone: 1-855-632-7633Lincoln: 402-473-7000Omaha: 402-595-1178

Prepared ByNEVADA – Medicaid NEW HAMPSHIRE – MedicaidMedicaid Website: http://dhcfp.nv.govMedicaid Phone: 1-800-992-0900Website: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 CHIP NEW YORK – MedicaidMedicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/Medicaid Phone: 609-631-2392CHIP Website:http://www.njfamilycare.org/index.htmlCHIP Phone: 1-800-701-0710Website:https://www.health.ny.gov/health_care/medicaid/Phone: 1-800-541-2831NORTH CAROLINA – Medicaid NORTH DAKOTA – MedicaidWebsite: https://medicaid.ncdhhs.gov/Phone: 919-855-4100Website: https://www.hhs.nd.gov/healthcarePhone: 1-844-854-4825OKLAHOMA – Medicaid and CHIP OREGON – Medicaid and CHIPWebsite: http://www.insureoklahoma.orgPhone: 1-888-365-3742Website: http://healthcare.oregon.gov/Pages/index.aspxPhone: 1-800-699-9075PENNSYLVANIA – Medicaid and CHIP RHODE ISLAND – Medicaid and CHIPWebsite: https://www.dhs.pa.gov/Services/Assistance/Pages/HIPP-Program.aspxPhone: 1-800-692-7462CHIP Website:Children'sHealth Insurance Program (CHIP)(pa.gov)CHIP Phone: 1-800-986-KIDS (5437)Website:http://www.eohhs.ri.gov/Phone: 1-855-697-4347, or401-462-0311 (Direct RIte Share Line)SOUTH CAROLINA – Medicaid SOUTH DAKOTA - MedicaidWebsite: https://www.scdhhs.govPhone: 1-888-549-0820Website: http://dss.sd.govPhone: 1-888-828-0059TEXAS – Medicaid UTAH – Medicaid and CHIPWebsite: Health Insurance Premium Payment (HIPP)Program| Texas Health and Human ServicesPhone: 1-800-440-0493Medicaid Website:https://medicaid.utah.gov/CHIP Website: http://health.utah.gov/chipPhone: 1-877-543-7669VERMONT– Medicaid VIRGINIA – Medicaid and CHIPWebsite: Health Insurance Premium Payment (HIPP) Program|Department of Vermont Health AccessPhone: 1-800-250-8427Website:https://coverva.dmas.virginia.gov/learn/premium-assistance/famis-selecthttps://coverva.dmas.virginia.gov/learn/premium-assistance/health-insurance-premium-payment-hipp-programsMedicaid/CHIP Phone: 1-800-432-5924WASHINGTON – Medicaid WEST VIRGINIA – Medicaid and CHIPWebsite: https://www.hca.wa.gov/Phone: 1-800-562-3022Website:https://dhhr.wv.gov/bms/http://mywvhipp.com/Medicaid Phone: 304-558-1700CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

Prepared ByWISCONSIN – Medicaid and CHIP WYOMING – MedicaidWebsite:https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htmPhone: 1-800-362-3002Website: 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, contact either:U.S. Department of LaborEmployee Benefits Security Administrationwww.dol.gov/agencies/ebsa1-866-444-EBSA (3272)U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov1-877-267-2323, Menu Option 4, Ext. 61565Paperwork Reduction Act StatementAccording to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, anddisplays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display acurrently valid OMB control number. See 44 U.S.C. 3512.The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Officeof Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.govand reference the OMB Control Number 1210-0137.OMB Control Number 1210-0137 (expires 1/31/2026)36

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