Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
2025 Employee Guide - City of Pasco (web)
EMPLOYEE BENEFIT GUIDE January 1, 2025 through December 31, 2025 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 refer to the Medicare Part D Notice section of this Guide for more details. This Benefit Guide provides a brief description of plan benefits. For more information on plan benefits, exclusions, and limitations, please refer to the Plan documents or contact the carrier/administrator directly. If any conflict arises between this Guide and any plan provisions, the terms of the actual plan document or other applicable documents will govern in all cases. Benefits are subject to modification at any time. PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. T A B L E O F C O N T E N T S WHO IS ELIGIBLE HOW TO ENROLL MID-YEAR CHANGES WELCOME TO YOUR BENEFITS WHAT’S OFFERED FOR 2025 QUESTIONS? EMPLOYEE PAYROLL DEDUCTIONS FIRST CHOICE HEALTH – PPO PLAN – PERS PLAN ENROLLEES FIRST CHOICE HEALTH – PPO PLAN – LEOFF PLAN ENROLLEES FIRST CHOICE HEALTH – PPO PLAN – LEOFF ENROLLEES (CONTINUED) VALUE ADDED RESOURCES- VIRTUAL CARE DELTA DENTAL OF WASHINGTON VISION SERVICE PLAN FLEXIBLE SPENDING ACCOUNT (FSA) HOW TO LOCATE A MEDICAL PROVIDER HOW TO LOCATE OTHER PROVIDERS EMPLOYEE ASSISTANCE PLAN (EAP) GROUP LIFE & AD&D INSURANCE VOLUNTARY LIFE/AD&D INSURANCE DISABILITY INSURANCE WASHINGTON PAID FAMILY AND MEDICAL LEAVE ACCIDENT INSURANCE CANCER INSURANCE CRITICAL ILLNESS INSURANCE HOSPITAL INDEMNITY INSURANCE TERM LIFE INSURANCE SHORT TERM DISABILITY INSURANCE SUMMARY OF BENEFITS AND COVERAGE & UNIFORM GLOSSARY ANNUAL HEALTH PLAN COMPLIANCE NOTICES PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. W H O I S E L I G I B L E Full time employees are eligible to participate in benefit plans on the first day of the month following your date of hire. To confirm the hourly requirement for your role and eligible dependents, please see your City of Pasco Human Resources team. Dependent children are eligible to age 26. H O W T O E N R O L L Eligible employees will receive information from their HR Department with detailed instructions for how to enroll for benefits. If you do not complete your enrollment during your designated window, you may not be able to enroll or make changes unless you experience a qualifying event, or until the next open enrollment period. M I D - Y E A R C H A N G E S Unless you have a qualifying event, you cannot make changes to the benefits you elect until the next open enrollment period. If you experience a qualified “change in status,” you must make any associated enrollment or benefit changes within 60 days of the event except for a Medicare or Medicaid entitlement event, in which case you must make changes within 60 days of the event. Qualified changes in status include: • Change in legal marital status (marriage, death of spouse, divorce, legal separation) • Change in number of dependents (birth, death, adoption, ceases to satisfy eligibility requirements, child support order) • Change in employment status • Loss of certain other health coverage • Medicare or Medicaid entitlement • Significant cost or other coverage changes • Family Medical Leave Act (FMLA) leave of absence, reduction of hours • Exchange/Marketplace enrollment Important! Please note that there are several conditions and/or limitations that apply to the events listed above. Please contact Human Resources if you have any questions or believe that you may qualify for an election change. W E L C O M E T O Y O U R B E N E F I T S During the annual open enrollment period, you may make changes to your benefit plan elections and/or the family members you cover. Changes can only be made outside of the annual enrollment period if you experience a qualified family status change that permits changes in your plan election. So now is the time to carefully review your plan options. On the next page is an overview of the offerings for the 2025 plan year. PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. W H A T ’ S O F F E R E D F O R 2 0 2 5 At the City of Pasco, we offer you and your eligible family members a comprehensive and valuable benefits program. We encourage you to take the time to educate yourself about your options and choose the best coverage for you and your family. You may choose to opt out if you have other coverage which you would like to keep. Plans Carriers Medical / RX First Choice Health / Elixir/MedImpact Dental Delta Dental Vision Vision Service Plan Flexible Spending Accounts Health Equity Employee Assistance Program (EAP) First Choice Health Life / AD&D Symetra Voluntary Life / AD&D Symetra Disability Guardian Voluntary Supplemental AFLAC Retirement Plans 457 Mission Square & DRS PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. Q U E S T I O N S ? Because the world of healthcare and insurance can be confusing and hard to navigate, we are pleased to introduce your team at Brown & Brown Insurance who will be able to assist you with all things related to your benefits. Brown & Brown will be working in conjunction with the Human Resources Department so that benefit needs are addressed in a timely fashion. Benefits Advocacy Team cityofpascobenefits@bbrown.com Human Resources 509-545-3408 hr@pasco-wa.gov Additionally, the carriers below may be able to assist. Plan Carrier Phone Website Medical First Choice Health Refer to ID Card 800-521-5858 (TTY:711) www.fchn.com Dental Delta Dental of Washington Refer to ID Card 800-554-1907 www.deltadentalwa.com Vision Vision Service Plan 800-877-7195 www.vsp.com Flexible Spending Accounts HealthEquity 877-924-3967 www.healthequity.com EAP First Choice 800-777-4114 www.fchn.com/EAP Life/AD&D Symetra 800-796-3872 www.symetra.com Disability Guardian 800-538-4583 www.guardianlife.com HRA / VEBA Gallagher 844-342-5505 www.healthinvesthra.com Supplemental Benefits AFLAC 800-992-3522 www.aflac.com Retirement Plans 457 Mission Square & Department of Retirement Systems 202-655-4011 800-547-6657 www.missionsq.org www.drs.wa.gov/contact Medicare Resource Jeff Johnson JBJ Insurance Group 253-249-7846 jeff@jbjinsurance.com www.jbjinsurance.com .777.4114 PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. E M P L O Y E E P A Y R O L L D E D U C T I O N S Below are the monthly employee costs. Group Plan Medical Dental Vision Administrative / Professional / Non-Rep. PERS $153.70 $11.59 $6.52 IOUE PERS $153.70 $11.59 $6.52 Non-Uniformed Police PERS $153.70 $11.59 $6.52 Firefighters / Firefighters Paramedics LEOFF $173.97 $11.59 $0.00 Uniformed Police Officers LEOFF $173.97 $11.59 $6.52 Police Commanding Officers Association LEOFF $173.97 $11.59 $6.52 LEOFF Management LEOFF $173.97 $11.59 $6.52 PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. M E D I C A L P L A N – P E R S P L A N E N R O L L E E S FIRST CHOICE HEALTH – PPO PLAN – PERS PLAN ENROLLEES Preferred Provider Organization (PPO) Plans allow you to choose to see PPO providers or non- network providers. When you use a provider who participates in the First Choice Health Network your out-of-pocket expenses for covered services will be lower. Therefore, it is to your advantage to use PPO providers, but it is not required. In Network Benefits First Choice Health PERS PPO Plan *Denotes deductible applies Annual Deductible $200 Individual $600 Family1 (embedded) Coinsurance You pay 20% Annual Out of Pocket Maximum (Includes deductible & copays) $2,200 Individual $13,200 Family2 (embedded) Preventive Care Covered in full Office Visit – Primary Office Visit – Specialist Office Visit – Virtual Care 20%* 20%* No charge through Transcarent, 20% through all other providers* Outpatient Diagnostic X-Ray & Lab You pay 20%* Major Lab – MRI, PET Scan, CAT Scan You pay 20%* Emergency Room 20%* Hospital Services – In-Patient Facility Fees Physician/Surgeon Fees First $1,000 per confinement at no charge, thereafter you pay 20%* You pay 20%* Prescription Drugs (30-day supply) Generic Drugs Brand Name Drugs No Charge Lesser of $150 or 20% of the allowed amount For up to a 90 day supply Out of Network Benefits PPO Network Annual Deductible $200 Individual $600 Family1 Coinsurance You pay 20% Annual Out of Pocket Maximum (Includes deductible & copays) $2,200 Individual $13,200 Family2 Prescription Drugs Cost share, then you pay 20% (to allowable) 1 Family embedded deductible – members must only satisfy the individual deductible before coinsurance benefits apply. 2 Family embedded out of pocket maximum – the out of pocket max (OOPM) for any one member cannot be more than the individual OOPM. For a full listing of the covered benefits, please contact your HR Department for copies of the Benefit Summary, Summary of Benefits and Coverage (SBC) and Booklet. PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. M E D I C A L P L A N – L E O F F P L A N E N R O L L E E S FIRST CHOICE HEALTH – PPO PLAN – LEOFF PLAN ENROLLEES Preferred Provider Organization (PPO) Plans allow you to choose to see PPO providers or non- network providers. When you use a provider who participates in the First Choice Health Network your out-of-pocket expenses for covered services will be lower. Therefore, it is to your advantage to use PPO providers, but it is not required. In Network Benefits First Choice Health LEOFF PPO Plan *Denotes deductible applies Annual Deductible Per Employee: $0 Per Individual Dependent: $200 Per Dependent Unit: $600 Coinsurance Employee: No Charge Dependent: You pay 20% Annual Out of Pocket Maximum (Includes deductible & copays) Employee: N/A Per Individual Dependent: $2,200 Per Dependent Unit: $13,200 Preventive Care Employee and Dependents: Covered in full Office Visit – Primary Office Visit – Specialist Office Visit – Virtual Care Employees No Charge No Charge No Charge Office Visit – Primary Office Visit – Specialist Office Visit – Virtual Care Dependents 20%* 20%* No charge through Transcarent, 20% through all other providers* Outpatient Diagnostic X-Ray & Lab Employee: No Charge Dependent: You pay 20%* Major Lab – MRI, PET Scan, CAT Scan Employee: No Charge Dependent: You pay 20%* Emergency Room (copay waived if admitted) Employee: No Charge Dependent: You pay 20%* Hospital Services – In-Patient Facility Fees Physician/Surgeon Fees Employee No Charge No Charge Hospital Services – In-Patient Facility Fees Physician/Surgeon Fees Dependents First $1,000 per confinement at no charge, thereafter you pay 20%* You pay 20%* Prescription Drugs (30-day supply) Generic Drugs Brand Name Drugs No Charge Employee: No Charge Dependents: Lesser of $150 or 20% of the allowed amount For up to a 90 day supply PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. M E D I C A L P L A N – L E O F F E N R O L L E E S ( C O N T . ) FIRST CHOICE HEALTH – PPO PLAN – LEOFF ENROLLEES (CONTINUED) Out of Network Benefits PPO Network Annual Deductible $200 Individual $600 Family1 Coinsurance You pay 20% Annual Out of Pocket Maximum (Includes deductible & copays) $2,200 Individual $13,200 Family2 Prescription Drugs Cost share, then you pay 20% (to allowable) 1 Family embedded deductible – members must only satisfy the individual deductible before coinsurance benefits apply. 2 Family embedded out of pocket maximum – the out of pocket max (OOPM) for any one member cannot be more than the individual OOPM. For a full listing of the covered benefits, please contact your HR Department for copies of the Benefit Summary, Summary of Benefits and Coverage (SBC) and Booklet. PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. V A L U E A D D E D R E S O U R C E S - V I R T U A L C A R E PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. D E N T A L P L A N DELTA DENTAL OF WASHINGTON Preferred Provider Organization (PPO) Plans allow you the freedom to use the dentist of your choice or access the PPO network of dentists. There are reduced fees for services based on negotiated rates. Out of network benefits are available; however You will pay the difference in cost between a non-network provider’s charges and the allowed amount. In Network Benefits PERS / LEOFF DEPENDENTS LEOFF EMPLOYEE Dental PPO Dental PPO Annual Deductible $25 Individual $75 Family Deductible is waived for Preventive Services No deductible Annual Benefit Maximum $1,500 $1,500 Class I Preventive & Diagnostic Services Routine Exam Cleanings Fluoride X-Rays Sealants Plan pays 100% Plan pays 100% Class II Basic Services Fillings Endodontics (Root Canal) Periodontics Oral Surgery Plan pays 80% Plan pays 80% Class III Major Services Dentures/Partial Dentures Bridges Crowns Implants Plan pays 50% Plan pays 50% Out of Network Benefits Annual Deductible Shared with In Network Shared with In Network Annual Benefit Maximum Shared with In Network Shared with In Network Preventive / Basic / Major Services 100% / 80% / 50% 100% / 80% / 50% Usual Customary Reimbursement (UCR) Contract Rate Schedule or 90th UCR Contract Rate Schedule or 90th UCR For a full listing of the covered benefits, please contact your HR Department for copies of the Benefit Summary, Summary of Benefits and Coverage (SBC) and Booklet. PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. V I S I O N P L A N VISION SERVICE PLAN The vision plan provides you with the freedom to use an eye doctor of your choice or access the VSP Network vision network of providers. If you use a provider participating in the network, your out-of-pocket expenses will be reduced. Extra Savings: In addition to the coverage below, the plan provides savings on additional pairs of glasses and sunglasses, retinal screening, and laser vision correction. In Network Benefits VISION SERVICE PLAN Vision Plan Combined Co-Pay $25 copay for Wellvision exam and glasses Eye Exam Covered in Full Prescription Lenses & Frames Single Vision Lined Bifocal Lined Trifocal Lenticular Frames Frames Allowance Covered in Full Covered in Full Covered in Full Covered in Full Covered in Full to Allowance $150 max allowance Lens Enhancements Standard Progressive Premium Progressive Custom Progressive $0 copay $80-$90 copay $120 -$160 copay Contact Lenses Lens Exam (fitting & evaluation) Elective Contacts (instead of glasses) Up to $60 $130 allowance Medically Necessary Lenses Paid in full Frequency Eye Exam Lenses – Eyeglass or Contacts Frames Every 12 months Every 12 months Every 24 months Out of Network Benefits See Benefit Summary U S I N G Y O U R B E N E F I T S I S E A S Y There’s no ID card necessary (but you can print a Member Vision Card if you’d like from www.vsp.com) Just tell your provider you have Vision Service Plan (VSP) coverage Give the provider the primary member’s name o It will be helpful to have the primary member’s Date of Birth and Social Security Number handy, in case the provider asks for additional information to look up the coverage For a full listing of the covered benefits, please contact your HR Department for copies of the Benefit Summary, Summary of Benefits and Coverage (SBC) and Booklet. PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. F L E X I B L E S P E N D I N G A C C O U N T ( F S A ) HEALTH EQUITY You have the opportunity to pay for out of pocket Medical, Dental, Vision, and/or Dependent Care expenses with pre-tax dollars through payroll deduction. This means that you don’t pay federal income or FICA taxes on the portion of your paycheck you contribute to your FSA. Plan Year: January 1, 2025 – December 31, 2025 Health Care Contribution Limit: $3,300 Dependent Care Contribution Limit: $5,000 Health Care FSA Set aside pre-tax dollars to pay for out-of-pocket health care expenses (medical, dental and vision) incurred by you, your spouse and/or your dependent children; whether you insure them or not. Dependent Care FSA Used to reimburse childcare expenses; while you or your spouse work, look for work or attend school full-time or are physically unable to care for your dependent. Eligible children are under age 13, or a dependent who is physically or mentally not able to care for themself. Eligible dependent care expenses include: Nanny Nursery school Before and after school care Day camp Daycare Run-Out Period If you still have money in your Health Care FSA account at the end of the Plan Year (December 31, 2025), you will have a 2.5- month run-out period to submit eligible expenses for reimbursement that were incurred during the plan year. Rollover / Carryover If you still have money in the account at the end of the run-out period, up to $660 of your unused balance will carry over into the new FSA plan year. Note: If hired after January 1st, you may enroll upon hire and utilize the funds for services that occur during your employment with the City of Pasco. PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. H O W T O L O C A T E A M E D I C A L P R O V I D E R PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. H O W T O L O C A T E A M E D I C A L P R O V I D E R PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. H O W T O L O C A T E O T H E R P R O V I D E R S Delta Dental www.deltadentalwa.com Scroll down to Patient Tools and click on Find a Dentist Enter your search criteria Create a user account with MySmile Use MySmile to: View your coverage Get personalized cost estimates Endorse your dentist Review your current and past explanation of benefits And more! PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. H O W T O L O C A T E O T H E R P R O V I D E R S VSP Vision Care www.vsp.com Click on Find a Doctor Enter a zip code and click Search Create a user account at vsp.com Use your account to: View your coverage Get personalized cost estimates Find a provider closest to you Review your current and past explanation of benefits And more! PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. E M P L O Y E E A S S I S T A N C E P L A N ( E A P ) FIRST CHOICE HEALTH EAP The EAP provides a positive, confidential tool to help resolve personal or family problems. You and your dependents can use EAP services to get support for and work towards solutions to solve a wide range of issues and concerns. You are automatically enrolled in the plan and this benefit is provided at no cost to you. Services include support for: Anxiety and Depression Couples/Relationship/Parenting Crisis Support Alcohol/Drug Problems Grief and Loss Work Conflict Compulsive Behaviors Domestic Violence Legal and Financial Childcare and Eldercare Home Ownership ID Theft Healthy Living Tips Your company’s complimentary EAP program is available 24/7 and covers not only you, but spouses, domestic partners and children up to age 26. The EAP is here to help when you’re facing issues that interfere with your health, well-being, and productivity at home or at work. The EAP offers up to 3 sessions face-to-face or telehealth (no copay, deductible or premium) with a qualified clinical expert who can assess your concerns and develop a plan of action. If you need legal* or financial consultation, or ID theft resolution, you can speak with an expert for up to 30 minutes at no charge. EAP consultants can also provide you with childcare and eldercare information and resources for anywhere in the country. Additionally, the Home Ownership program is a valuable tool to gain a competitive edge as a buyer and can save you thousands when buying or selling a home. Sign up for First Choice Health EAP BenefitHub Discount Marketplace for exclusive access to amazing discounts on thousands of the brands you love. Simply call us at 800.777.4114 or visit our website to request an appointment. *Workplace issues are excluded. Pasco PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. G R O U P L I F E & A D & D I N S U R A N C E SYMETRA Group Life and AD&D Insurance is arranged through Symetra. All benefit eligible employees receive life and accidental death & dismemberment (AD&D) insurance. This benefit is provided at no cost to you. Benefits Basic Life Coverage Amount Your Basic Life coverage amount is based on your current role: Department Directors - $100,000 Division Managers - $75,000 Non-Uniform Police Officers Associates - $50,000 Administrative, Professional, and International Union of Operating Engineers - $50,000 All Eligible Uniformed Employees of the Pasco Police Officers Association - $50,000 Basic AD&D Coverage Amount Your Basic AD&D coverage amount is equal to your Basic Term life coverage amount. For a covered accidental loss of life, your Basic AD&D coverage amount is equal to your Basic Life coverage amount. For other covered losses, a percentage of this benefit will be payable, please refer to the contract for details. Age Reductions The amount of insurance reduces to 65 percent at the age of 70, to 50 percent at the age of 75 and to 30 percent at age 80, adjusted at policy renewal following the change in age. Other Basic Life Features and Services Accelerated Death Benefit Portability of Insurance Provision Waiver of Premium Right to Convert Provision Other Basic AD&D Features and Services Air Bag Benefit Seat Belt Benefit For a full listing of the covered benefits, please contact your HR Department for copies of the Benefit Summary and Certificate. PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. V O L U N T A R Y L I F E / A D & D I N S U R A N C E Voluntary Life and AD&D Insurance is arranged through Symetra. This insurance can help your family meet daily expenses, maintain their standard of living, pay off debt, secure your children’s education, and more in the event of your passing. Coverage Information Within the coverage amount guidelines shown below, you select the amount of Voluntary Life and Dependent Life insurance for which you are interested in applying. $10,000, $25,000, $50,000or 1X Basic Annual Earnings rounded to the next higher amount $1,000, if not already a multiple thereof, maximum $100,000 as selected by the employee. Guarantee issue of $100,000. Spouse coverage available to 50% of the employee Supplemental Life Benefit Amount up to a maximum of $50,000. Guarantee Issue of $50,000. Dependent Children coverage available - $5,000. Please refer to contract for age limitations. What is Guarantee Issue? This is the maximum amount of coverage you can elect during your initial enrollment as a new hire without answering health questions. Otherwise, all elections require the completion of a health statement and are subject to underwriting approval. Age Reductions The amount of insurance reduces to 65 percent at the age of 70, to 50 percent at the age of 75 and to 30 percent at age 80, adjusted at policy renewal following the change in age. Additional Features Accelerated Death Benefit Waiver of Premium Right to Convert Provision Rates and Calculation PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. D I S A B I L I T Y I N S U R A N C E Without disability coverage, you and your family may struggle to get by if you miss work due to an injury or illness. If you become disabled from an injury or sickness, disability income benefits will provide a partial replacement of lost income. The City of Pasco provides eligible employees the option to purchase disability on a voluntary basis, through payroll deduction. GUARDIAN Voluntary Long Term Disability Benefits Begin 91st day Percentage of Pre-Disability Income Replaced 60% Duration of Benefits Payable Until age 65 or Social Security Normal Retirement Age Maximum Benefit Up to $5,000 monthly Minimum Benefit $100 monthly Waiting Period None Monthly Rates – Your age as of July 1st Long Term Disability Per $100 Monthly 15-24 $0.24 25-29 $0.32 30-34 $0.39 35-39 $0.55 40-44 $0.82 45-49 $1.34 50-54 $1.88 55-59 $2.11 60+ $1.49 How to Calculate Your Monthly Premiums For a full listing of the covered benefits, please contact your HR Department for copies of the Benefit Summary and Certificate. PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. W A S H I N G T O N P A I D F A M I L Y A N D M E D I C A L L E A V E Paid Family and Medical Leave provides paid time off when a serious health condition prevents you from working, when you need to care for a family member or a new child, or for certain military-related events. It’s here for you when you need it most, so you can focus on what matters. You apply for leave with the Employment Security Department and will get partial wage replacement, up to 90 percent of your typical pay, capped at $1,456 per week. Don’t’ forget to file for Washington Paid Family & Medical Leave In general, insurance carriers will assume that you are taking WPFML concurrently with any disability and will automatically reduce your benefit by the anticipated WPFML you would receive. If you do not qualify for WPFML, the insurance carrier will reinstate your full benefit upon receipt of documentation that you are not eligible or that WPFML benefits have been denied. How long will benefits last? Nearly every Washington worker is eligible for up to 12 weeks of Paid Family and Medical Leave. You need to work 820 hours in Washington, or about 16 hours per week, over the course of about a year. You can get up to 16 weeks if you have family and medical events in the same year, or up to 18 weeks in some cases. Leave doesn’t have to be taken all at once. You can use these weeks within your “claim year,” which starts when you apply and then runs for the next 52 weeks. When that claim year expires you can then be eligible for leave again. What if I have Long Term Disability? For most people, WPFML and LTD will never overlap. If your approved WPFML does overlap slightly with an LTD claim, benefits will continue to be reduced until your WFPML benefits have been exhausted. Once WPFML benefits are exhausted, your full disability benefit would be reinstated. If you have Long Term Disability, without a Short Term Disability benefit, you will still report the WPFML benefit as income being received. You should indicate when the WPFML benefits are expected to end, and it would be beneficial to include a copy of your WPFML benefit letter to confirm the benefit expiration date. Resources Please review your specific disability plan booklet/contract for specific details of coverage and coordination of benefits Washington Paid Family Medical Leave https://paidleave.wa.gov/individuals-and-families/ PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. A F L A C Who hasn’t received an unexpected medical bill? That’s why there’s Aflac. They can help take care of expenses health insurance doesn’t cover, so you can care about everything else. A C C I D E N T I N S U R A N C E Individual accident insurance can help with unexpected expenses associated with an accidental injury, so you can focus on getting better. C A N C E R I N S U R A N C E Aflac cancer/specified-disease policy provides robust benefits so you can seek the treatment you need while easing the financial concerns that often accompany it before, during and after diagnosis. C R I T I C A L I L L N E S S I N S U R A N C E An Aflac specified health event policy is designed to help with the costs of treatment if you experience a covered health event. H O S P I T A L I N D E M N I T Y I N S U R A N C E Health insurance isn’t meant to cover all expenses associated with hospitalization – like deductibles and copays. Aflac hospital insurance can help minimize those out-of-pocket costs so you can focus on recovery. T E R M L I F E I N S U R A N C E With Aflac’s term life insurance, you can rest easy knowing that your family can have financial security when they need it most. S H O R T T E R M D I S A B I L I T Y I N S U R A N C E What if you couldn’t work due to injury or illness? Aflac Short Term Disability insurance helps replace some of your income and keeps working when you can’t. Please contact your AFLAC representative for more information regarding plan offerings and costs. Tricia Charles Phone: 509.833.1215 Email: tricia_charles@us.aflac.com PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. S U M M A R Y O F B E N E F I T S A N D C O V E R A G E & U N I F O R M G L O S S A R Y The next pages contain the following mandatory compliance information: • An easy-to-understand summary of benefits and coverage for the medical plan(s) offered by your employer • PERS PPO Plan • LEOFF PPO Plan SBCs are also located on the City’s PowerDMS. • A uniform glossary of terms commonly used in health insurance coverage such as “deductible” and “copayment” (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 6 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2025 – 12/31/2025 City of Pasco: PERS Plan Coverage for: Individual + Family Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage visit www.fchn.com or 800-521-5858. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or call 800-521-5858 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? Per calendar year: $200/individual, $600/family. Deductibles reset on a calendar year basis. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Prescription drugs, hospital confinement, and preventive care are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No.You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? Per calendar year: $2,200/individual, $13,200/family. Out-of-pocket limits reset on a calendar basis. 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 network providers see www.fchn.com or call 800-521- 5858. This plan uses a provider network which allows for discounted rates on covered services. Your plan benefits are the same whether you use a Network or Non-Network provider; however, if you use a Non-Network provider you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. * For more information about limitations and exceptions, see the plan or policy document at www.fchn.com. Page 2 of 6 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information If You Use a Network or Non-Network Provider (Non-Network services may be subject to provider balance billing) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness 20% coinsurance None. Specialist visit 20% coinsurance None. Preventive care/screening/ immunization No Charge You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance None. Imaging (CT/PET scans, MRIs) 20% coinsurance Preauthorization is required for PET scans or claim may be denied. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.elixirsolutions.com Generic drugs No Charge Up to a 90-day supply. Prescription drugs apply to the medical out-of- pocket amount. After the out-of-pocket amount is satisfied each calendar year, prescription drugs are reimbursed at 100%. The medical deductible is waived. Brand drugs Lesser of $150 or 20% of the allowed amount If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% coinsurance None. Physician/surgeon fees 20% coinsurance None. * For more information about limitations and exceptions, see the plan or policy document at www.fchn.com. Page 3 of 6 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information If You Use a Network or Non-Network Provider (Non-Network services may be subject to provider balance billing) If you need immediate medical attention Emergency room care 20% coinsurance None. Emergency medical transportation 20% coinsurance Transportation limited to the nearest hospital or skilled nursing facility that can provide the necessary medical treatment. Urgent care 20% coinsurance None. If you have a hospital stay Facility fee (e.g., hospital room) First $1,000 per confinement at No Charge; thereafter, 20% coinsurance Deductible waived Preauthorization required. Physician/surgeon fees 20% coinsurance None. If you need mental health, behavioral health, or substance abuse services Outpatient services 20% coinsurance None. Inpatient services 20% coinsurance Preauthorization required. If you are pregnant Office visits Global Prenatal Care – No Charge Dependent Maternity (other than the Spouse), services are not a covered benefit except what is covered by the Affordable Care Act. Postnatal subject to applicable Plan Benefits and applicable benefit eligible individual. Childbirth/delivery professional services 20% coinsurance None. Childbirth/delivery facility services First $1,000 per confinement at No Charge; thereafter, 20% coinsurance None. If you need help recovering or have other special health needs Home health care 20% coinsurance Limited to 130 visits/calendar year Rehabilitation services 20% coinsurance Preauthorization required for Inpatient Services.Habilitation services 20% coinsurance Skilled nursing care 20% coinsurance Preauthorization required. Durable medical equipment 20% coinsurance None. * For more information about limitations and exceptions, see the plan or policy document at www.fchn.com. Page 4 of 6 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information If You Use a Network or Non-Network Provider (Non-Network services may be subject to provider balance billing) Hospice services 20% coinsurance Preauthorization required for Inpatient Hospice and Respite Care. 12 months lifetime maximum for Hospice. 30-day maximum within 12 months for Respite Care. If your child needs dental or eye care Children’s eye exam No charge – Birth up to 19 years Limited to one exam/calendar year. Children’s glasses Not covered May be covered by another plan offered through your employer. Children’s dental check-up No charge – Birth up to 19 years Limited to one exam, cleaning & polishing/calendar year regardless of network. Excludes dental x-rays. 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.) Bariatric Surgery Cosmetic Surgery Dental Care (Adult): Separate dental plan is available. Hearing Aids Infertility Treatment Long-term Care Non-emergency care when traveling outside the U.S. Routine Eye Care (Adult) Routine Foot Care Weight Loss Programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Acupuncture Chiropractic Care Private-duty Nursing Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: 1-866-EBSA or www.dol.gov/ebsa/healthreform. 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 more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: 800-521-5858 or visit www.fchn.com or 1-866-444-EBSA www.dol.gov/ebsa/healthreform. * For more information about limitations and exceptions, see the plan or policy document at www.fchn.com. Page 5 of 6 Does this plan provide Minimum Essential Coverage?Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the 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 800-521-5858 [Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 800-521-5858 [Chinese (中文): 如果需要中文的帮助, 请拨打这个号码 800-521-5858 [Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 800-521-5858 PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244- 1850. To see examples of how this plan might cover costs for a sample medical situation, see the next section. Page 6 of 6 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. The plan’s overall deductible $200 Specialist coinsurance 20% 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 $12,700 In this example, Peg would pay: Cost Sharing Deductibles $200 Copayments $0 Coinsurance $2,000 What isn’t covered Limits or exclusions $60 The total Peg would pay is $2,260 The plan’s overall deductible $200 Specialist coinsurance 20% Hospital (facility) coinsurance 20% Other coinsurance 20% 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) Total Example Cost $5,600 In this example, Joe would pay: Cost Sharing Deductibles $200 Copayments $0 Coinsurance $300 What isn’t covered Limits or exclusions $20 The total Joe would pay is $520 The plan’s overall deductible $200 Specialist coinsurance 20% Hospital (facility) coinsurance 20% Other coinsurance 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Mia would pay: Cost Sharing Deductibles $200 Copayments $0 Coinsurance $500 What isn’t covered Limits or exclusions $0 The total Mia would pay is $700 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) Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 7 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2025 – 12/31/2025 City of Pasco: LEOFF Plan Coverage for: Individual + Family Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage visit www.fchn.com or 800-521-5858. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or call 800-521-5858 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? Per calendar year: Per Employee: $0 $200 per individual dependent and $600 per dependent unit Deductibles reset on a calendar year basis. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Employees: all Covered Services. Dependents: Prescription drugs, hospital confinement, and preventive care are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No.You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? Per calendar year: Per employee: $0 $2,200 per individual dependent and $13,200 per dependent unit. Out-of-pocket limits reset on a calendar basis. 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. * For more information about limitations and exceptions, see the plan or policy document at www.fchn.com. Page 2 of 7 Important Questions Answers Why This Matters: Will you pay less if you use a network provider? Yes. For a list of network providers see www.fchn.com or call 800-521- 5858. This plan uses a provider network which allows for discounted rates on covered services. Your plan benefits are the same whether you use a Network or Non-Network provider; however, if you use a Non-Network provider you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information If You Use a Network or Non-Network Provider (Non-Network services may be subject to provider balance billing) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness Employee: No Charge Dependents: 20%coinsurance None. Specialist visit Employee: No Charge Dependents: 20%coinsurance None. Preventive care/screening/ immunization No Charge You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) Employee: No Charge Dependents: 20%coinsurance None. Imaging (CT/PET scans, MRIs) Employee: No Charge Dependents: 20% coinsurance Preauthorization is required for PET scans or claim may be denied. * For more information about limitations and exceptions, see the plan or policy document at www.fchn.com. Page 3 of 7 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information If You Use a Network or Non-Network Provider (Non-Network services may be subject to provider balance billing) If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.elixirsolutions.com Generic drugs No Charge Up to a 90-day supply. Experimental and Investigational drugs are excluded. Brand drugs Employee: No Charge Dependents: Lesser of $150 or 20% of the allowed amount. Deductible waived If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) Employee: No Charge Dependents: 20% coinsurance None. Physician/surgeon fees Employee: No Charge Dependents: 20% coinsurance None. If you need immediate medical attention Emergency room care Employee: No Charge Dependents: 20% coinsurance None. Emergency medical transportation Employee: No Charge Dependents: 20% coinsurance Transportation limited to the nearest hospital or skilled nursing facility that can provide the necessary medical treatment. Urgent care Employee: No Charge Dependents: 20% coinsurance None. If you have a hospital stay Facility fee (e.g., hospital room) Employee: No Charge Dependents: First $1,000 per confinement at No Charge; thereafter, 20% coinsurance Deductible waived Preauthorization required. Physician/surgeon fees Employee: No Charge Dependents: 20% coinsurance None. * For more information about limitations and exceptions, see the plan or policy document at www.fchn.com. Page 4 of 7 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information If You Use a Network or Non-Network Provider (Non-Network services may be subject to provider balance billing) If you need mental health, behavioral health, or substance abuse services Outpatient services Employee: No Charge Dependents: 20% coinsurance None. Inpatient services Employee: No Charge Dependents: 20% coinsurance Preauthorization required. If you are pregnant Office visits Global Prenatal Care – No Charge Dependent Maternity (other than the Spouse), services are not a covered benefit except what is covered by the Affordable Care Act. Postnatal subject to applicable Plan Benefits and applicable benefit eligible individual. Childbirth/delivery professional services Employee: No Charge Spouse: 20% coinsurance Dependents (other than spouse): Not Covered None. Childbirth/delivery facility services Employee: No Charge Spouse: First $1,000 per confinement at No Charge; thereafter, 20% coinsurance Dependents (other than spouse): Not Covered None. If you need help recovering or have other special health needs Home health care 20% coinsurance Limited to 130 visits/calendar year Rehabilitation services 20% coinsurance Preauthorization required for Inpatient Services.Habilitation services 20% coinsurance Skilled nursing care 20% coinsurance Preauthorization required. Durable medical equipment 20% coinsurance None. Hospice services 20% coinsurance Preauthorization required for Inpatient Hospice and Respite Care. 12 months lifetime maximum for Hospice. 30-day maximum within 12 months for Respite Care. * For more information about limitations and exceptions, see the plan or policy document at www.fchn.com. Page 5 of 7 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information If You Use a Network or Non-Network Provider (Non-Network services may be subject to provider balance billing) If your child needs dental or eye care Children’s eye exam No charge – Birth up to 19 years Limited to one exam/calendar year. Children’s glasses Not covered May be covered by another plan offered through your employer. Children’s dental check-up No charge – Birth up to 19 years Limited to one exam, cleaning & polishing/calendar year regardless of network. Excludes dental x-rays. 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.) Bariatric Surgery Cosmetic Surgery Dental Care (Adult): Separate dental plan is available. Hearing Aids Infertility Treatment Long-term Care Non-emergency care when traveling outside the U.S. Routine Eye Care (Adult) Routine Foot Care Weight Loss Programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Acupuncture Chiropractic Care Private-duty Nursing Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: 1-866-EBSA or www.dol.gov/ebsa/healthreform. 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 more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: 800-521-5858 or visit www.fchn.com or 1-866-444-EBSA www.dol.gov/ebsa/healthreform. Does this plan provide Minimum Essential Coverage?Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the 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. * For more information about limitations and exceptions, see the plan or policy document at www.fchn.com. Page 6 of 7 Language Access Services: [Spanish (Español): Para obtener asistencia en Español, llame al 800-521-5858 [Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 800-521-5858 [Chinese (中文): 如果需要中文的帮助, 请拨打这个号码 800-521-5858 [Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 800-521-5858 PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244- 1850. To see examples of how this plan might cover costs for a sample medical situation, see the next section. Page 7 of 7 About these Coverage Examples for Dependents: 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. The plan’s overall deductible $200 Specialist coinsurance 20% 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 $12,700 In this example, Peg would pay: Cost Sharing Deductibles $200 Copayments $0 Coinsurance $2,000 What isn’t covered Limits or exclusions $60 The total Peg would pay is $2,260 The plan’s overall deductible $200 Specialist coinsurance 20% Hospital (facility) coinsurance 20% Other coinsurance 20% 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) Total Example Cost $5,600 In this example, Joe would pay: Cost Sharing Deductibles $200 Copayments $0 Coinsurance $300 What isn’t covered Limits or exclusions $20 The total Joe would pay is $520 The plan’s overall deductible $200 Specialist coinsurance 20% Hospital (facility) coinsurance 20% Other coinsurance 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Mia would pay: Cost Sharing Deductibles $200 Copayments $0 Coinsurance $500 What isn’t covered Limits or exclusions $0 The total Mia would pay is $700 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) Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) Glossary of Health Coverage and Medical Terms Page 1 of 4 Glossary of Health Coverage and Medical Terms • This glossary has many commonly used terms, but isn’t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document.) • Bold blue text indicates a term defined in this Glossary. • See page 4 for an example showing how deductibles, co-insurance and out-of-pocket limits work together in a real life situation. Allowed Amount Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.) Appeal A request for your health insurer or plan to review a decision or a grievance again. Balance Billing When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services. Co-insurance Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount. Complications of Pregnancy Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non- emergency caesarean section aren’t complications of pregnancy. Co-payment A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service. Deductible The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services. Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics. Emergency Medical Condition An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm. Emergency Medical Transportation Ambulance services for an emergency medical condition. Emergency Room Care Emergency services you get in an emergency room. Emergency Services Evaluation of an emergency medical condition and treatment to keep the condition from getting worse. (See page 4 for a detailed example.) Jane pays 100% Her plan pays 0% (See page 4 for a detailed example.) Jane pays 20% Her plan pays 80% OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Glossary of Health Coverage and Medical Terms Page 2 of 4 Excluded Services Health care services that your health insurance or plan doesn’t pay for or cover. Grievance A complaint that you communicate to your health insurer or plan. Habilitation Services Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Health Insurance A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium. Home Health Care Health care services a person receives at home. Hospice Services Services to provide comfort and support for persons in the last stages of a terminal illness and their families. Hospitalization Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care. Hospital Outpatient Care Care in a hospital that usually doesn’t require an overnight stay. In-network Co-insurance The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance. In-network Co-payment A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments. Medically Necessary Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine. Network The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services. Non-Preferred Provider A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Out-of-network Co-insurance The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out- of-network co-insurance usually costs you more than in- network co-insurance. Out-of-network Co-payment A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network co- payments usually are more than in-network co-payments. Out-of-Pocket Limit The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit. Physician Services Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates. (See page 4 for a detailed example.) Jane pays 0% Her plan pays 100% Glossary of Health Coverage and Medical Terms Page 3 of 4 Plan A benefit your employer, union or other group sponsor provides to you to pay for your health care services. Preauthorization A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost. Preferred Provider A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more. Premium The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly. Prescription Drug Coverage Health insurance or plan that helps pay for prescription drugs and medications. Prescription Drugs Drugs and medications that by law require a prescription. Primary Care Physician A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient. Primary Care Provider A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services. Provider A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law. Reconstructive Surgery Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions. Rehabilitation Services Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings. Skilled Nursing Care Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home. Specialist A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care. UCR (Usual, Customary and Reasonable) The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount. Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. Glossary of Health Coverage and Medical Terms Page 4 of 4 How You and Your Insurer Share Costs - Example Jane’s Plan Deductible: $1,500 Co-insurance: 20% Out-of-Pocket Limit: $5,000 Jane reaches her $1,500 deductible, co-insurance begins Jane has seen a doctor several times and paid $1,500 in total. Her plan pays some of the costs for her next visit. Office visit costs: $75 Jane pays: 20% of $75 = $15 Her plan pays: 80% of $75 = $60 Jane hasn’t reached her $1,500 deductible yet Her plan doesn’t pay any of the costs. Office visit costs: $125 Jane pays: $125 Her plan pays: $0 January 1st Beginning of Coverage Period December 31st End of Coverage Period more costs more costs Jane reaches her $5,000 out-of-pocket limit Jane has seen the doctor often and paid $5,000 in total. Her plan pays the full cost of her covered health care services for the rest of the year. Office visit costs: $200 Jane pays: $0 Her plan pays: $200 Jane pays 100% Her plan pays 0% Jane pays 20% Her plan pays 80% Jane pays 0% Her plan pays 100% PRESENTED BY: & © 2024 Brown & Brown, Inc. All rights reserved. A N N U A L H E A L T H P L A N C O M P L I A N C E N O T I C E S TABLE OF CONTENTS CHIP Notice COBRA General Notice General FMLA Notice Genetic Information Nondiscrimination Act (GINA) Disclosures Health Insurance Exchange Notice (for companies who offer a health plan) Medicare Part D Creditable Coverage Notice Mental Health Parity and Addiction Equity Act (MHPAEA) Disclosure Newborns’ and Mothers’ Health Protection Act Notice No Surprise Billing Notice of Privacy Practices Special Enrollment Rights Notice Uniformed Services Employment and Reemployment Rights Act (USERRA) Notice WHCRA Notice 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, 2024. Contact your State for more information on eligibility – ALABAMA – Medicaid ALASKA – Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447 The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: https://health.alaska.gov/dpa/Pages/default.aspx ARKANSAS – Medicaid CALIFORNIA – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447) Health Insurance Premium Payment (HIPP) Program Website: http://dhcs.ca.gov/hipp Phone: 916-445-8322 Fax: 916-440-5676 Email: hipp@dhcs.ca.gov COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) FLORIDA – Medicaid Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/State Relay 711 CHP+: https://hcpf.colorado.gov/child-health-plan-plus CHP+ Customer Service: 1-800-359-1991/State Relay 711 Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrec overy.com/hipp/index.html Phone: 1-877-357-3268 Health Insurance Buy-In Program (HIBI): https://www.mycohibi.com/ HIBI Customer Service: 1-855-692-6442 GEORGIA – Medicaid INDIANA – Medicaid GA HIPP Website: https://medicaid.georgia.gov/health- insurance-premium-payment-program-hipp Phone: 678-564-1162, Press 1 GA CHIPRA Website: https://medicaid.georgia.gov/programs/third-party- liability/childrens-health-insurance-program- reauthorization-act-2009-chipra Phone: 678-564-1162, Press 2 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: https://www.in.gov/medicaid/ Phone: 1-800-457-4584 IOWA – Medicaid and CHIP (Hawki) KANSAS – Medicaid Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: Hawki - Healthy and Well Kids in Iowa | Health & Human Services Hawki Phone: 1-800-257-8563 HIPP Website: Health Insurance Premium Payment (HIPP) | Health & Human Services (iowa.gov) HIPP Phone: 1-888-346-9562 Website: https://www.kancare.ks.gov/ Phone: 1-800-792-4884 HIPP Phone: 1-800-967-4660 KENTUCKY – Medicaid LOUISIANA – Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihip p.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: https://kynect.ky.gov Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov/agencies/dms Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP) MAINE – Medicaid MASSACHUSETTS – Medicaid and CHIP Enrollment Website: https://www.mymaineconnection.gov/benefits/s/?lang uage=en_US Phone: 1-800-442-6003 TTY: Maine relay 711 Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms Phone: 1-800-977-6740 TTY: Maine relay 711 Website: https://www.mass.gov/masshealth/pa Phone: 1-800-862-4840 TTY: 711 Email: masspremassistance@accenture.com MINNESOTA – Medicaid MISSOURI – Medicaid Website: https://mn.gov/dhs/health-care-coverage/ Phone: 1-800-657-3672 Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.ht m Phone: 573-751-2005 MONTANA – Medicaid NEBRASKA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIP P Phone: 1-800-694-3084 Email: HHSHIPPProgram@mt.gov Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178 NEVADA – Medicaid NEW HAMPSHIRE – Medicaid Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900 Website: https://www.dhhs.nh.gov/programs- services/medicaid/health-insurance-premium-program Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852- 3345, ext. 5218 Email: DHHS.ThirdPartyLiabi@dhhs.nh.gov NEW JERSEY – Medicaid and CHIP NEW YORK – Medicaid Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Phone: 1-800-356-1561 CHIP Premium Assistance Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 (TTY: 711) Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA – Medicaid NORTH DAKOTA – Medicaid Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100 Website: https://www.hhs.nd.gov/healthcare Phone: 1-844-854-4825 OKLAHOMA – Medicaid and CHIP OREGON – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 Website: http://healthcare.oregon.gov/Pages/index.aspx Phone: 1-800-699-9075 PENNSYLVANIA – Medicaid and CHIP RHODE ISLAND – Medicaid and CHIP Website: https://www.pa.gov/en/services/dhs/apply- for-medicaid-health-insurance-premium-payment- program-hipp.html Phone: 1-800-692-7462 CHIP Website: Children's Health Insurance Program (CHIP) (pa.gov) CHIP Phone: 1-800-986-KIDS (5437) Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line) SOUTH CAROLINA – Medicaid SOUTH DAKOTA - Medicaid Website: https://www.scdhhs.gov Phone: 1-888-549-0820 Website: http://dss.sd.gov Phone: 1-888-828-0059 TEXAS – Medicaid UTAH – Medicaid and CHIP Website: Health Insurance Premium Payment (HIPP) Program | Texas Health and Human Services Phone: 1-800-440-0493 Utah’s Premium Partnership for Health Insurance (UPP) Website: https://medicaid.utah.gov/upp/ Email: upp@utah.gov Phone: 1-888-222-2542 Adult Expansion Website: https://medicaid.utah.gov/expansion/ Utah Medicaid Buyout Program Website: https://medicaid.utah.gov/buyout-program/ CHIP Website: https://chip.utah.gov/ To see if any other states have added a premium assistance program since July 31, 2024, 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 ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137. OMB Control Number 1210-0137 (expires 1/31/2026) VERMONT– Medicaid VIRGINIA – Medicaid and CHIP Website: Health Insurance Premium Payment (HIPP) Program | Department of Vermont Health Access Phone: 1-800-250-8427 Website: https://coverva.dmas.virginia.gov/learn/premium- assistance/famis-select https://coverva.dmas.virginia.gov/learn/premium- assistance/health-insurance-premium-payment-hipp- programs Medicaid/CHIP Phone: 1-800-432-5924 WASHINGTON – Medicaid WEST VIRGINIA – Medicaid and CHIP Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022 Website: https://dhhr.wv.gov/bms/ http://mywvhipp.com/ Medicaid Phone: 304-558-1700 CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-699- 8447) WISCONSIN – Medicaid and CHIP WYOMING – Medicaid Website: https://www.dhs.wisconsin.gov/badgercareplus/p- 10095.htm Phone: 1-800-362-3002 Website: https://health.wyo.gov/healthcarefin/medicaid/program s-and-eligibility/ Phone: 1-800-251-1269 General Notice of COBRA Rights (For use by single-employer group health plans) Continuation Coverage Rights Under COBRA Introduction You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. 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 and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. What is COBRA continuation coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. 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’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: Your hours of employment are reduced, or Your employment ends for any reason other than your gross misconduct. If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: Your spouse dies; Your spouse’s hours of employment are reduced; Your spouse’s employment ends for any reason other than his or her gross misconduct; Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: 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; or The child stops being eligible for coverage under the Plan as a “dependent child.” Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to City of Pasco, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. When is COBRA continuation 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. The employer must notify the Plan Administrator of the following qualifying events: The end of employment or reduction of hours of employment; Death of the employee; The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 30 days after the qualifying event occurs. You must provide this notice to: Sara Matzen 525 N. Third Avenue Pasco, WA 99301 How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, Children’s Health Insurance Program (CHIP), or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov. Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends? In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have an 8-month special enrollment period1 to sign up for Medicare Part A or B, beginning on the earlier of The month after your employment ends; or The month after group health plan coverage based on current employment ends. If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage may 1 https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b/part-a-part-b-sign-up-periods. not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage. If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare. For more information visit https://www.medicare.gov/medicare-and-you. If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.healthcare.gov. Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan contact information 2025 Plan Year Sara Matzen 525 N. Third Avenue Pasco, WA 99301 General FMLA Notice EMPLOYEE RIGHTS UNDER THE FAMILY AND MEDICAL LEAVE ACT The United States Department of Labor Wage and Hour Division Leave Entitlements Eligible employees who work for a covered employer can take up to 12 weeks of unpaid, job-protected leave in a 12-month period for the following reasons: The birth of a child or placement of a child for adoption or foster care; To bond with a child (leave must be taken within 1 year of the child’s birth or placement); To care for the employee’s spouse, child, or parent who has a qualifying serious health condition; For the employee’s own qualifying serious health condition that makes the employee unable to perform the employee’s job; For qualifying exigencies related to the foreign deployment of a military member who is the employee’s spouse, child, or parent. An eligible employee who is a covered servicemember’s spouse, child, parent, or next of kin may also take up to 26 weeks of FMLA leave in a single 12-month period to care for the servicemember with a serious injury or illness. An employee does not need to use leave in one block. When it is medically necessary or otherwise permitted, employees may take leave intermittently or on a reduced schedule. Employees may choose, or an employer may require, use of accrued paid leave while taking FMLA leave. If an employee substitutes accrued paid leave for FMLA leave, the employee must comply with the employer’s normal paid leave policies. Benefits & Protections While employees are on FMLA leave, employers must continue health insurance coverage as if the employees were not on leave. Upon return from FMLA leave, most employees must be restored to the same job or one nearly identical to it with equivalent pay, benefits, and other employment terms and conditions. An employer may not interfere with an individual’s FMLA rights or retaliate against someone for using or trying to use FMLA leave, opposing any practice made unlawful by the FMLA, or being involved in any proceeding under or related to the FMLA. Eligibility Requirements An employee who works for a covered employer must meet three criteria in order to be eligible for FMLA leave. The employee must: Have worked for the employer for at least 12 months; Have at least 1,250 hours of service in the 12 months before taking leave;* and Work at a location where the employer has at least 50 employees within 75 miles of the employee’s worksite. *Special “hours of service” requirements apply to airline flight crew employees. Requesting Leave Generally, employees must give 30-days’ advance notice of the need for FMLA leave. If it is not possible to give 30-days’ notice, an employee must notify the employer as soon as possible and, generally, follow the employer’s usual procedures. Employees do not have to share a medical diagnosis, but must provide enough information to the employer so it can determine if the leave qualifies for FMLA protection. Sufficient information could include informing an employer that the employee is or will be unable to perform his or her job functions, that a family member cannot perform daily activities, or that hospitalization or continuing medical treatment is necessary. Employees must inform the employer if the need for leave is for a reason for which FMLA leave was previously taken or certified. Employers can require a certification or periodic recertification supporting the need for leave. If the employer determines that the certification is incomplete, it must provide a written notice indicating what additional information is required. Employer Responsibilities Once an employer becomes aware that an employee’s need for leave is for a reason that may qualify under the FMLA, the employer must notify the employee if he or she is eligible for FMLA leave and, if eligible, must also provide a notice of rights and responsibilities under the FMLA. If the employee is not eligible, the employer must provide a reason for ineligibility. Employers must notify its employees if leave will be designated as FMLA leave, and if so, how much leave will be designated as FMLA leave. Enforcement Employees may file a complaint with the U.S. Department of Labor, Wage and Hour Division, or may bring a private lawsuit against an employer. The FMLA does not affect any federal or state law prohibiting discrimination or supersede any state or local law or collective bargaining agreement that provides greater family or medical leave rights. For additional information or to file a complaint: 1-866-4-USWAGE (1-866-487-9243) TTY: 1-877-889-5627 www.dol.gov/whd U.S. Department of Labor | Wage and Hour Division Genetic Information Nondiscrimination Act (GINA) Disclosures Genetic Information Nondiscrimination Act of 2008 The Genetic Information Nondiscrimination Act of 2008 (“GINA”) protects employees against discrimination based on their genetic information. Unless otherwise permitted, your Employer may not request or require any genetic information from you or your family members. The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. Health Insurance Exchange Notice For Employers Who Offer a Health Plan to Some or All Employees New Health Insurance Marketplace Coverage Options and Your Health Coverage PART A: General Information Even if you are offered health coverage through your employment, you may have other coverage options through the Health Insurance Marketplace (“Marketplace”). To assist you as you evaluate options for you and your family, this notice provides some basic information about the Health Insurance Marketplace and health coverage offered through your employment. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options in your geographic area. Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium and other out-of-pocket costs, but only if your employer does not offer coverage, or offers coverage that is not considered affordable for you and doesn’t meet certain minimum value standards (discussed below). The savings that you're eligible for depends on your household income. You may also be eligible for a tax credit that lowers your costs. Does Employment-Based Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that is considered affordable for you and meets certain minimum value standards, you will not be eligible for a tax credit, or advance payment of the tax credit, for your Marketplace coverage and may wish to enroll in your employment-based health plan. However, you may be eligible for a tax credit, and advance payments of the credit that lowers your monthly premium, or a reduction in certain cost-sharing, if your employer does not offer coverage to you at all or does not offer coverage that is considered affordable for you or meet minimum value standards. If your share of the premium cost of all plans offered to you through your employment is more than 9.12%2 of your annual household income, or if the coverage through your employment does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit, and advance payment of the credit, if you do not enroll in the employment-based health coverage. For family members of the employee, coverage is considered affordable if the employee’s cost of premiums for the lowest-cost plan that would cover all family members does not exceed 9.12% of the employee’s household income..13 Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered through your employment, then you may lose access to whatever the employer contributes to the employment-based coverage. Also, this employer contribution -as well as your employee contribution to employment-based coverage- is generally excluded from income for federal and state income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. In addition, note that if the health coverage offered through your employment does not meet the affordability 2 Indexed annually; see https://www.irs.gov/pub/irs-drop/rp-22-34.pdf for 2023. 3 An employer-sponsored or other employment-based health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs. For purposes of eligibility for the premium tax credit, to meet the “minimum value standard,” the health plan must also provide substantial coverage of both inpatient hospital services and physician services. or minimum value standards, but you accept that coverage anyway, you will not be eligible for a tax credit. You should consider all of these factors in determining whether to purchase a health plan through the Marketplace. When Can I Enroll in Health Insurance Coverage through the Marketplace? You can enroll in a Marketplace health insurance plan during the annual Marketplace Open Enrollment Period. Open Enrollment varies by state but generally starts November 1 and continues through at least December 15. Outside the annual Open Enrollment Period, you can sign up for health insurance if you qualify for a Special Enrollment Period. In general, you qualify for a Special Enrollment Period if you’ve had certain qualifying life events, such as getting married, having a baby, adopting a child, or losing eligibility for other health coverage. Depending on your Special Enrollment Period type, you may have 60 days before or 60 days following the qualifying life event to enroll in a Marketplace plan. There is also a Marketplace Special Enrollment Period for individuals and their families who lose eligibility for Medicaid or Children’s Health Insurance Program (CHIP) coverage on or after March 31, 2023, through July 31, 2024. Since the onset of the nationwide COVID-19 public health emergency, state Medicaid and CHIP agencies generally have not terminated the enrollment of any Medicaid or CHIP beneficiary who was enrolled on or after March 18, 2020, through March 31, 2023. As state Medicaid and CHIP agencies resume regular eligibility and enrollment practices, many individuals may no longer be eligible for Medicaid or CHIP coverage starting as early as March 31, 2023. The U.S. Department of Health and Human Services is offering a temporary Marketplace Special Enrollment period to allow these individuals to enroll in Marketplace coverage. Marketplace-eligible individuals who live in states served by HealthCare.gov and either- submit a new application or update an existing application on HealthCare.gov between March 31, 2023 and July 31, 2024, and attest to a termination date of Medicaid or CHIP coverage within the same time period, are eligible for a 60-day Special Enrollment Period. That means that if you lose Medicaid or CHIP coverage between March 31, 2023, and July 31, 2024, you may be able to enroll in Marketplace coverage within 60 days of when you lost Medicaid or CHIP coverage. In addition, if you or your family members are enrolled in Medicaid or CHIP coverage, it is important to make sure that your contact information is up to date to make sure you get any information about changes to your eligibility. To learn more, visit HealthCare.gov or call the Marketplace Call Center at 1-800-318-2596. TTY users can call 1-855-889-4325. What about Alternatives to Marketplace Health Insurance Coverage? If you or your family are eligible for coverage in an employment-based health plan (such as an employer- sponsored health plan), you or your family may also be eligible for a Special Enrollment Period to enroll in that health plan in certain circumstances, including if you or your dependents were enrolled in Medicaid or CHIP coverage and lost that coverage. Generally, you have 60 days after the loss of Medicaid or CHIP coverage to enroll in an employment-based health plan, but if you and your family lost eligibility for Medicaid or CHIP coverage between March 31, 2023 and July 10, 2023, you can request this special enrollment in the employment-based health plan through September 8, 2023. Confirm the deadline with your employer or your employment-based health plan. Alternatively, you can enroll in Medicaid or CHIP coverage at any time by filling out an application through the Marketplace or applying directly through your state Medicaid agency. Visit https://www.healthcare.gov/medicaid-chip/getting-medicaid-chip/ for more details. How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact: Sara Matzen 525 N. Third Avenue Pasco, WA 99301 The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area. PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application. Here is some basic information about health coverage offered by this employer: As your employer, we offer a health plan to: СSome employees. Eligible employees are: full time employees working 36+ hours per week. With respect to dependents: СWe do offer coverage. Eligible dependents are: Legal Spouses and children up to age 26 С If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages. Note: Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount. 3. Employer name City of Pasco 4. Employer Identification Number (EIN) 91-6001264 5. Employer address 525 N. 3rd Avenue 6. Employer phone number (509) 545-3408 7. City Pasco 8. State WA 9. ZIP code 99301 10. Who can we contact about employee health coverage at this job? Sara Matzen 11. Phone number (509) 545-3473 12. Email address matzens@pasco-wa.gov Medicare Part D Creditable Coverage Notice Important Notice from City of Pasco 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 City of Pasco 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 an 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. City of Pasco has determined that the prescription drug coverage offered by the City of Pasco Plan is, 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. Because 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 Medicare drug plan. When Can You Join a Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable 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 City of Pasco coverage will not be affected. Plan participants can keep their prescription drug coverage under the group health plan if they continue to meet the eligibility requirements set forth in the plan document and select Medicare Part D prescription drug coverage. If they select Medicare Part D prescription drug coverage, the group health plan prescription drug coverage will coordinate with the Medicare Part D prescription drug coverage. Reenrollment in the group health plan is subject to all special enrollment and open enrollment plan provisions. If you do decide to join a Medicare drug plan and drop your current City of Pasco coverage, be aware that you and your dependents will 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 City of Pasco 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 call Sara Matzen at (509) 545-3473. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through City of Pasco changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit www.medicare.gov Call your State Health Insurance Assistance Program (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 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). Date: 11/4/2024 Name of Entity/Sender: City of Pasco Contact--Position/Office: Sara Matzen, Human Resources Director Address: 525 N. Third Avenue Pasco, WA 99301 Phone Number: (509) 545-3473 Mental Health Parity and Addiction Equity Act (MHPAEA) Disclosure The Mental Health Parity and Addiction Equity Act of 2008 generally requires group health plans and health insurance issuers to ensure that financial requirements (such as co-pays and deductibles) and treatment limitations (such as annual visit limits) applicable to mental health or substance use disorder benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits. For information regarding the criteria for medical necessity determinations made under the plan with respect to mental health or substance use disorder benefits, please contact your plan administrator at (509) 545-3473. Newborns' and Mothers' Health Protection Act Notice Group 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 the mother 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 as applicable). 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). Your Rights and Protections Against Surprise Medical Bills What is “balance billing” (sometimes called “surprise billing”)? When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. “Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit. “Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service. You’re protected from balance billing for: When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible. Emergency services If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services. See how new rules help protect people from surprise medical bills and remove consumers from payment disputes between a provider or a health care facility and their health plan. https://www.cms.gov/nosurprises Certain services at an in-network hospital or ambulatory surgical center When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in- network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network. In 2019, the Washington state legislature enacted the Balance Billing Protection Act (BBPA) which took effect on Jan. 1, 2020. This law prohibits balance billing for emergency services and for non- emergency “surgical and ancillary services” provided at in-network hospitals and ambulatory surgical facilities. Under the law, a consumer cannot be asked by any health care provider, facility or insurer to waive their balance billing protections. https://www.insurance.wa.gov/federal-no-surprises-act When balance billing isn’t allowed, you also have these protections: You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly. Generally, your health plan must: o Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”). o Cover emergency services by out-of-network providers. o Base what you owe the provider or facility (cost-sharing) on what it would pay an in- network provider or facility and show that amount in your explanation of benefits. o Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit. If you think you’ve been wrongly billed, contact the No Surprises Help Desk, operated by the U.S. Department of Health and Human Services, at 1-800-985-3059. Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law. Notice of Privacy Practices City of Pasco 525 N. 3rd Avenue Pasco, WA 99301 Privacy Official: Sara Matzen 525 N. Third Avenue Pasco, WA 99301 Effective Date: 11/4/2024 Your Information. Your Rights. Our Responsibilities. This 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. Your Rights You have the right to: Get a copy of your health and claims records Correct your health and claims records Request confidential communication Ask us to limit the information we share Get a list of those with whom we’ve shared your information Get a copy of this privacy notice Choose someone to act for you File a complaint if you believe your privacy rights have been violated Your Choices You have some choices in the way that we use and share information as we: Answer coverage questions from your family and friends Provide disaster relief Market our services and sell your information Our Uses and Disclosures We may use and share your information as we: Help manage the health care treatment you receive Run our organization Pay for your health services Administer your health plan Help with public health and safety issues Do research Comply with the law Respond to organ and tissue donation requests and work with a medical examiner or funeral director Address workers’ compensation, law enforcement, and other government requests Respond to lawsuits and legal actions Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get a copy of health and claims records You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct health and claims records You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not. Ask us to limit what we use or share You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. Get a list of those with whom we’ve shared information You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated You can complain if you feel we have violated your rights by contacting us at: Sara Matzen 525 N. Third Avenue Pasco, WA 99301 You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint. Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: • Share information with your family, close friends, or others involved in payment for your care • Share information in a disaster relief situation If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission: • Marketing purposes • Sale of your information Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Help manage the health care treatment you receive We can use your health information and share it with professionals who are treating you. Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services. Run our organization We can use and share your information to run our organization and contact you when necessary. We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans. Example: We use health information about you to develop better services for you. Pay for your health services We can use and disclose your health information as we pay for your health services. Example: We share information about you with your dental plan to coordinate payment for your dental work. Administer your plan We may disclose your health information to your health plan sponsor for plan administration. Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. Help with public health and safety issues We can share health information about you for certain situations such as: Preventing disease Helping with product recalls Reporting adverse reactions to medications Reporting suspected abuse, neglect, or domestic violence Preventing or reducing a serious threat to anyone’s health or safety Do research We can use or share your information for health research. Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Respond to organ and tissue donation requests and work with a medical examiner or funeral director We can share health information about you with organ procurement organizations. We can share health information with a coroner, medical examiner, or funeral director when an individual dies. Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you: For workers’ compensation claims For law enforcement purposes or with a law enforcement official With health oversight agencies for activities authorized by law For special government functions such as military, national security, and presidential protective services Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you. Notice of Special Enrollment Rights If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. If you or your dependent(s) lose coverage under a state Children’s Health Insurance Program (CHIP) or Medicaid, you may be able to enroll yourself and your dependents. However, you must request enrollment within 60 days after the loss of CHIP or Medicaid coverage. If you or your dependent(s) become eligible to receive premium assistance under a state CHIP or Medicaid, you may be able to enroll yourself and your dependents. However, you must request enrollment within 60 days of the determination of eligibility for premium assistance from state CHIP or Medicaid. To request special enrollment or obtain more information, contact: Sara Matzen 525 N. Third Avenue Pasco, WA 99301 USERRA Notice Your Rights Under USERRA A. The Uniformed Services Employment and Reemployment Rights Act USERRA protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake military service or certain types of service in the National Disaster Medical System. USERRA also prohibits employers from discriminating against past and present members of the uniformed services, and applicants to the uniformed services. B. Reemployment Rights You have the right to be reemployed in your civilian job if you leave that job to perform service in the uniformed service and: You ensure that your employer receives advance written or verbal notice of your service; You have five years or less of cumulative service in the uniformed services while with that particular employer; You return to work or apply for reemployment in a timely manner after conclusion of service; and You have not been separated from service with a disqualifying discharge or under other than honorable conditions. If you are eligible to be reemployed, you must be restored to the job and benefits you would have attained if you had not been absent due to military service or, in some cases, a comparable job. C. Right to Be Free from Discrimination and Retaliation If you: Are a past or present member of the uniformed service; Have applied for membership in the uniformed service; or Are obligated to serve in the uniformed service; then an employer may not deny you o Initial employment; o Reemployment; o Retention in employment; o Promotion; or o Any benefit of employment because of this status. In addition, an employer may not retaliate against anyone assisting in the enforcement of USERRA rights, including testifying or making a statement in connection with a proceeding under USERRA, even if that person has no service connection. D. Health Insurance Protection If you leave your job to perform military service, you have the right to elect to continue your existing employer-based health plan coverage for you and your dependents for up to 24 months while in the military. Even if you do not elect to continue coverage during your military service, you have the right to be reinstated in your employer's health plan when you are reemployed, generally without any waiting periods or exclusions (e.g., pre-existing condition exclusions) except for service- connected illnesses or injuries. E. Enforcement The U.S. Department of Labor, Veterans' Employment and Training Service (VETS) is authorized to investigate and resolve complaints of USERRA violations. For assistance in filing a complaint, or for any other information on USERRA, contact VETS at 1-866-4- USA-DOL or visit its Web site at http://www.dol.gov/vets. An interactive online USERRA Advisor can be viewed at http://www.dol.gov/elaws/userra.htm. If you file a complaint with VETS and VETS is unable to resolve it, you may request that your case be referred to the Department of Justice or the Office of Special Counsel, as applicable, for representation. You may also bypass the VETS process and bring a civil action against an employer for violations of USERRA. The rights listed here may vary depending on the circumstances. The text of this notice was prepared by VETS, and may be viewed on the Internet at this address: http://www.dol.gov/vets/programs/userra/poster.htm. Federal law requires employers to notify employees of their rights under USERRA, and employers may meet this requirement by displaying the text of this notice where they customarily place notices for employees. U.S. Department of Labor, Veterans' Employment and Training Service, 1-866-487-2365. Women's Health and Cancer Rights Act (WHCRA) Notices Enrollment Notice If 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, call your plan administrator at (509) 545-3473. Annual Notice Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema? Call your plan administrator at (509) 545-3473 for more information.