CONFIDENTIAL AND PROPRIETARY: This document and the information contained herein is confidential and proprietary information of USI Insurance Services, LLC ("USI"). Recipient agrees not to copy, reproduce or distribute this document, in whole or in part, without the prior written consent of USI. Estimates are illustrative given data limitation, may not be cumulative and are subject to change based on carrier underwriting. © 2022 USI Insurance Services. All rights reserved. 2023 Employee Benefits Enrollment Guide
1 Table of Contents Benefit Items........................................................................................................................................................... 2 Contact Information................................................................................................................................................ 3 Medical Benefits ..................................................................................................................................................... 4 2024 Wellness Incentive ......................................................................................................................................... 5 Teladoc.................................................................................................................................................................... 6 AroRx....................................................................................................................................................................... 8 Health Savings Account (HSA)............................................................................................................................... 13 Flexible Spending Account (FSA)........................................................................................................................... 14 Dental .................................................................................................................................................................... 15 Vision..................................................................................................................................................................... 16 Life Insurance – Police Officers ............................................................................................................................. 17 Life Insurance – Full-Time Exempt Employees ..................................................................................................... 18 Voluntary Accidental Death & Dismemberment .................................................................................................. 19 Voluntary Short-Term Disability ........................................................................................................................... 22 Employee Assistance Program.............................................................................................................................. 23 Worksite Benefits.................................................................................................................................................. 24 KPERS / KP&F ........................................................................................................................................................ 26 457 Deferred Compensation Plan......................................................................................................................... 33 Legal Notices ......................................................................................................................................................... 35
2 Benefit Items You’re eligible for benefits if you are an active full-time employee working at least 30 hours per week. Coverage goes into effect the first of the month following your date of hire. You must enroll within 30 days of your hire date. You may also enroll your eligible dependents as follows: • Your legally married spouse • Eligible children to age 26 – your natural child, lawfully adopted child (including a child placed with you for adoption but for whom the adoption is not yet final), stepchild or other child for whom you have obtained legal guardianship pursuant to a court order, until such child attains age 26 (or until such child attains age 18 in the case of legal guardianship). Listed below are the City of Hutchinson benefits available during open enrollment: • Medical • Dental • Vision • Health Savings Account • Life and AD&D • Voluntary AD&D • Short Term Disability • Employee Assistance Program • Flexible Spending Accounts • Critical Illness • Accident The open enrollment elections you make will be effective 01/01/2023 through 12/31/2023. You may only change coverage if you experience a qualifying life event. You may change your benefit elections during the year if you experience an event such as: • Marriage • Divorce or legal separation • Birth of your child or your domestic partner’s child • Death of your spouse or dependent child • Adoption of or placement for adoption of your child • Change in employment status of employee, spouse, or dependent child • Qualification by the Plan Administrator of a child support order for medical coverage • Entitlement to Medicare or Medicaid You must notify Human Resources within 30 days of a qualifying life event (or 60 days if the qualifying event is coverage lost under Medicaid or State CHIP program or if you or your dependents become eligible for a premium assistance subsidy from the state). Supporting documentation must be provided.
3 Contact Information Benefit Plans Carrier Phone Number Website Medical (TPA) Meritain Health (800) 925-2272 www.meritain.com Medical Provider Network Aetna Choice POS II (800) 343-3140 www.aetna.com/docfind/custom./m ymeritain Medical Precertification Meritain Medical Management (800) 242-1199 Medical Chronic Conditions Meritain Disease Management (888) 610-0089 Medical Prescriptions AroRx (833) 306-4092 Members.arorx.com Medical – Telephonic Acccess Teladoc (800) 362-2667 www.MyDrConsult.com Dental Delta Dental of Kansas (800) 234-3375 www.deltadentalks.com Vision Surency Life and Health (866) 818-8805 www.surency.com/vision Health Savings Account Empower (800) 819-9571 Flexible Spending Accounts Empower (800) 819-9571 Life and AD&D Lincoln Financial Group (800) 432-2765 www.lincolnfinancial.com Voluntary Life and AD&D Lincoln Financial Group (800) 432-2765 www.lincolnfinancial.com Voluntary Short Term Disability Lincoln Financial Group (800) 432-2765 www.lincolnfinancial.com Employee Assistance Program EMPAC (800) 234-0630 www.empac-eap.com Critical Illness Allstate (800) 521-3535 Accident Allstate (800) 521-3535 Wellness Program WellWorks (800) 425-4657 Wellworksforyou.com Benefit Resource Center USI (855) 874-0742 Email: [email protected] KPERS/KP&F Optional Life The Standard (844) 289-2306 Email: [email protected] Retirement KPERS/KP&F (888) 275-5737 www.kpers.org 457 Deferred Comp Mission Square (800) 669-7400 www.icmarc.org
4 Medical Benefits The City of Hutchinson offers two plans to choose form, a Traditional PPO medical plan and a Qualified High Deductible plan that can be paired with a Health Savings Account (HSA). • Meritain is City of Hutchinson’s Third-Party Administrator (TPA) for claims processing. Both plans are PPO plans. This means that you have a network of providers that you are encouraged to use for a deeper discount. However, if you see an out-ofnetwork provider, you will pay higher out-of-pocket costs. • Our Network is Aetna Choice POS II • You are not required to designate a primary care physician (PCP) and do not have to receive a referral to see a specialist. • To locate a network provider, please visit www.aetna.com/docfind/custom/mymeritain or call 800-343-3140. • Benefit Coverage Meritain Health (TPA) $1,250 deductible 16569 Meritain Health (TPA) $3,000 Deductible HDHP 16569 In-Network Benefits Out-of-Network Benefits In-Network Benefits Out-of-Network Benefits Annual Deductible Individual $1,250 $1,250 $3,000 $3,000 Family $2,500 $2,500 $6,000 $6,000 Coinsurance (Plan Pays) 80% 60% 100% 80% Maximum Out-of-Pocket Individual $4,000 $8,000 $3,000 $6,000 Family $8,000 $16,000 $6,000 $12,000 Physician Office Visit Primary Care $20 copay 60% after deductible 0% after deductible 80% after deductible Specialty Care $40 copay 60% after deductible 0% after deductible 80% after deductible Preventive Care Adult Periodic Exams Covered at 100% 40% after deductible Covered at 100% 20% after deductible Well-Child Care Covered at 100% 40% after deductible Covered at 100% 20% after deductible Diagnostic Services (Member Pays) X-ray and Lab Tests 20% after deductible 40% after deductible 0% after deductible 20% after deductible Complex Radiology 20% after deductible 40% after deductible 0% after deductible 20% after deductible Urgent Care Facility $50 copay 40% after deductible 0% after deductible 20% after deductible Emergency Room Facility Charges $200 copay then 20% after deductible $200 copay then 20% after deductible 0% after deductible Subject to deductible Inpatient Facility Charges 20% after deductible 40% after deductible 0% after deductible 20% after deductible Outpatient Facility and Surgical Charges 20% after deductible 40% after deductible 0% after deductible 20% after deductible Mental Health Inpatient 20% after deductible 40% after deductible 0% after deductible 20% after deductible Outpatient $20 copay 40% after deductible 0% after deductible 20% after deductible Substance Abuse Inpatient 20% after deductible 40% after deductible 0% after deductible 20% after deductible Outpatient $20 copay 40% after deductible 0% after deductible 20% after deductible Other Services Chiropractic 20% after deductible 40% after deductible 0% after deductible 20% after deductible
5 Benefit Coverage Meritain Health (TPA) $1,250 deductible 16569 Meritain Health (TPA) $3,000 Deductible HDHP 16569 In-Network Benefits Out-of-Network Benefits In-Network Benefits Out-of-Network Benefits Retail Pharmacy (30 Day Supply) Generic (Tier 1) 25% Not covered 0% after deductible Not covered Preferred (Tier 2) 25% Not covered 0% after deductible Not covered Non-Preferred (Tier 3) 35% Not covered 0% after deductible Not covered Preferred Specialty (Tier 4) Not covered – contact AroRx Not covered Not covered – contact AroRx Not covered Mail Order Pharmacy (90 Day Supply) Generic (Tier 1) $25 copay Not covered 0% after deductible Not covered Preferred (Tier 2) $25 copay Not covered 0% after deductible Not covered Non-Preferred (Tier 3) $35 copay Not covered 0% after deductible Not covered Preferred Specialty (Tier 4) Not covered Not covered Not covered Not covered Bundled Medical & Vision Monthly Employee Contributions $1,250 Deductible $3,000 HDHP Employee $59.10 $0.00 Employee + Spouse $254.12 $113.20 Employee + Child(ren) $244.88 $109.08 Family $570.30 $369.52 2024 Wellness Incentive The City of Hutchinson will be adding a wellness program through WellWorks. You will have until October 31, 2023, to complete an annual physical with your Primary Care Physician and to complete a Tobacco Attestation form. The incentive will be a medical premium differential for the 2024 plan year. The incentive will be released later in 2023. Stay tuned for more details.
6 Teladoc
7
8 Introducing ARORx! 833-306-4092 With ARORx, you have access to all national pharmacy chains and most smaller local pharmacies. You will continue to get your prescriptions under the same copay structure you currently do and use the same retail pharmacies you always have. New Card. Look out for your new prescription card in the mail. Give to your pharmacist on your next fill, on or after the effective date. You usually only need to give your new information 1x at the pharmacy to keep on file for future fills. New Mail Order Pharmacy and Website. If you haven’t already, set up your new mail order account at members.arorx.com We Are adding ARORx to your current Maxor Rx coverage! Effective January 1, 2023 Your employer has partnered with ARORx for your prescription drug coverage. So what’s different?
9 Price Drug & Find Pharmacy. After creating your account, utilize the “Price Drug & Find Pharmacy” to search for different pharmacies and pricing in your area. High Cost Drug Program. Did you know the cost of drugs has increased up to 5,000% in the past 5 years and 2% of claimants account for 40-50% of overall spending? ARORx’s high cost drug service reduces cost on drug spend for you and your employer, often getting your high cost medication for free & delivered right to your door. To find out if you’re taking a high cost drug, take a look at page 11 & 12. If you see your Rx on the list, contact ARORx at 833-306-4092 by November 1, 2022 to set up your new fill process. Be sure to engage with ARORx promptly to ensure timely processing and no disruption to your fill. See page 5 for high cost drug program details. If you’re not taking a high cost drug, continue to use the same retail pharmacy at the same copays as before. So what’s different (continued)?
10 Every change has its challenges. Follow these best practices for a smooth transition. Tips for a successful start: 1. Refill your prescription right before the effective date so you have a full supply on hand. Most plans allow you to refill your prescriptions before you completely run out. 2. Once your new plan starts, don’t fill your first prescription going into a weekend, a holiday, or right before your vacation. Please fill with at least 3 business days to spare so our team can solve any scenarios that may pop up. 3. Call your pharmacy before you pick up your first fill on the new plan to give them your new plan information and confirm your cost before you’re standing in line. 99% of pharmacy calls ARORx receives during implementation are due to pharmacies running old plan information. 4. Call ARORx for assistance. If you have any questions or need assistance, contact ARORx 24/7 at 833-306-4092. After the effective date, if you receive a new prescription from your doctor: After the effective date (January 1, 2023), if you receive a new prescription from your doctor: ’s c le s. 1. Call the pharmacy before picking up the new drug to confirm your cost. 2. When the pharmacy runs your prescription in their system, they will be notified if it’s a drug you’ll need to fill through ARORx. 3. Contact ARORx to start the process immediately, or ARORx will contact you the following business day.
11 High Cost Drug List The most common high cost drugs are listed below. This list is not an exhaustive list of all high cost drugs, and ARORx may contact you on drugs not listed.
12 High Cost Drug List - Continued
13 Health Savings Account (HSA) 2023 HSA Contribution Limits Individual: $3,850 Family: $7,750 *Individuals 55 and over may contribute an extra $1,000 towards their HSA HSA Administrator: Empower (800) 819-9571
14 Flexible Spending Account (FSA) Flex Administrator: Empower (800) 819-9571 or [email protected]
15 Dental Monthly Employee Dental Contributions Employee $3.16 Employee & Spouse $12.92 Employee & Child(ren) $11.02 Family $25.00
16 Vision
17 Life Insurance – Police Officers
18 Life Insurance – Full-Time Exempt Employees
19 Voluntary Accidental Death & Dismemberment
20
21
22 Voluntary Short-Term Disability
23 Employee Assistance Program
24 Worksite Benefits
25
KPERS
27
28
29
30
31
32
33
34
35 Legal Notices Important Legal Notices Affecting Your Health Plan Coverage 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. Therefore, the following deductibles and coinsurance apply: $1,250/$2,500 at 80% coinsurance and $3,000/$6,000 at 100% coinsurance. 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). 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). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. Further, if you decline enrollment for yourself or eligible dependents (including your spouse) while Medicaid coverage or coverage under a State CHIP program is in effect, you may be able to enroll yourself and your dependents in this plan if: • coverage is lost under Medicaid or a State CHIP program; or • you or your dependents become eligible for a premium assistance subsidy from the State. In either case, you must request enrollment within 60 days from the loss of coverage or the date you become eligible for premium assistance. To request special enrollment or obtain more information, contact the person listed at the end of this summary. THE WOMEN’S HEALTH CANCER RIGHTS ACT OF 1998 (WHCRA) NEWBORNS ACT DISCLOSURE - FEDERAL NOTICE OF SPECIAL ENROLLMENT RIGHTS
36 City of Hutchinson Wellness Program is a voluntary wellness program available to all employees. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program you will be asked to complete your annual wellness exam, which will include a blood test for blood glucose and blood lipids. You are not required to complete your annual well exam, or to participate in the blood test or other medical examinations. However, employees who choose to participate in the wellness program will receive an incentive of reduced healthcare premiums incentive for the 2024 plan year. Although you are not required to complete the annual wellness exam or blood test, only employees who do so will receive reduced healthcare premium incentive. The reduced healthcare premium incentive is also combined with a Tobacco Attestation form. If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive, you may be entitled to a reasonable accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by contacting Tom Sanders, Director of Human Resources. The information from your annual wellness exam and blood test will be used to provide you with information to help you understand your current health and potential risks, and may also be used to offer you services through the wellness program, such as a tobacco cessation program. You also are encouraged to share your results or concerns with your own doctor. Protections from Disclosure of Medical Information We are required by law to maintain the privacy and security of your personally identifiable health information. Although the wellness program and City of Huthcinson may use aggregate information it collects to design a program based on identified health risks in the workplace, City of Hutchinson Wellness Program will never disclose any of your personal information either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment. Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information is WellWorks, in order to provide you with services under the wellness program. In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making any employment decision. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you immediately. You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate. NOTICE REGARDING WELLNESS PROGRAMS
37 If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact Tom Sanders, Director of Human Resources at 620-694-2620. Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact us at WellWorks Customer Service at 800-425-4657 or Human Resources at 620-694-2620 and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status. CONTACT INFORMATION Questions regarding any of this information can be directed to: Tom Sanders 125 E. Avenue B Hutchinson, KS 67504 620-694-2620 [email protected] «Notice of Privacy Practices» WELLNESS PROGRAM DISCLOSURE CONTACT INFORMATION
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 Information. Your Rights. Our Responsibilities. Recipients of the notice are encouraged to read the entire notice. Contact information for questions or complaints is available at the end of the notice. 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.
39 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, usually 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. 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 up to 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.
40 File a complaint if you feel your rights are violated • You can complain if you feel we have violated your rights by contacting us using the information at the end of this notice. • 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 1-877-6966775, 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. 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. Run our organization • We can use and disclose 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.
41 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/index.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.
42 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 (if applicable), and we will mail a copy to you. Other Instructions for Notice • January 1, 2023 • Tom Sanders, Director of Human Resources, 620-694-2620
OMB 0938-0990 MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE FOR USE ON OR AFTER APRIL 1, 2011 If you are receiving this electronically, you are responsible for providing a copy of this notice to any Medicare Part Deligible dependents who are covered under the group health plan. Important Notice from City of Hutchinson 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 Hutchinson 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 Hutchinson has determined that the prescription drug coverage offered by the City of Hutchinson, 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. CMS Form 10182-CC Updated April 1, 2011 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 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, 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. OMB 0938-0990 MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE FOR USE ON OR AFTER APRIL 1, 2011
44 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 Hutchinson coverage will not be affected. If you do decide to join a Medicare drug plan and drop your current City of Hutchinson 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 Hutchinson and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through City of Hutchinson changes. You also may request a copy of this notice at any time. CMS Form 10182-CC Updated April 1, 2011 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 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, 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. OMB 0938-0990 MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE FOR USE ON OR AFTER APRIL 1, 2011 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.
45 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: January 1, 2023 Name of Entity/Sender: Tom Sanders, City of Hutchinson Contact--Position/Office: Director of Human Resources Address: 125 E. Avenue B, Hutchinson, KS 67504 Phone Number: 620-694-2620 CMS Form 10182-CC Updated April 1, 2011 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 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, 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.
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, 2022. Contact your State for more information on eligibility – ALABAMA – Medicaid CALIFORNIA – Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447 Website: Health Insurance Premium Payment (HIPP) Program http://dhcs.ca.gov/hipp Phone: 916-445-8322 Fax: 916-440-5676 Email: [email protected] ALASKA – Medicaid COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: [email protected] Medicaid Eligibility: https://health.alaska.gov/dpa/Pages/default.aspx Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/child-healthplan-plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711 Health Insurance Buy-In Program (HIBI): https://www.colorado.gov/pacific/hcpf/healthinsurance-buy-program HIBI Customer Service: 1-855-692-6442 ARKANSAS – Medicaid FLORIDA – Medicaid
47 Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447) Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplreco very.com/hipp/index.html Phone: 1-877-357-3268 GEORGIA – Medicaid MASSACHUSETTS – Medicaid and CHIP GA HIPP Website: https://medicaid.georgia.gov/healthinsurance-premium-payment-program-hipp Phone: 678-564-1162, Press 1 GA CHIPRA Website: https://medicaid.georgia.gov/programs/third-partyliability/childrens-health-insurance-programreauthorization-act-2009-chipra Phone: (678) 564-1162, Press 2 Website: https://www.mass.gov/masshealth/pa Phone: 1-800-862-4840 TTY: (617) 886-8102 INDIANA – Medicaid MINNESOTA – Medicaid 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 Website: http://mn.gov/dhs/people-weserve/seniors/health-care/health-careprograms/programs-and-services/medical-assistance.jsp https://mn.gov/dhs/people-we-serve/children-andfamilies/health-care/health-care-programs/programs-andservices/other-insurance.jsp Phone: 1-800-657-3739 IOWA – Medicaid and CHIP (Hawki) MISSOURI – Medicaid Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563 HIPP Website: https://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp HIPP Phone: 1-888-346-9562 Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005 KANSAS – Medicaid MONTANA – Medicaid Website: https://www.kancare.ks.gov/ Phone: 1-800-792-4884 Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084 Email: [email protected] KENTUCKY – Medicaid NEBRASKA – Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.a spx Phone: 1-855-459-6328 Email: [email protected] KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178 LOUISIANA – Medicaid NEVADA – Medicaid Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-6185488 (LaHIPP) Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900 MAINE – Medicaid NEW HAMPSHIRE – Medicaid
48 Enrollment Website: https://www.maine.gov/dhhs/ofi/applications-forms Phone: 1-800-442-6003 TTY: Maine relay 711 Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms Phone: -800-977-6740. TTY: Maine relay 711 Website: https://www.dhhs.nh.gov/programsservices/medicaid/health-insurance-premium-program Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext 5218 NEW JERSEY – Medicaid and CHIP SOUTH DAKOTA - Medicaid Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 Website: http://dss.sd.gov Phone: 1-888-828-0059 NEW YORK – Medicaid TEXAS – Medicaid Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831 Website: http://gethipptexas.com/ Phone: 1-800-440-0493 NORTH CAROLINA – Medicaid UTAH – Medicaid and CHIP Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100 Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669 NORTH DAKOTA – Medicaid VERMONT– Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825 Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427 OKLAHOMA – Medicaid and CHIP VIRGINIA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 Website: https://www.coverva.org/en/famis-select https://www.coverva.org/en/hipp Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-800-432-5924 OREGON – Medicaid WASHINGTON – Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075 Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022 PENNSYLVANIA – Medicaid WEST VIRGINIA – Medicaid and CHIP Website: https://www.dhs.pa.gov/Services/Assistance/Pages/HIPPProgram.aspx Phone: 1-800-692-7462 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) RHODE ISLAND – Medicaid and CHIP WISCONSIN – Medicaid and CHIP Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line) Website: https://www.dhs.wisconsin.gov/badgercareplus/p10095.htm Phone: 1-800-362-3002 SOUTH CAROLINA – Medicaid WYOMING – Medicaid
49 To see if any other states have added a premium assistance program since July 31, 2022, or for more information on special enrollment rights, contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210-0137. OMB Control Number 1210-0137 (expires 1/31/2023) Website: https://www.scdhhs.gov Phone: 1-888-549-0820 Website: https://health.wyo.gov/healthcarefin/medicaid/programsand-eligibility/ Phone: 1-800-251-1269
flippingbook.comRkJQdWJsaXNoZXIy MTMyNDE0NQ==