Benefit Plan Legal Notices 2019 / 2020 - Taylor Corporation...cost sharing for the first family member who meets the per-person deductible. The family deductible must then be met by

Benefit Plan Legal Notices

2019 / 2020

To be used in conjunction with Open Enrollment materials.

Table of Contents

Notice Page Your 2020 Summaries of Benefits and Coverage 4

4 10

PPO Plus Plan PPO Plan HSA (HDHP) Plan 15

20

22

25

26

28 30

Medicare Part D Notice

Children’s Health Insurance Program (CHIP) Notice

Special Enrollment Notice

2018 Summary Annual Report

Health Insurance Marketplace Notice

HIPAA Notice of Privacy Practices

NOTICE: If you (and/or your dependents) have Medicare, or will become eligible for Medicare in the next 12 months, a Federal law gives you more choices about your prescription drug coverage. Please see pages 20 and 21 for more details.

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Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2020 – 12/31/2020 PPO Plus Coverage for: Single, Single + 1, and Family | Plan Type: PPO

This is only a Summary: If you want more detail about your coverage and costs, you can call toll-free 1-866-289-5154.

Important Questions Answers Why This Matters:

What is the overall deductible?

In-Network $1,500 Individual $3,000 Single + 1

$3,000 Family

Out-of-Network $4,000 Individual $8,000 Single + 1

$8,000 Family

You must pay all of the costs from providers up to the deductible amount before this plan begins to pay for covered services. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. This plan has an embedded deductible. The plan begins paying benefits that require cost sharing for the first family member who meets the per-person deductible. The family deductible must then be met by one or more of the remaining family members and then the plan pays benefits for all covered family members.

Are there services covered before you meet your deductible?

Yes. See “Preventive Care/Screening/ Immunization” services.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply.

Are there other deductibles for specific services?

There are no other deductibles for specific services.

You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.

What is the out-of-pocket limit for this plan?

For network providers $6,600 individual / $13,200 family; for out-of-network providers $12,700 individual / $25,400 family.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

premiums, balance-billing charges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

Will you pay less if you use a network provider?

Yes. For a list of preferred providers, see www.bluecrossmnonline.com or call toll-free 1-866-289-5154.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participation for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do you need a referral to see a specialist?

No. You can see the specialist you choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes. Some of the services this plan doesn’t cover are listed on page 4. See your policy or plan document for additional information about excluded services.

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Released on April 6, 2016

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• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s

allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met yourdeductible.

• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, youmay have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000 youmay have to pay the $500 difference. (This is called balance billing.)

• This plan may encourage you to use In-Network providers by charging you lower deductibles, copayments and coinsurance amounts.

Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information Network Provider (You will pay the least) Out-of-Network

Provider (You will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

$25 copay/visit. Deductible does not apply.

40% coinsurance None

Specialist visit $35 copay/visit. Deductible does not apply.


Preventive care/screening/ immunization

Covered 100% for eligible Preventive Care that physician’s code as preventive. See SPD for details.


If you have a test

Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance

None

Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance

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If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.caremark.com

Generic drugs (Tier 1)

90 day Rx: Generic drugs (Tier 1)

$10 copay/prescription for retail drugs. Deductible does not apply.

$25

Covers up to a 30-day supply (retail subscription); no coverage for mail service pharmacy drugs from Out-of-Network providers.

Preferred brand drugs (Tier 2)

90 day Rx: Preferred brand drugs (Tier 2)

Greater of $40 copay or 20% to max of $80. Deductible does not apply.



Non-preferred brand drugs (Tier 3)

90 day Rx: Non-preferred brand drugs (Tier 3)

Greater of $60 copay or 50% to a max of $120. Deductible does not apply.

Greater of $150 copay or 50% to a max of $300. Deductible does not apply.


Specialty drugs (Tier 4) Greater of $75 copay or 20% to a max of $150. Deductible does not apply.


If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance None

Physician/surgeon fees 20% coinsurance 40% coinsurance None

If you need immediate medical attention

Emergency room care 20% coinsurance

None Emergency medical transportation 20% coinsurance

Urgent care $25 copay/visit. Deductible does not apply.

40% coinsurance

If you have a hospital stay

Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance None Physician/surgeon fees 20% coinsurance 40% coinsurance None

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If you need mental health, behavioral health, or substance abuse services

Outpatient services 20% coinsurance 40% coinsurance *Services for marriage / couples Counseling isnot covered.Inpatient services 20% coinsurance 40% coinsurance

If you are pregnant Prenatal and postnatal care 20% coinsurance for non-preventive services, 0% coinsurance for preventive


Delivery and all inpatient services 20% coinsurance 40% coinsurance

If you need help recovering or have other special health needs

Home health care 20% coinsurance 40% coinsurance 100 visit maximum applies for all networks.

Rehabilitation services $25 copay / office visit / therapy. Deductible does not apply.

40% coinsurance

None

Habilitation services $25 copay / office visit / therapy. Deductible does not apply.

40% coinsurance

Skilled nursing care 20% coinsurance 40% coinsurance 90 day maximum applies for all networks. Durable medical equipment 20% coinsurance None Hospice services 20% coinsurance 40% coinsurance None

If your child needs dental or eye care

Vision Screening under age 6 Covered 100% 40% coinsurance None Children’s glasses Not Covered Not covered Services are not covered. Children’s dental check-up Not Covered Not covered Services are not covered.

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Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Cosmetic Surgery• Dental Care

• Long Term Care• Weight loss programs

• Routine eye care (Adult)• Routine Foot Care

Other Covered Services (This isn’t a complete list. Please see your plan document for other covered services, limitations, and your costs for these services.)

• Acupuncture (subject for coverage limitations• Bariatric Surgery

• Chiropractic Care• Hearing Aids (external only & subject to coverage

limitations• Infertility treatment

Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if:

You commit fraud The insurer stops offering services in the State You move outside the coverage area.

For more information, on your rights to continue coverage, contact the insurer toll-free at 1-866-289-5154. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For questions about your rights, this notice, or assistance, you can contact: The Claims Administrator by calling toll-free 1-866-289-5154.

Does this plan provide Minimum Essential Coverage? Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-866-289-5154. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-289-5154. Chinese (中文): 如果需要中文的帮助，请请打请个号请 1-866-289-5154. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-289-5154.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

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The plan would be responsible for the other costs of these EXAMPLE covered services.

Peg is Having a Baby (9 months of in-network pre-natal care and a

hospital delivery)

Mia’s Simple Fracture (in-network emergency room visit and follow up

care)

Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well-

controlled condition)

The plan’s overall deductible $1,500 Specialist copayment $35 Hospital (facility) coinsurance 20% Other coinsurance 20%

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost $12,800

In this example, Peg would pay: Cost Sharing

Deductibles $1,500 Copayments $700 Coinsurance $2,000

What isn’t covered Limits or exclusions $60 The total Peg would pay is $4,260


This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)


In this example, Joe would pay: Cost Sharing

Deductibles $1,500 Copayments $1,100 Coinsurance $370

What isn’t covered Limits or exclusions $55 The total Joe would pay is $3,025


This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)


In this example, Mia would pay: Cost Sharing

Deductibles $1,150 Copayments $250 Coinsurance $300

What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,700

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact HRConnect at 877-252-9861 or [email protected].

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Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2020 – 12/31/2020 PPO Coverage for: Single, Single + 1, and Family | Plan Type: PPO




In-Network $2,500 Individual $5,000 Single + 1

$5,000 Family

Out-of-Network $5,000 Individual

$10,000 Single + 1 $10,000 Family






There are no other deductibles for covered services.






Premiums, balance-billing charges, and health care this plan doesn’t cover.










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What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)


Primary care visit to treat an injury or illness

Primary Care: $40 copay/visit. Deductible does not apply. 40% coinsurance None

Specialist visit $60 copay/visit. Deductible does not apply. 40% coinsurance None


Covered 100% for eligible Preventive Care that physician’s code as preventive. See SPD for details.


If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance None Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance


Generic drugs (Tier 1)


$10 copay/prescription for retail drugs. Deductible does not apply.

$25


Preferred brand drugs (Tier 2)





Non-preferred brand drugs (Tier 3) 90 day Rx: Non-Preferred brand drugs (Tier 3)

Greater of $60 copay or 50% to a max of $120. Deductible does not apply. Greater of $150 copay or 20% to max of $300. Deductible does not apply.


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Specialty drugs (Tier 4) Greater of $75 copay or 20% to a max of $150. Deductible does not apply.


If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance None

Physician/surgeon fees 20% coinsurance 40% coinsurance None


Emergency room care 20% coinsurance

None Emergency medical transportation 20% coinsurance

Urgent care $40 copay/visit. Deductible does not apply. 40% coinsurance


Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance None

Physician/surgeon fees 20% coinsurance 40% coinsurance None If you need mental health, behavioral health, or substance abuse services

Outpatient services 20% coinsurance 40% coinsurance *Services for marriage / couplesCounseling is not covered.Inpatient services 20% coinsurance 40% coinsurance

If you are pregnant Prenatal and postnatal care 20% coinsurance for non-preventive services, 0% coinsurance for preventive


Delivery and all inpatient services 20% coinsurance 40% coinsurance


Home health care 20% coinsurance 40% coinsurance 100 visit maximum applies for all networks.

Rehabilitation services $40 copay / office visit / therapy. Deductible does not apply.

40% coinsurance

None

Habilitation services $40 copay / office visit / therapy. Deductible does not apply.

40% coinsurance

Skilled nursing care 20% coinsurance 40% coinsurance 90 day maximum applies for all networks. Durable medical equipment 20% coinsurance None Hospice services 20% coinsurance 40% coinsurance None

12

https://www.healthcare.gov/sbc-glossary/#specialty-drughttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#emergency-room-care-emergency-serviceshttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#emergency-medical-transportationhttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#urgent-carehttps://www.healthcare.gov/sbc-glossary/#copaymenthttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#home-health-carehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#rehabilitation-serviceshttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#habilitation-serviceshttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#skilled-nursing-carehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#durable-medical-equipmenthttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#hospice-serviceshttps://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#coinsurance

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Vision Screening under age 6 Covered 100% 40% coinsurance None Children’s glasses Not Covered Not covered Services are not covered. Children’s dental check-up Not Covered Not covered Services are not covered.
















13

https://www.healthcare.gov/sbc-glossary/#coinsurancehttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#excluded-serviceshttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#marketplacehttps://www.healthcare.gov/sbc-glossary/#marketplacehttp://www.healthcare.gov/https://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#claimhttps://www.healthcare.gov/sbc-glossary/#grievancehttps://www.healthcare.gov/sbc-glossary/#appealhttps://www.healthcare.gov/sbc-glossary/#minimum-essential-coveragehttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#minimum-value-standardhttps://www.healthcare.gov/sbc-glossary/#premium-tax-creditshttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#marketplace

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hospital delivery)


care)







Deductibles $2,500 Copayments $1,140 Coinsurance $2,000






Deductibles $1,500 Copayments $1,300 Coinsurance $400










Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact HRConnect at 877-252-9861 or [email protected]

14


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Coverage Period: 01/01/2020 – 12/31/2020 Summary of Benefits and Coverage: What this Plan Covers & What it Costs HSA (HDHP) Plan Coverage for: Single, Single + 1, and Family | Plan Type: PPO




In-Network $6,600 Individual

$13,200 Single + 1 $13,200 Family

Out-of-Network $12,700 Individual $25,400 Single + 1

$25,400 Family






There are no other deductibles for specific services.






Premiums, balance-billing charges, and health care this plan doesn’t cover.










15


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Primary care visit to treat an injury or illness Covered 100% after deductible None

Specialist visit Covered 100% after deductible None


Covered 100% for eligible Preventive Care that physician’s code as preventive. See SPD for details. None

If you have a test Diagnostic test (x-ray, blood work) Covered 100% after deductible None Imaging (CT/PET scans, MRIs) Covered 100% after deductible


Retail: Generic drugs (Tier 1)


Covered 100% after deductible

Participants pay full retail price for prescriptions up to the deductible

No coverage for mail service pharmacy drugs from Out-of-Network providers.

Retail: Preferred brand drugs (Tier 2)




Retail: Non-preferred brand drugs (Tier 3)

90 day Rx: Non-preferred brand drugs (Tier 3)



Specialty drugs (Tier 4) Covered 100% after deductible Not Covered If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) Covered 100% after deductible None

16

https://www.healthcare.gov/sbc-glossary/#providerhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#specialisthttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#preventive-carehttps://www.healthcare.gov/sbc-glossary/#screeninghttps://www.healthcare.gov/sbc-glossary/#diagnostic-testhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#prescription-drug-coveragehttps://www.healthcare.gov/sbc-glossary/#prescription-drug-coveragehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#specialty-drughttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductible

3 of 5




Physician/surgeon fees Covered 100% after deductible None


Emergency room care Covered 100% after deductible

None Emergency medical transportation Covered 100% after deductible

Urgent care Covered 100% after deductible


Facility fee (e.g., hospital room) Covered 100% after deductible None

Physician/surgeon fees Covered 100% after deductible None If you need mental health, behavioral health, or substance abuse services

Outpatient services Covered 100% after deductible *Services for marriage / couplesCounseling is not covered.Inpatient services Covered 100% after deductible

If you are pregnant Prenatal and postnatal care Covered 100% after deductible

None Delivery and all inpatient services Covered 100% after deductible


Home health care Covered 100% after deductible 100 visit maximum applies for all networks. Rehabilitation services Covered 100% after deductible None Habilitation services Covered 100% after deductible

Skilled nursing care Covered 100% after deductible 90 day maximum applies for all networks. Durable medical equipment Covered 100% after deductible None Hospice services Covered 100% after deductible None


Vision Screening under age 6 Covered 100% after deductible None Children’s glasses Not Covered Not covered Services are not covered. Children’s dental check-up Not Covered Not covered Services are not covered.

17

https://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#emergency-room-care-emergency-serviceshttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#emergency-medical-transportationhttps://www.healthcare.gov/sbc-glossary/#emergency-medical-transportationhttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#urgent-carehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#home-health-carehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#rehabilitation-serviceshttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#habilitation-serviceshttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#skilled-nursing-carehttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#durable-medical-equipmenthttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#hospice-serviceshttps://www.healthcare.gov/sbc-glossary/#deductiblehttps://www.healthcare.gov/sbc-glossary/#deductible

4 of 5
















18

https://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#excluded-serviceshttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#marketplacehttps://www.healthcare.gov/sbc-glossary/#marketplacehttp://www.healthcare.gov/https://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#claimhttps://www.healthcare.gov/sbc-glossary/#grievancehttps://www.healthcare.gov/sbc-glossary/#appealhttps://www.healthcare.gov/sbc-glossary/#minimum-essential-coveragehttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#minimum-value-standardhttps://www.healthcare.gov/sbc-glossary/#premium-tax-creditshttps://www.healthcare.gov/sbc-glossary/#planhttps://www.healthcare.gov/sbc-glossary/#marketplace

5 of 5



hospital delivery)


care)























Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact HRConnect at 877-252-9861 or [email protected].

19


Date: 10/01/2019

Important Notice From Taylor Corporation (the Company) About Your Prescription Drug Coverage and Medicare

Notice Pertains To The Following Health Plan: PPO Plus and PPO Plans Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the Company and about your options under Medicare’s prescription drug coverage. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. This information can help you decide whether or not you want to join a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage ifyou join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offersprescription drug coverage. All Medicare prescription 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 Company has determined that the prescription drug coverage offered by your employer through the TaylorCorporation Self-Insured Hospitalization Welfare Plan – PPO and PPO Plus Plans is, on average for all plan participants,expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore consideredCreditable Coverage. Because your existing coverage is on average, at least as good as standard Medicare prescriptiondrug coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicaredrug 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 15 th to December 7th.However, if you lose creditable prescription drug coverage through no fault of your own, you will 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 coverage will not be affected. If you do decide to join a Medicare drug plan and drop your current Company coverage, be aware that you and your dependents might not be able to get this coverage back, depending on your employer’s eligibility policy. This may affect your medical coverage as well, so be sure to contact HRConnect at 877-252-9861, [email protected] .

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 the Company and do not 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 percent of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go 19 months without creditable coverage, your premium may consistently be at least 19 percent higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the pharmacy vendor at the telephone number listed on the back of your pharmacy member card. NOTE: You will receive this notice each year. You will also receive it before the next period you can join a Medicare drug plan and if this coverage through the Company changes. You may request a copy of this notice anytime.

For More Information About Your Options Under 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, or Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage, and therefore, whether you are required to pay a higher premium (a penalty).

20

mailto:[email protected]://www.medicare.gov/http://www.socialsecurity.gov/

Date: 10/01/2019

Important Notice From Taylor Corporation (the Company) About Your Prescription Drug Coverage and Medicare

Notice Pertains To The Following Health Plan: HSA Plan Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the Company and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are three important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage ifyou join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offersprescription drug coverage. All Medicare prescription 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 Company has determined that the prescription drug coverage offered by your employer through the TaylorCorporation Self-Insured Hospitalization Welfare Plan – HSA Plan is, on average for all plan participants, NOT expected topay out as much as standard Medicare prescription drug coverage pays, and is therefore considered Non-CreditableCoverage. This is important because, most likely, you will get more help with your drug costs if you join a Medicare drugplan than if you only have prescription drug coverage from the Company. This is important because it may mean that youmay pay a higher premium (a penalty) if you do not join a Medicare drug plan when you first become eligible.

3. You can keep your current coverage from the Company. However, because your coverage is non-creditable, you havedecisions to make about Medicare prescription drug coverage that may affect how much you pay for that coverage,depending on if and when you join a drug plan. When you make your decision, you should compare your currentcoverage, including what drugs are covered, with the coverage and cost of the plans offering Medicare prescription drugcoverage in your area. Read this notice carefully — it explains your options.

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 decide to drop your current coverage with the Company, since it is employer/sponsored group coverage, you will be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan; however, you may have to pay a higher premium (a penalty) because you did not have creditable coverage under your Plan with the Company.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? Since the coverage under your current Company plan is not creditable, depending on how long you go without creditable prescription drug coverage, you may pay a penalty to join a Medicare drug plan. Starting with the end of the last month that you were first eligible to join a Medicare drug plan but did not join, if you go 63 continuous days or longer without prescription drug coverage that is creditable, your monthly premium may go up at least 1 percent of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go 19 months without creditable coverage, your premium may consistently be at least 19 percent 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.

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 Company coverage may be affected. If you do decide to join a Medicare drug plan and drop your current Company prescription drug coverage, be aware that you and your dependents might not be able to get this coverage back, depending on your employer’s eligibility policy. This may affect your medical coverage as well, so be sure to contact HRConnect at 877-252-9861, [email protected] .

For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the pharmacy vendor at the telephone number listed on the back of our pharmacy member card. 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 coverage through the Company changes. You may request a copy of this notice anytime.

For More Information About Your Options Under Medicare Prescription Drug Coverage… Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You”

handbook for their telephone number) for personalized help Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486- 2048

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800- 772-1213 (TTY 1-800-325-0778).

Remember: Keep this Non-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 you are required to pay a higher premium (a penalty).

21

mailto:[email protected]://www.medicare.gov/file:///C:/Users/cjross/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.Outlook/IUT44VYX/www.socialsecurity.gov

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has aprogram that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2019. Contact your State for more information on eligibility –

ALABAMA – Medicaid FLORIDA – Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447

Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268

ALASKA – Medicaid GEORGIA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp Phone: 678-564-1162 ext 2131

ARKANSAS – Medicaid INDIANA – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1-800-403-0864

COLORADO – Health First Colorado

(Colorado’s Medicaid Program) & Child Health

Plan Plus (CHP+)

IOWA – Medicaid

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus

CHP+ Customer Service: 1-800-359-1991/ State Relay 711

Website: http://dhs.iowa.gov/Hawki Phone: 1-800-257-8563

22

http://www.healthcare.gov/http://www.insurekidsnow.gov/http://www.askebsa.dol.gov/http://myalhipp.com/http://flmedicaidtplrecovery.com/hipp/http://myakhipp.com/mailto:[email protected]://dhss.alaska.gov/dpa/Pages/medicaid/default.aspxhttps://gcc01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fmedicaid.georgia.gov%2Fhealth-insurance-premium-payment-program-hipp&data=02%7C01%7Cstashlaw%40dch.ga.gov%7C98b18a96ce1b49d087f708d709449652%7C512da10d071b4b948abc9ec4044d1516%7C0%7C0%7C636988062560854968&sdata=7rziGawQfBKcW1N2%2Bdi2j8cyHpaCYURGdtF8Hk%2By6FM%3D&reserved=0https://gcc01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fmedicaid.georgia.gov%2Fhealth-insurance-premium-payment-program-hipp&data=02%7C01%7Cstashlaw%40dch.ga.gov%7C98b18a96ce1b49d087f708d709449652%7C512da10d071b4b948abc9ec4044d1516%7C0%7C0%7C636988062560854968&sdata=7rziGawQfBKcW1N2%2Bdi2j8cyHpaCYURGdtF8Hk%2By6FM%3D&reserved=0http://myarhipp.com/http://www.in.gov/fssa/hip/http://www.indianamedicaid.com/https://www.healthfirstcolorado.com/https://www.colorado.gov/pacific/hcpf/child-health-plan-plushttps://www.colorado.gov/pacific/hcpf/child-health-plan-plushttp://dhs.iowa.gov/Hawkihttp://dhs.iowa.gov/Hawki

KANSAS – Medicaid NEW HAMPSHIRE – Medicaid

Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512

Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext 5218

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP Website: https://chfs.ky.gov Phone: 1-800-635-2570

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

LOUISIANA – Medicaid NEW YORK – Medicaid Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711

Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP Website: https://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/other-insurance.jsp Phone: 1-800-657-3739

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

MISSOURI – Medicaid OREGON – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

MONTANA – Medicaid PENNSYLVANIA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

Website: http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htm Phone: 1-800-692-7462

NEBRASKA – Medicaid RHODE ISLAND – Medicaid and CHIP Website: http://www.ACCESSNebraska.ne.gov Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-1178

Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347, or 401-462-0311 (Direct RIte Share Line)

23

http://www.kdheks.gov/hcf/https://www.dhhs.nh.gov/oii/hipp.htmhttps://chfs.ky.gov/http://www.state.nj.us/humanservices/dmahs/clients/medicaid/http://www.state.nj.us/humanservices/dmahs/clients/medicaid/http://www.njfamilycare.org/index.htmlhttp://dhh.louisiana.gov/index.cfm/subhome/1/n/331https://www.health.ny.gov/health_care/medicaid/http://www.maine.gov/dhhs/ofi/public-assistance/index.htmlhttp://www.maine.gov/dhhs/ofi/public-assistance/index.htmlhttps://medicaid.ncdhhs.gov/http://www.mass.gov/eohhs/gov/departments/masshealth/http://www.mass.gov/eohhs/gov/departments/masshealth/http://www.nd.gov/dhs/services/medicalserv/medicaid/http://www.nd.gov/dhs/services/medicalserv/medicaid/https://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/other-insurance.jsphttps://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/other-insurance.jsphttps://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/other-insurance.jsphttp://www.insureoklahoma.org/http://www.dss.mo.gov/mhd/participants/pages/hipp.htmhttp://healthcare.oregon.gov/Pages/index.aspxhttp://www.oregonhealthcare.gov/index-es.htmlhttp://dphhs.mt.gov/MontanaHealthcarePrograms/HIPPhttp://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htmhttp://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htmhttp://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htmhttp://www.accessnebraska.ne.gov/http://www.eohhs.ri.gov/

NEVADA – Medicaid SOUTH CAROLINA – Medicaid

Medicaid Website: https://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900

Website: https://www.scdhhs.gov Phone: 1-888-549-0820

To see if any other states have added a premium assistance program since July 31, 2019, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 12/31/2019)

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid WEST VIRGINIA – Medicaid Website: http://gethipptexas.com/ Phone: 1-800-440-0493

Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002

VERMONT– Medicaid WYOM

Documents

Benefit Plan Legal Notices 2019 / 2020 - Taylor Corporation...cost sharing for the first family member who meets the per-person deductible. The family deductible must then be met by