enefits Enrollment Guidebrochure.fringebenefitsgroup.com/icss comml oe... · 5Visit or call Toll Free (855) 495 / -1189 for more information / 5 Enrolling in Your Benefits Alternatively,

Benefits Enrollment Guide January 1, 2016—December 31, 2016 Plan Year

Commercial Employees

—Without Life

2

/ Visit www.mycontractorsplan.com or call Toll Free (855) 495-1189 for more information / 2

Table of Contents

Overview & Eligibility ........................ 3

Dependent Eligibility .......................... 4

Enrolling in Benefits ........................... 5

Major Medical .................................. 6

Dental ................................................ 9

Vision ................................................ 10

Short-Term Disability ......................... 11

Critical Illness ..................................... 12

Accident Benefit ................................ 13

Commuter & Transit ........................... 14

COBRA ............................................... 15

Disclaimers & Notices ........................ 16

Welcome

Important Phone Numbers

Plan Administrator: The Contractors Plan

Inter-Con Member Services: Toll-Free (855) 495-1189

Hours of Operations are Monday through Friday

7 am—7 pm CST.

Blue Shield of Northeastern New York:

Medical: Toll-Free (800) 888-1238

MetLife:

Dental: Toll-Free (800) 275-4638

Vision: Toll-Free (855) 638-3931

Transamerica:

Disability & Critical Illness: Toll-Free (855) 433-2981

Standard Security Life

Accident Benefit: Toll-Free (855) 495-1190

3


Overview & Eligibility

Employee Status Health Specialty Benefits Optional Coverage

Full-Time

Part-Time Eligible

Blue Shield EPO 8000 Blue Shield EPO 6017 Blue Shield EPO 6000

MetLife Dental MetLife VSP Vision Transamerica Short

Term Disability

Transamerica Critical Illness Standard Security Life Accident

Coverage eFlex Commuter/Parking/

Transit

Part-Time

Working an average less than

30 hours per week.

Determined by prior year

annual calculation.

Not eligible MetLife Dental MetLife VSP Vision Transamerica Short

Term Disability

Transamerica Critical Illness Standard Security Life Accident

Coverage eFlex Commuter/Parking/

Transit

Employees may be eligible for the benefits described in the enrollment guide when they work on average 30 hours or

more per week. Those employees who are working on average less than 30 hours per week may not be eligible to en-

roll. Part-Time eligibility is based on an annual determination from prior year.

The table below shows the benefit options that are available to both Full-Time and Part-Time Employees. All benefits

are voluntary and you must take action and enroll in coverage.

All Coverage is Opt In

If you are a Full or Part-Time employee and wish to be cov-

ered by any of our benefit plan options, you must take ac-

tion and opt-in for coverage. Coverage is not automatic.

If you are currently enrolled in benefits and do not process

your benefit elections for the coming year, your current

enrollments will continue into 2016 at the new 2016 contri-

bution levels.

Declining Coverage

You may chose to not participate in our benefit plans. If

you waive coverage, your next opportunity to enroll will be

our Benefits Open Enrollment 2017 which will be held in

November 2016.

Paying For Coverage—Payroll Contributions

When you start work, you will be eligible for coverage the first of the

month following 60 days of employment. Inter-Con Security may

make a contribution toward your coverage. Any additional contribu-

tions will made through payroll deduction. Contributions are taken

on a 24-pay cycle.

When Coverage Begins and Ends

Coverage will begin the first day of the month following your first 60

days of continuous employment.

Your coverage will end due to:

Non-payment of premium or in the event of insufficient hours.

You have 30 days to make a payment for any missed premiums.

If you miss two consecutive payments and payment is not re-

ceived within 30 days, your coverage is cancelled back to the last

day of the month that the full premium was received.

If your Employment Ends, coverage is effective through the last

day of the month in which your employment ends. For example,

if your employment ends January 15, your coverage will end

January 31.

4


Dependent Eligibility Determining Eligibility You may enroll eligible dependents in your benefit coverage.

Eligible dependents include:

Your legal spouse

Your same sex domestic partner

Same Sex Domestic Partners must be 18 years of age

or older, residing together, unmarried, not related by

marriage or blood in way that would bar their

marriage to each other; and financially dependent

upon each other.

Same Sex Domestic Partnership must have existed

for a period of at least six (6) months prior to

becoming eligible for coverage under this plan. Also,

you must submit a signed and notarized BlueShield

Medical Affidavit of Domestic Partnership. You may

obtain this form by contacting The Contractors Plan.

Your children, including step-children, legally adopted

children, children who have been placed with you for

adoption, or children for whom you have been a court

appointed legal guardian.

In most cases, your dependent children are

eligible until the end of the month in which they

turn 26 years of age.

Benefits available for dependents include: Blue Shield Medical Plans

MetLife Dental Plan

MetLife/VSP Vision Plan

Transamerica Critical Illness Plans

Standard Security Accident Plan

Dependent Verification: The Contractors Plan requires documentation of a dependent’s eligibility at initial enrollment. Proof may include Marriage license, birth certificate, adoption paperwork, or domestic partner affidavit. If documentation is required, you will be given information on what to submit at the time of the request.

Making Changes During the Plan Year You can change your dependent(s) coverage during the year,

according to IRS rules, only when you experience a qualifying

event such as:

Marriage, divorce, or legal separation

Death of spouse, same sex domestic partner, or dependent

Birth or adoption of a new dependent or gaining legal cus-

tody of a new dependent

A change in a dependent’s eligibility status

Employment change for a spouse or same sex domestic

partner resulting in a loss or gain of employer-sponsored

coverage

A change in your employment status

You must make a coverage change due to a qualifying life event

within 30 days of the event, and the election change must be

consistent with the event. For example, if your dependent child

no longer meets eligibility requirements (if he or she reaches

age 26), you can drop coverage only for that dependent.

Special Enrollment

If you are declining benefit coverage because of other group

health plan coverage, you may be able to enroll in this plan if

you lose eligibility for the other coverage. However, you must

enroll within 30 days after your other coverage ends.

In addition, if you have a new dependent as a result of

marriage, birth, adoption, or placement for adoption, you may

be able to enroll your dependents. However, you must request

enrollment within 30 days of the marriage, birth, adoption, or

placement for adoption.

If you miss this 30-day special enrollment window, you will have

to wait until Open Enrollment 2017.

5


Enrolling in Your Benefits

Alternatively, you may enroll by phone:

Call (855) 495-1189 Monday through Friday 7:00 AM to 7:00 PM Central Time

Dependent Enrollment

When enrolling eligible dependents, please be prepared to pro-

vide their name, date of birth, and Social Security Number.

Confirmation Number

1. You may still make changes to your benefit elections during

Open Enrollment after receiving a confirmation number.

2. Any changes you make, for example, if you originally elected

Dental, but after enrolling, you decide to remove Dental

coverage, will result in a different confirmation number up-

on completion. If you do not receive a confirmation num-

ber, this means you have not completed your enrollment

and should keep clicking the CONTINUE button until you see

the confirmation page which includes a confirmation num-

ber and effective date.

How To Enroll Online

1. Go to www.contractorsplan.com 2. For returning users, enter your established user name

and password in the appropriate fields at the top of the screen.

3. If you are a new user click the Register Here link, beside New Users to create a new account. Click Social Security # in the New User Field. Then enter your Social Security number and Date of Birth in the fields provided. Click Continue.

4. Create your User Name and Password-keep this password for future use. Setup your security questions and read the Terms of Use. Click Continue.

5. Make your elections for each benefit. Enroll dependents in dependent coverage as you choose. Also, remember to include any beneficiary designations.

6. The enrollment will be summarized for your review and confirmation. If you have made any mistakes and would like to make changes, you may select the My Plans tab or select the shopping car icon to empty or delete your elections and begin again. Once you are satisfied with your elections, click Continue.

7. Once you receive your confirmation number and pro-jected effective date, your enrollment is complete. This confirmation number is for your records only. Note: Receipt of confirmation number Is receipt of a transaction completion. The confirmation number is not confirmation of benefits.

6


Major Medical EPO Plan 8000-Core

Services Available to You

Your Cost for a Network Provider

Primary Care Visit 20% After Deductible

Specialty Care Visit 20% After Deductible

Preventative Care $0

Outpatient Surgery 20% After Deductible

Inpatient Surgery 20% After Deductible

Emergency Room

Urgent Care

20% After Deductible

20% After Deductible

Deductible

(counts towards out-of-pocket costs)

$5,000 Individually

$10,000 For Family

Coinsurance-Plan Pays 80%

Out-Of-Pocket Costs $6,350 Individually

$12,700 For Family

Prescription Drug Tier 1: Generic Brand $15 After Deductible

Prescription Drug Tier 2: Brand Name $50 After Deductible

Prescription Drug Tier 3: Non-Formulary 50% After Deductible

Information Available For You

Medical information is available whenever you need it via

www.bsneny.com or the BCBS Mobile App.

Find a network provider and estimate costs

Review your coverage and accounts

ID Cards are issued when you first enroll, add dependents or

change plans. If ID cards are generated, they should arrive to

your home by the 1st week in January. Additionally, you may

obtain an ID Cards online or by calling member services.

Our medical plans are designed to help maintain wellness and protect

you and your family from major financial hardship in the event of ill-

ness or injury. We offer several medical insurance coverage options,

all of which comply with the standards provided by the Patient Protec-

tion and Affordable Care Act (Federal Health Care Reform). All include

preventative care paid at 100% and we encourage you to get your

annual physical as an early detection method.

Each health plan provides a comprehensive list of medical providers

and access to local, regional and national medical centers to address

routine or complex issues of medical care. You must use a network

provider. The difference in the plans are the costs you will pay for

services.

The chart below provides a summary of the costs for some of the cov-

ered services. Please refer to the Summary of Benefits and Coverage

(SBC) for a complete chart of services and costs associated with these

services.

How to Find a Medical Provider

How Find a Medical Provider

Go to www.bsneny.com

Click on Find a Doctor Icon

Click Start Searching Today

Click on Blue National Finder

Choose Your Network-BlueCard PPO/EPO

You can search by Name or by Location

BlueShield of Northeastern New York EPO 8000 Plan-Core

Our medical plan includes unlimited access to your own personal

health advocate, free of charge. Health Advocate is available 24/7.

Call 1-800-359-5465 or email: [email protected]

Website: http://www.healthadvocate.com/ : Click on purple member box. Organiza-

tion name is Blue Shield NENY. Privacy is protected. Medical and personal information

is strictly confidential.

mailto:[email protected]

http://www.healthadvocate.com/

7


Major Medical EPO Plan 6017-Buy Up

BlueShield of Northeastern New York EPO 6017 Plan-Buy Up



Primary Care Visit $30 Copay

Specialty Care Visit $30 Copay


Outpatient Surgery $50

Inpatient Surgery 20% after Deductible

Emergency Room

Urgent Care

$50 Copay

$35 Copay

Deductible


$2,000 Individually

$4,000 For Family



$8,000 For Family

Prescription Drug Tier 1: Generic Brand $10

Prescription Drug Tier 2: Brand Name $30

Prescription Drug Tier 3: Non-Formulary 50%


Medical information is available whenever you need it

via www.bsneny.com or the BCBS Mobile App.



Get ID Cards

Review claims and treatment history

The chart below provides a summary of the costs for some of

the covered services. Please refer to the SBC for a complete

chart of services and costs.

8


Major Medical EPO Plan 6000-Buy Up

BlueShield of Northeastern New York EPO 6000 Plan-Buy Up



Primary Care Visit $25 Copay

Specialty Care Visit $25 Copay


Outpatient Surgery $50

Inpatient Surgery 10% after Deductible

Emergency Room

Urgent Care

$50 Copay

$35 Copay

Deductible


$1,500 Individually

$3,000 For Family



$6,000 For Family

Prescription Drug Tier 1: Generic Brand $10

Prescription Drug Tier 2: Brand Name $30

Prescription Drug Tier 3: Non-Formulary 50%


Medical information is available whenever you need it

via www.bsneny.com or the BCBS Mobile App.



Get ID Cards


The chart below provides a summary of the costs for some of

the covered services. Please refer to the SBC for a complete

chart of services and costs.

9


Dental Coverage

Coverage Type

In-Network1

% of PDP Fee

Out-of-Network1

Based on Maximum Allowed Charge

Type A—Preventive 100% 100%

Type B—Basic Restorative 80% 80%

Type C—Major Restorative 50% 50%

Type D—Orthodontia 50% 50%

Deductible (waived for preventive)

Individual $50 $50

Family $150 $150

Annual Maximum Benefits

Per Person $1,500 $1,500

Orthodontia Lifetime Maximum $1,000 $1,000

Ortho Applies to Child Only Child to age 19

1” In-Network Benefits” means benefits under this plan for covered dental services provided by a MetLife PDP dentist. “Out-of-Network Bene-

fits” means benefits under this plan for covered dental services that are not provided by a MetLife PDP Dentist.

As part of the benefits Inter-Con provides you to maintain your

health and well-being, dental is provided to full-time and part-

time employees through MetLife.

Our Preferred Provider Organization(PPO) allows dental services

to be provided through Metlife Dental PPO network, or, you can

choose any dentist not affiliated with Metlife.


Dental information is available whenever you need it via

www.mybenefits.metlife.com. When the website asks for a Com-

pany Name, type: The Contractors Plan Trust and you will be di-

rected to the benefit plan home page.

Find a dentist near you

View your plan


No ID card is issued. You can print an ID card from MetLife

website.

10


Vision Coverage

Coverage Type In-Network Coverage Out-of-Network Coverage

Comprehensive Visual Exam Covered after $10 copay Covered up to $45 allowance

Base Lenses

Single Vision

Lined Bifocal

Lined Trifocal

Lenticular

Covered in full

Covered up to:

$30 Allowance

$50 Allowance

$65 Allowance

$100 Allowance

Frame Allowance Covered in full up to $130

Costco: covered in full up to $70

allowance

Up to $70 Allowance

Contact Lenses

(Fitting and Evaluation)

Standard or Premium Fit: Member

receives 15% off; copay will not

exceed $60

Not Covered

Contact Lenses (Elective) Covered up to $130 Allowance Covered up to $105 Allowance

Benefit Frequency

Vision Exam Every 12 months

Lenses Every 12 months

Frames Every 12 months

Contacts Every 12 months

As part of the benefits Inter-Con provides you to maintain your

health and well-being, vision coverage is provided to full-time

and part-time employees through MetLife.

Finding the right eyecare provider for you is important to your

eye health and overall wellness. That’s why you can choose to

see any eyecare provider-a VSP doctor, retail chain affiliate

(including Costco or Walmart) or any other provider.

The vision plan includes benefits for eye exams, eyeglasses and

contact lenses. You may visit a doctor within the VSP network

and take advantage of higher benefits coverage, or visit an out-of

-network provider of your choice for a reduced benefit.


Vision information is available whenever you need it via

www.mybenefits.metlife.com. When the website asks

for a Company Name type: The Contractors Plan Trust

and you will be directed to the benefit plan home page.

Find a vision provider near you

View your plan


No ID card is issued. You can print an ID card from

MetLife website.

Either glasses (Base Lenses & Frames)

or Contact Lenses allowed per frequency.

Not Both.

11


Short-Term Disability

Disability insurance offers financial protection to you and your

family in the event that you cannot work due to an illness or

accident that did not occur at work. The Contractors Plan

offers disability coverage provided by Transamerica.

Eligibility

If you are a full-time or part-time employee, you may choose

to enroll into Transamerica’s Short-Term Disability benefits

plan.

Short-Term Disability

There is a 14 day elimination period in the event of a sickness

or accident. Once you have met this 14 day elimination period

the plan will provide:

80% of your earnings up to $600 per week

Benefit duration of 6 months

Short-Term Disability only covers

illnesses and accidents that occur

outside of work.

Pre-Existing Condition

Pre-existing condition means a sickness or accidental injury for

which the employee:

Received medical treatment, consultation, care, or services

in the last 12 months.

Took prescription medication or had medications pre-

scribed in the 12 months before insurance is effective.

Pre-Existing conditions are not covered until you have

been continuously insured under the short-term disability

policy for 12 months.

12


Critical Illness

Critical Illness provides a benefit in the event you are diagnosed

with a covered illness. Diagnosis may occur after death. The

plan will pay a lump sum in the event of a diagnosis of a covered

illness.

What is Covered

There are two coverage options available for you to choose

from; the Low Option will provide a $5,000 Flat amount and the

High Option will provide a $10,000 Flat amount. Please review

the table below to see which illnesses are covered and for how

much the plan will pay out for each illness.

Amount the Plan will Pay $5,000 or $10,000 Flat Amount

Family/dependent coverage: 50% of the employee benefit

Covered Illnesses: heart attack, stroke, heart and major organ

transplants, end of stage renal failure, paralysis of all four

limbs, burns, coma, loss of sight, speech or hearing, invasive

cancer, bone marrow transplant

100% of the employee benefit

Covered Illnesses: Paralysis of three or fewer limbs not due to

stroke; recurrent critical illness


Covered Illnesses: Alzheimer’s Disease 30% of employee benefit

Covered Illnesses: Coronary bypass surgery, carcinoma in situ,

prostate cancer with TNM classification of TI


There is a Low Option and a High Option of Critical Illness coverage available for

you to choose from.

13


Accident Benefit

The Accident plan is not a substitute for minimum essen-

tial health coverage under the Affordable Care Act (ACA);

and does not qualify as minimum essential coverage un-

der the Affordable Care Act (ACA).

This plan helps to cover some of the costs associated with

being in the hospital.

Coverage

Hospital Admission Benefit $1,000

Benefit payable only once during any period of confinement.

Requires 24 hour hospital stay.

Daily In-Hospital Benefit $100

Benefit payable per day. Up to a maximum of 500 days of

confinement (except for Substance Abuse, Mental Illness Dis-

order, and In-patient Skilled Nursing Facility).

Requires 24 hour hospital stay.

Intensive Care Benefit $200

Double the daily in-hospital benefit will be paid, up to a maxi-

mum of 30 days per calendar year.

Mental Illness Disorder $50 per day

$50 per day will be paid up to a $5,000 calendar year maxi-

mum and a lifetime maximum of $30,000 for hospitalization

due to Mental Illness

Substance Abuse $50 per day

Maximum 30 days

Inpatient Skilled Nursing Facility $50 per day

Maximum 60 days

Accident Expense Benefit $1,000

100% of charges incurred within 90 days of a bodily injury.

14


Commuter & Transit Benefit Eligible Expenses

Expenses that are eligible for reimbursement under the

Transit include:

Parking your vehicle in a facility at or near your place

of employment

Parking at a location from where you commute, e.g.,

a train station

Transit passes to and from work, including the cost of

tokens, passes, fare cards, vouchers, etc.

Mass transit public systems (Mass transit can be

a public system, or a private enterprise provided

by a company or individual who is in the business

for transporting people in a “Commuter highway

vehicle”)

Transportation provided by a qualified, private

transportation company.

How Much Can I Contribute to my

Transit Account?

You may elect to have any amount up to the monthly pre-tax

maximums set by the IRS. In some cases, the monthly maximum

may not be enough to cover your transit expenses.

Parking

For your parking account, simply submit a claim form with

attached documentation (if available) for reimbursement

under your eflex transit plan. We can also set up parking

claims on a recurring bases. This feature allows you to

submit a single claim, while continuing to receive reim-

bursements throughout the plan year.

To set up a recurring claim, simply follow the instructions

on the claim form. We’ll take care of the rest. You’ll re-

ceive your parking reimbursement each time there’s a

payroll deduction. Download the claim form and instruc-

tions at www.eflexgroup.com.

Transportation

Under the eflex Transit plan, you can pay for your transportation

expenses using the eflex card or by submitting a manual claim.

The amount you have available in your eflex Transit account is

the balance on the eflex Card, which is how much you contribute

each month. You may use the eflex Card up to this amount, but

never over.

Funds are only disbursed as the account is replenished with pay-

roll deductions. You may check your available balance at

www.eflexgroup.com. Because funds are not available prior to

the first month’s payroll deduction, you'll need to use post-tax

dollars for the first month of the plan year.

You may contribute any amount up

to the pre-tax maximums set by

the IRS.

15


INTRODUCTION

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of

1985 (COBRA). COBRA continuation coverage can become available to you when you would otherwise lose your group health cov-

erage. It also can become available to other members of your family who are covered under the Plan when they would otherwise

lose their group health coverage. For additional information about your rights and obligations under the Plan and under federal

law, you should review the Plan’s Summary Plan Description, which will be mailed to you following your enrollment in the plan.

WHAT IS COBRA CONTINUATION COVERAGE?

COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event

known as a “qualifying event.” Specific qualifying events are listed below. After a qualifying event, COBRA continuation coverage

must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become

qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who

elect COBRA continuation coverage must pay for COBRA continuation coverage.

If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the

following qualifying events happens:

Your hours of employment are reduced

Your employment ends for any reason other than your gross misconduct

If you are the spouse or same sex domestic partner of an employee, you will become a qualified beneficiary if you lose your cover-

age under the Plan because any of the following qualifying events happens:

Your spouse or same sex domestic partner dies

Your spouse’s or same sex domestic partner’s hours of employment are reduced

Your spouse’s or same sex domestic partner’s employment ends for any reason other than his or her gross misconduct

Your spouse or same sex domestic partner’s becomes entitled to Medicare benefits (under Part A, Part B, or both)

You become divorced or legally separated from your spouse or same sex domestic partner

Your dependent children will become qualified beneficiaries if they lose coverage under the plan because any of the following

qualifying events happen:

The parent/employee dies

The parent/ employee’s hours of employment are reduced

The parent/ employee’s employment ends for any reason other than his or her gross misconduct.

The parent/ employee becomes entitled to Medicare benefits (Part A, Part B, or both)

The parents become divorced or legally separated

The child stops being eligible for coverage under the plan as a “dependent child”

WHEN IS COBRA COVERAGE AVAILABLE?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that

a qualifying event has occurred. When the qualifying event is: the end of employment, a reduction of hours of employment, death

of the employee, commencement of a proceeding in bankruptcy with respect to the employer, or the employee’s becoming enti-

tled to Medicare benefits (under Part A, Part B, or both); the employer must notify the Plan Administrator of the qualifying event.

COBRA

About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Inter-Con

Security Systems, Inc. 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. 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. 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 if you join a Medicare Prescription

Drug Plan or join a Medicare Advantage Plan (like a HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard

level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. Inter-Con Security Systems has determined that the prescription drug coverage offered by the BSNENY 6017 & 6000 Medical Plans are, on average for all

plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Be-

cause your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medi-

care drug plan.

When Can You Join A Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

However, if you lose your current creditable 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 Current Coverage If You Decide to Join A Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current Inter-Con Security Systems coverage may be affected.

If you do decide to join a Medicare drug plan and drop your current Inter-Con Security Systems coverage, be aware that you and your dependents may not be

able to get this coverage back.

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 Inter-Con Security Systems and don’t join a Medicare drug plan within 63 continuous

days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base

beneficiary premium per month for every month that you did not have that coverage. For 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 Current Prescription Drug Coverage…

Contact the person listed below for further information

NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, as well as if there are any changes with

coverage through Inter-Con Security Systems. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You ’ll get a copy of the hand-

book 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:

o Visit www.medicare.gov.

o 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.

o 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 or not you are

required to pay a higher premium (a penalty). Name of Entity/Sender: Inter-Con Security Systems

Contact - Human Resources

Address: 210 South De Lacey Avenue, Pasadena, CA 91105

Phone Number: (626) 535-2200

17


The Women’s Health and Cancer Rights Act of 1998—Important Notice

In October 1998, Congress enacted the Women’s Health and Cancer Rights Act of 1998. This notice explains some important provi-

sions of the Act. Please review this information carefully.

As specified in the Women’s Health and Cancer Rights Act, a plan participant or beneficiary who elects breast reconstruction in

connection with a mastectomy is also entitled to the following benefits:

Reconstruction of the breast on which the mastectomy has been performed

Surgery and reconstruction of the other breast to produce a symmetrical appearance

Prosthesis and treatment of physical complications in all stages of mastectomy, including lymphedemas.

Health plans must determine the manner of coverage in consultation with the attending physician and the patient. Coverage for

breast reconstruction and related services may be subject to deductibles and coinsurance amounts that are consistent with those

that apply to other benefits under the plan.

HIPAA Privacy Notice—Important Notice about Your Health Information

The HIPAA Notice of Privacy Practices applies to Protected Health Information associated with the Group Health plan provided to

our employees, employees’ dependents and, as applicable, retired employees. The Notice describes that Inter-Con Security Sys-

tems may use and disclose Protected Health Information to carry out payment and health care operations, and for other purposes

that are permitted or required by law.

We are required by the privacy regulations issued under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”)

to maintain the privacy of Protected Health Information and to provide individuals covered under our group health plan with notice

of our legal duties and privacy practices concerning Protected Health Information. We are required to abide by the terms of the

Notice so long as it remains in effect. We reserve the right to change the terms of the Notice as necessary and to make the new

Notice effective for all Protected Health Information maintained by us. If we make material changes to our privacy practices, copies

of revised notices will be mailed to all policyholders then covered by the Group Health plan. Copies of our current Notice can be

obtained by contacting:

Human Resources—Phone: (626) 535-2200

Address: 210 South De Lacey Avenue Pasadena, CA 91105

Newborns and Mothers Health Protection Act

Under federal law, group health plans and health insurance issuers offering group health insurance coverage generally may not

restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours

following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the plan or issuer may pay for

a shorter stay if the attending provider (e.g., your physician, nurse midwife, or physician assistant), after consultation with the

mother, discharges the mother or newborn earlier.

Also, under federal law, plans and issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48

hour (or 96 hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay.

In addition, a plan or issuer may not, under federal law, require that a physician or other health care provider obtain authorization

for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your

out-of-pocket costs, you may be required to obtain precertification. For information on precertification, contact your plan adminis-

trator.

18


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 a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2015. Contact your State for more information on eligibility –

ALABAMA – Medicaid GEORGIA – Medicaid

Website: www.myalhipp.com

Phone: 1-855-692-5447

Website: http://dch.georgia.gov/

- Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP)

Phone: 404-656-4507

ALASKA – Medicaid INDIANA – Medicaid

Website: http://health.hss.state.ak.us/dpa/programs/medicaid/

Phone (Outside of Anchorage): 1-888-318-8890

Phone (Anchorage): 907-269-6529

Website: http://www.in.gov/fssa

Phone: 1-800-889-9949

COLORADO – Medicaid IOWA – Medicaid

Medicaid Website: http://www.colorado.gov/hcpf

Medicaid Customer Contact Center: 1-800-221-3943

Website: www.dhs.state.ia.us/hipp/

Phone: 1-888-346-9562

FLORIDA – Medicaid KANSAS – Medicaid

Website: https://www.flmedicaidtplrecovery.com/

Phone: 1-877-357-3268

Website: http://www.kdheks.gov/hcf/

Phone: 1-800-792-4884

19


KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid

Website: http://chfs.ky.gov/dms/default.htm

Phone: 1-800-635-2570

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf

Phone: 603-271-5218

LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP

Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331

Phone: 1-888-695-2447

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

MAINE – Medicaid NEW YORK – Medicaid

Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html

Phone: 1-800-977-6740

TTY 1-800-977-6741

Website: http://www.nyhealth.gov/health_care/medicaid/

Phone: 1-800-541-2831

MASSACHUSETTS – Medicaid and CHIP NORTH CAROLINA – Medicaid

Website: http://www.mass.gov/MassHealth

Phone: 1-800-462-1120

Website: http://www.ncdhhs.gov/dma

Phone: 919-855-4100

MINNESOTA – Medicaid NORTH DAKOTA – Medicaid

Website: http://www.dhs.state.mn.us/id_006254

Click on Health Care, then Medical Assistance

Phone: 1-800-657-3739

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/

Phone: 1-800-755-2604

MISSOURI – Medicaid OKLAHOMA – Medicaid and CHIP

Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

Phone: 573-751-2005

Website: http://www.insureoklahoma.org

Phone: 1-888-365-3742

MONTANA – Medicaid OREGON – Medicaid

Website: http://medicaid.mt.gov/member

Phone: 1-800-694-3084

Website: http://www.oregonhealthykids.gov

http://www.hijossaludablesoregon.gov Phone: 1-800-699-9075

NEBRASKA – Medicaid PENNSYLVANIA – Medicaid

Website: www.ACCESSNebraska.ne.gov

Phone: 1-855-632-7633

Website: http://www.dhs.state.pa.us/hipp

Phone: 1-800-692-7462

NEVADA – Medicaid RHODE ISLAND – Medicaid

Medicaid Website: http://dwss.nv.gov/

Medicaid Phone: 1-800-992-0900

Website: http://www.eohhs.ri.gov/

Phone: 401-462-5300

http://www.ncdhhs.gov/dma

http://www.insureoklahoma.org

http://www.oregonhealthykids.gov

http://dhhs.ne.gov/medicaid/Pages/med_kidsconx.aspx

http://dwss.nv.gov

20


SOUTH CAROLINA – Medicaid VIRGINIA – Medicaid and CHIP

Website: http://www.scdhhs.gov

Phone: 1-888-549-0820

Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm

Medicaid Phone: 1-800-432-5924

CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm

CHIP Phone: 1-855-242-8282

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid

Website: http://dss.sd.gov

Phone: 1-888-828-0059

Website: http://www.hca.wa.gov/medicaid/premiumpymt/pages/ index.aspx

Phone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid WEST VIRGINIA – Medicaid

Website: http://gethipptexas.com/

Phone: 1-800-440-0493

Website: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspx

Phone: 1-877-598-5820, HMS Third Party Liability

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP

Website:

Medicaid: http://health.utah.gov/medicaid

CHIP: http://health.utah.gov/chip

Phone: 1-866-435-7414

Website:

https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm

Phone: 1-800-362-3002

VERMONT– Medicaid WYOMING – Medicaid

Website: http://www.greenmountaincare.org/

Phone: 1-800-250-8427

Website: https://wyequalitycare.acs-inc.com/

Phone: 307-777-7531

http://www.hca.wa.gov/medicaid/premiumpymt/pages/%20index.aspx

http://www.hca.wa.gov/medicaid/premiumpymt/pages/%20index.aspx

Documents

enefits Enrollment Guidebrochure.fringebenefitsgroup.com/icss comml oe... · 5Visit or call Toll Free (855) 495 / -1189 for more information / 5 Enrolling in Your Benefits Alternatively,