2026 Benefits Guide by Snellings Walters
This document provides information on employee benefits offered by Snellings Walters for the year 2026.
KAGD 36@67;FE8G;56
TABLE OF CONTENTS OPEN ENROLLMENT O PEN ENROLLMENT – B ENEFITS :AIFA6@DA>>;@36@67;FE I:6@FA6@DA>> @6I6?B>AK66E MEDICAL USING YOUR MEDICAL COVERAGE ?65;42>B>2@EA776D65 :E2 : 62>F: E 2H;@8E 2 44AG@F DENTAL DENTAL PLANS | V ALUE P LAN AND NAP PLAN E2?B>6A7E6DH;46E4AH6D65 8G2D5;2@4:A;46 ͼ 255;F;A@2>56F2;>E A D2> : 62>F: D 6I2D5E B DA8D2? VISION VISON PLAN DETAILS LIFE INSURANCE BASIC LIFE VOLUNTARY LIFE DISABILITY INSURANCE SHORT TERM DISABILITY LONG TERM DISABILITY AF:6D BENEFITS 7 CRITI 4 AL ILLNESS ACCIDENT INSURANCE EMPLOYEE ASSITANCE PROGRAM ͛ IWcV8dMaQWM]I;>> BaR_ FSA – FLEXIBLE DEPENDENT CARE ACCOUNT | OPTUM :62>F:6@L – KEEP IT SIMPLE SURGERY PROGRAM 42@46D42D6 4A@F24F;@7AD?2F;A@ D2F6;@7AD?2F;A@
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AcVRaOR]RSWcbMaR^SSRaRQOh 8dMaQWM] AF:6D36@67;FE GUARDIAN® is a registered trademark of The Guardian Life Insurance Company of America © Copyright 2020 The Guardian Life Insurance Company of America How it can help This service is only available if you purchase qualifying lines of coverage. See your plan administrator for more details. WillPrep Services are provided by Uprise Health, and its contractors. The Guardian Life Insurance Company of America (Guardian) does not provide any part of Will Prep Services. Guardian is not responsible or liable for care or advice given by any provider or resource under the program. This information is for illustrative purposes only. It is not a contract. Only the Administration Agreement can provide the actual terms, services, limitations and exclusions. Guardian and Uprise Health reserve the right to discontinue the WillPrep Services at any time without notice. Legal services will not be provided in connection with or preparation for any action against Guardian, Uprise Health, or your employer. Prepare your will with the assistance or support of an attorney Access simple documents including wills and power of attorney letters Speak with consultants to discuss estate planning How to access To access WillPrep Services, you’ll need a few personal details. Visit willprep.uprisehealth.com Username WillPrep Password GLIC09 For more information or support, you can reach out by phoning 1 877 433 6789 . WillPrep Protect the ones you love with a range of dedicated services designed to help you provide for your family. WillPrep Services includes a range of different resources that make it easier for you to prepare a will. These range from a library of online planning documents to accessing experienced professionals that can help you with the more complicated details.
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HealthJoy Helps You and Your Family Meet Emily, a busy customer service representative who’s expecting her first baby this year. Cost Estimation Before she gives birth, Emily asks a healthcare concierge to estimate out-of-pocket costs. Provider Search Emily uses the provider search ̇ ̆˔˧˨˥ ̆˧ˢЃˡ˗˔ˣ ̆˗ ̃˔˧˥ ̃˖ ̃˔ˡ ̇ˢ˥ her new baby. Rx Savings Review Her husband requests a review and Ѓˡ˗˦˔˟ˢ˪ ̆˥ʠ˖ˢ˦˧ˣ˥ ̆˦˖˥ ̃ˣ˧ ̃ˢˡ ̇ˢ˥ his allergies. How will HealthJoy help YOU this year? Click the Download and Activate link in your email or visit www.healthjoy.com/activate to get started Telemedicine When her baby is sick on Christmas, Emily uses telemedicine to get quick answers. Medical Plan Details ʸˠ ̃˟ˬ˨˦ ̆˦ ̨ ̆˥˕ ̆ˡ ̆Ѓ˧˦˪˔˟˟ ̆˧ to track out-of-pocket and deductible spending. HealthJoy connects you with the right care and support throughout the year, making it easier to be healthy and well. m er o’s 23
ʻ ̆˔˟˧ ̨ʽˢˬ ̃˦˧ ̨ ̆˩ ̃˥˧˨˔˟˔˖˖ ̆˦˦ˣˢ ̃ˡ˧ ̇ˢ˥˔˟˟ˬˢ˨˥ ̨ ̆˔˟˧ ̨˖˔˥ ̆ ˡ˔˩ ̃ ̊˔˧ ̃ˢˡ˔ˡ˗ ̆ˠˣ˟ˢˬ ̆ ̆˕ ̆ˡ ̆ ̇ ̃˧˦ˡ ̆ ̆˗˦ʡˊ ̆Ϡ˥ ̆ˣ˥ˢ˩ ̃˗ ̆˗ ̇˥ ̆ ̆˕ˬˬˢ˨˥ ̆ˠˣ˟ˢˬ ̆˥˧ˢ ̨ ̆˟ˣ˨ˡ˗ ̆˥˦˧˔ˡ˗˔ˡ˗ˠ˔˞ ̆˧ ̨ ̆ ˠˢ˦˧ˢ ̇ˬˢ˨˥˕ ̆ˡ ̆ ̇ ̃˧˦ʡˊ ̆˖ˢˡˡ ̆˖˧ˬˢ˨˔ˡ˗ˬˢ˨˥ ̇˔ˠ ̃˟ˬ˪ ̃˧ ̨ ˧ ̨ ̆˥ ̃ ̊ ̨˧˕ ̆ˡ ̆ ̇ ̃˧˦˔˧˧ ̨ ̆˥ ̃ ̊ ̨˧ˠˢˠ ̆ˡ˧ ̃ˡˬˢ˨˥˖˔˥ ̆ ̋ˢ˨˥ˡ ̆ˬʟ ˦˔˩ ̃ˡ ̊ˬˢ˨˧ ̃ˠ ̆ʟˠˢˡ ̆ˬʟ˔ˡ˗ ̇˥˨˦˧˥˔˧ ̃ˢˡʡ ʻ ̆˟ˣʹˢ˥ˌˢ˨˥ʻ ̆˔˟˧ ̨˖˔˥ ̆ʽˢ˨˥ˡ ̆ˬʡ ˊ ̃˧ ̨ʥʧʢʪ˔˖˖ ̆˦˦˧ˢˢ˨˥˗ ̆˗ ̃˖˔˧ ̆˗ ̨ ̆˔˟˧ ̨˖˔˥ ̆˖ˢˡ˖ ̃ ̆˥ ̊ ̆ ˧ ̆˔ˠʟ˩ ̃˦ ̃˧˦ʟ˔ˡ˗˖˔˥ ̆ˡ˔˩ ̃ ̊˔˧ ̃ˢˡ˧ˢˢ˟˦ʟˬˢ˨ˡ ̆˩ ̆˥ ̨˔˩ ̆˧ˢ ˪˔˟˞˔˟ˢˡ ̆ʡʻ ̆˔˟˧ ̨ʽˢˬ ̨ ̆˟ˣ˦ˬˢ˨˟ˢ˖˔˧ ̆ ̃ˡʠˡ ̆˧˪ˢ˥˞˗ˢ˖˧ˢ˥˦ʟ ̇ ̃ˡ˗ ̆˫˧˥˔˦˔˩ ̃ˡ ̊˦ˢˡˬˢ˨˥ˣ˥ ̆˦˖˥ ̃ˣ˧ ̃ˢˡ˦ʟ˔ˡ˗ˡ˔˩ ̃ ̊˔˧ ̆ˬˢ˨˥ ˕ ̆ˡ ̆ ̇ ̃˧˦ʡ˂˨˥ˠˢ˕ ̃˟ ̆˔ˣˣ˔ˡ˗˗ ̆˗ ̃˖˔˧ ̆˗ˠ ̆ˠ˕ ̆˥˦˨ˣˣˢ˥˧ ˧ ̆˔ˠ˔˥ ̆˔˟˪˔ˬ˦ˢˡ ̨˔ˡ˗˧ˢ ̨ ̆˟ˣˠ˔˞ ̆ ̃˧ ̆˔˦ ̃ ̆˥˧ˢ˦˧˔ˬ ̨ ̆˔˟˧ ̨ˬ˔ˡ˗˪ ̆˟˟ʡ ʶ ̨˔˧˪ ̃˧ ̨˨˦˧ˢ˗˔ˬ˕ˬ˟ˢ ̊ ̊ ̃ˡ ̊ ̃ˡ˧ˢ˧ ̨ ̆ ʻ ̆˔˟˧ ̨ʽˢˬ˔ˣˣˢ˥˖˔˟˟ʛʫʪʪʜʨʣʣʠʦʥʤʥ ʻ ̆˔˟˧ ̨ʽˢˬˀ˔˞ ̆˦ ̃˧ʸ˔˦ ̃ ̆˥ ˧ˢ˕ ̆ʻ ̆˔˟˧ ̨ˬ˔ˡ˗ˊ ̆˟˟ʡ ʵʸˁʸʹʼˇˆ ˊʴʿʿʸˇ ʻʸʴʿˇʻʶʴ˅ʸ ʶ˂ˁʶʼʸ˅ʺʸ ˅ˋˆʴˉʼˁʺˆ ˅ʸˉʼʸˊ ʴ˃˃˂ʼˁˇˀʸˁˇ ʵ˂˂ʾʼˁʺ ˃˅˂ˉʼʷʸ˅ ˅ʸʶ˂ˀˀʸˁʷʴˇʼ˂ˁˆ ʻˆʴʢʹˆʴ ˆˈ˃˃˂˅ˇ ʼ˧˦˔˩ ̆˗ˠ ̆˧ ̨ ̆˧ ̃ˠ ̆ʼ˪ˢ˨˟˗ ̨˔˩ ̆˦ˣ ̆ˡ˧ʺˢˢ ̊˟ ̃ˡ ̊˥ ̆˦˨˟˧˦ʟ˖˔˟˟ ̃ˡ ̊˦ˣ ̆˖ ̃˔˟ ̃˦˧˦ʟ ˔ˡ˗˦ ̆˔˥˖ ̨ ̃ˡ ̊ ̇ˢ˥˔ˡ˔ˣˣˢ ̃ˡ˧ˠ ̆ˡ˧ʡʼˡ˦˧ ̆˔˗ʟʼ ̋˨˦˧ˣ˨˧ ̃ˡ˧ ̨ ̆˥ ̆ˤ˨ ̆˦˧ʟ˔ˡ˗ ʻ ̆˔˟˧ ̨ʽˢˬ˗ ̃˗˧ ̨ ̆˪ˢ˥˞ʡˇ ̨ ̆˔ˣˣ ̃˦˟ ̃˞ ̆ˠˬ˟ ̃˧˧˟ ̆˔˦˦ ̃˦˧˔ˡ˧ʔ ʼ˧ ˔ Ϣ ˗ ϣ ˉ ̆˥ˢˡ ̃˖˔ʟʴˍ
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General Medical Request an on-demand visit or schedule a visit at your preferred time Using interpreters allows us to provide several language options for our telemedicine visits, including ASL. ʶˢˡˡ ̆˖˧˪ ̃˧ ̨ˈˆ˕ˢ˔˥˗ʠ˖ ̆˥˧ ̃Ѓ ̆˗ˣ ̨ˬ˦ ̃˖ ̃˔ˡ˦ with an average of 20 years’ experience ʴ˩ˢ ̃˗˧˥ ̃ˣ˦˧ˢ˧ ̨ ̆˗ˢ˖˧ˢ˥Ϡ˦ˢ ̇Ѓ˖ ̆˔ˡ˗˖ˢ˦˧˟ˬ visits to the emergency room General Medical provides critical care 24/7 for non- ̆ˠ ̆˥ ̊ ̆ˡ˖ˬ˖ˢˡ˗ ̃˧ ̃ˢˡ˦˟ ̃˞ ̆˖ˢ˟˗ʟЄ˨ʟ˦ ̃ˡ˨˦ ̃ˡ ̇ ̆˖˧ ̃ˢˡ˦ʟ and allergies. It also provides care for specialty needs ˦˨˖ ̨˔˦˗ ̆˥ˠ˔˧ˢ˟ˢ ̊ˬ˔ˡ˗ˡ˨˧˥ ̃˧ ̃ˢˡ˖ˢˡ˦˨˟˧˔˧ ̃ˢˡ˦ʡ guage 26
How It Works Outcomes ʴ˖˖ ̆˦˦˧ ̨ ̆˦ ̆˥˩ ̃˖ ̆˧ ̨˥ˢ˨ ̊ ̨˧ ̨ ̆ʻ ̆˔˟˧ ̨ʽˢˬ ̨ˢˠ ̆ ˦˖˥ ̆ ̆ˡ˧ˢˤ˨ ̃˖˞˟ˬ˖ˢˡˡ ̆˖˧˪ ̃˧ ̨˔˟ ̃˖ ̆ˡ˦ ̆˗˖˔˥ ̆ ˣ˥ˢ˩ ̃˗ ̆˥˩ ̃˔ˣ ̨ˢˡ ̆ˢ˥˩ ̃˗ ̆ˢʡˇ ̨ ̆ˬ˖˔ˡ ̨ ̆˟ˣ˪ ̃˧ ̨ ˔ˡ˔˥˥˔ˬˢ ̇ ̆˩ ̆˥ˬ˗˔ˬ ̃˦˦˨ ̆˦˧ ̨˔˧˥˔ˡ ̊ ̆ ̇˥ˢˠ˖ˢ˟˗ ˔ˡ˗Є˨ʟ˧ˢ˔˥˔˦ ̨ˢ˥˦˨ˡ˕˨˥ˡʡ ˅ ̆ˤ˨ ̆˦˧˔ˡˢˡʠ˗ ̆ˠ˔ˡ˗˩ ̃˦ ̃˧ˢ˥˦˖ ̨ ̆˗˨˟ ̆˔˩ ̃˦ ̃˧˔˧ ˬˢ˨˥ˣ˥ ̆ ̇ ̆˥˥ ̆˗˧ ̃ˠ ̆ʡ˅ ̆˖ ̆ ̃˩ ̆˔˗ ̃˔ ̊ˡˢ˦ ̃˦ʟ˧˥ ̆˔˧ˠ ̆ˡ˧ plan, and even a prescription if necessary. ˅ ̆˖ ̆ ̃˩ ̆˔˩ ̃˦ ̃˧˦˨ˠˠ˔˥ˬ˧ˢˬˢ˨˥Ѓ˟ ̆˔ˡ˗˦ ̆ˡ˗˔ ˣ˥ ̆˦˖˥ ̃ˣ˧ ̃ˢˡ˧ˢˬˢ˨˥˟ˢ˖˔˟ˣ ̨˔˥ˠ˔˖ˬ ̃ ̇ˡ ̆˖ ̆˦˦˔˥ˬʡ 90% 92% $465 Member satisfaction Resolution rate on Ѓ˥˦˧˩ ̃˦ ̃˧˦ Average claims savings per visit ˊ ̃˧ ̨Ѓ˩ ̆˞ ̃˗˦˔˧ ̨ˢˠ ̆ˬˢ˨˖˔ˡ ̃ˠ˔ ̊ ̃ˡ ̆˧ ̨ ̆˔ˠˢ˨ˡ˧ˢ ̇˧ ̃ˠ ̆˦ˣ ̆ˡ˧˔˧ ˗ˢ˖˧ˢ˥˦Ϡˢ ̇Ѓ˖ ̆˦˔˦˧ ̨ ̆ˬ˦ˣ˥ ̆˔˗˧ ̨ ̆Є˨˧ˢ ̆˔˖ ̨ˢ˧ ̨ ̆˥ʡʼ˖˔ˡ˦ ̆˧˨ˣ˔ˡ ˔ˣˣˢ ̃ˡ˧ˠ ̆ˡ˧˔ˡ˗ˡ ̆˩ ̆˥˟ ̆˔˩ ̆ ̨ˢˠ ̆ʡˇ ̨ ̃˦˦ ̆˥˩ ̃˖ ̆ ̃˦˔˟ ̃ ̇ ̆˦˔˩ ̆˥ʡϣ MISTY GENERAL MEDICAL USER 27
General Medical FAQs When should I use General Medical services? Can Teladoc Health handle emergency situations? Will I talk with a real doctor? Does the doctor review my medical history before a visit? ʶ˔ˡʼ˥ ̆ˤ˨ ̆˦˧˔˦ˣ ̆˖ ̃Ѓ˖˗ˢ˖˧ˢ˥ʲ ˌˢ˨˦ ̨ˢ˨˟˗˖ ̨ˢˢ˦ ̆ʺ ̆ˡ ̆˥˔˟ˀ ̆˗ ̃˖˔˟˔ˡˬ˧ ̃ˠ ̆ˬˢ˨˪˔ˡ˧˧ˢ˧˔˟˞˧ˢ˔˗ˢ˖˧ˢ˥ ̃ˡˠ ̃ˡ˨˧ ̆˦ ˔˕ˢ˨˧ˡˢˡʠ ̆ˠ ̆˥ ̊ ̆ˡ˖ˬ ̨ ̆˔˟˧ ̨ ̃˦˦˨ ̆˦˟ ̃˞ ̆˦ ̃ˡ˨˦ˣ˥ˢ˕˟ ̆ˠ˦ʟ˥ ̆˦ˣ ̃˥˔˧ˢ˥ˬ ̃ˡ ̇ ̆˖˧ ̃ˢˡ˦ʟ ˔˟˟ ̆˥ ̊ ̃ ̆˦ʟЄ˨˦ˬˠˣ˧ˢˠ˦ʟ˥˔˦ ̨ ̆˦ʟ˔ˡ˗ˠ˔ˡˬˢ˧ ̨ ̆˥ ̃˟˟ˡ ̆˦˦ ̆˦ʡʷˢ˖˧ˢ˥˦˔˥ ̆˔˩˔ ̃˟˔˕˟ ̆ʥʧʢʪ ˪ ̃˧ ̨ ̃ˡ˧ ̨ ̆ʻ ̆˔˟˧ ̨ʽˢˬ˔ˣˣʡˌˢ˨˥˗ˢ˖˧ˢ˥˪ ̃˟˟˗ ̃˔ ̊ˡˢ˦ ̆ˬˢ˨˥˦ˬˠˣ˧ˢˠ˦˔ˡ˗ˣ˥ˢ˩ ̃˗ ̆˔ ˧˥ ̆˔˧ˠ ̆ˡ˧ˣ˟˔ˡʟ˪ ̨ ̃˖ ̨ˠ˔ˬˢ˥ˠ˔ˬˡˢ˧ ̃ˡ˖˟˨˗ ̆˔ˣ˥ ̆˦˖˥ ̃ˣ˧ ̃ˢˡʡ ˌˢ˨˦ ̨ˢ˨˟˗ˡˢ˧˨˦ ̆ˇ ̆˟˔˗ˢ˖ʻ ̆˔˟˧ ̨ ̃ ̇ˬˢ˨˔˥ ̆ ̆˫ˣ ̆˥ ̃ ̆ˡ˖ ̃ˡ ̊˔ˠ ̆˗ ̃˖˔˟ˢ˥ˠ ̆ˡ˧˔˟ ̨ ̆˔˟˧ ̨ ̆ˠ ̆˥ ̊ ̆ˡ˖ˬʡʼˡ˧ ̨ ̆ ̆˩ ̆ˡ˧ˢ ̇˔ˠ ̆˗ ̃˖˔˟ ̆ˠ ̆˥ ̊ ̆ˡ˖ˬʟˣ˟ ̆˔˦ ̆˖˔˟˟ʬʤʤʡʼˡ˧ ̨ ̆ ̆˩ ̆ˡ˧ˢ ̇˔ ˠ ̆ˡ˧˔˟ ̨ ̆˔˟˧ ̨ ̆ˠ ̆˥ ̊ ̆ˡ˖ˬʟ˖˔˟˟ʬʫʫʡ ˇ ̨ ̆ˣ˥ˢ˩ ̃˗ ̆˥˦ ̃ˡˢ˨˥ʺ ̆ˡ ̆˥˔˟ˀ ̆˗ ̃˖˔˟˖˔˥ ̆ˢ ̇ ̇ ̆˥ ̃ˡ ̊˔˥ ̆˕ˢ˔˥˗ʠ˖ ̆˥˧ ̃Ѓ ̆˗ ̃ˡ˧ ̆˥ˡ ̃˦˧˦ʟ ̇˔ˠ ̃˟ˬ˗ˢ˖˧ˢ˥˦ʟˣ˦ˬ˖ ̨ ̃˔˧˥ ̃˦˧˦ʟ˗ ̆˥ˠ˔˧ˢ˟ˢ ̊ ̃˦˧˦ʟ˔ˡ˗ˣ ̆˗ ̃˔˧˥ ̃˖ ̃˔ˡ˦˟ ̃˖ ̆ˡ˦ ̆˗˧ˢˣ˥˔˖˧ ̃˖ ̆ ˠ ̆˗ ̃˖ ̃ˡ ̆ ̃ˡ˧ ̨ ̆ˈˆʡˊ ̨ ̆ˡˬˢ˨˥ ̆ˤ˨ ̆˦˧˔˩ ̃˦ ̃˧ʟˇ ̆˟˔˗ˢ˖ʻ ̆˔˟˧ ̨˪ ̃˟˟˖ˢˡˡ ̆˖˧ˬˢ˨˪ ̃˧ ̨ ˔˗ˢ˖˧ˢ˥˟ ̃˖ ̆ˡ˦ ̆˗ ̃ˡˬˢ˨˥˦˧˔˧ ̆ˢ˥ˣ˥ˢ˩ ̃ˡ˖ ̆ʡʴ˟˟ˣ˥ˢ˩ ̃˗ ̆˥˦˖˔ˡ˗ ̃˔ ̊ˡˢ˦ ̆ʟ˧˥ ̆˔˧ʟ˔ˡ˗ ˣ˥ ̆˦˖˥ ̃˕ ̆ˠ ̆˗ ̃˖˔˧ ̃ˢˡ˦ ̇ˢ˥˖ˢˠˠˢˡʟˡˢˡʠ ̆ˠ ̆˥ ̊ ̆ˡ˖ˬ ̨ ̆˔˟˧ ̨ ̃˦˦˨ ̆˦˕ˬˣ ̨ˢˡ ̆ˢ˥˩ ̃˗ ̆ˢʡ ˌˢ˨˪ ̃˟˟˖ˢˠˣ˟ ̆˧ ̆˔˕˥ ̃ ̆ ̇ˠ ̆˗ ̃˖˔˟ ̨ ̃˦˧ˢ˥ˬˣ˥ ̃ˢ˥˧ˢ˥ ̆ˤ˨ ̆˦˧ ̃ˡ ̊ˬˢ˨˥Ѓ˥˦˧˩ ̃˦ ̃˧ʡˇ ̨ ̃˦ ̃˦ ˦ ̃ˠ ̃˟˔˥˧ˢЃ˟˟ ̃ˡ ̊ˢ˨˧ ̇ˢ˥ˠ˦˕ ̆ ̇ˢ˥ ̆˔ˡ ̃ˡʠˣ ̆˥˦ˢˡ˗ˢ˖˧ˢ˥˩ ̃˦ ̃˧ʡˌˢ˨˖˔ˡ˨ˣ˗˔˧ ̆ˬˢ˨˥ ˠ ̆˗ ̃˖˔˟ ̨ ̃˦˧ˢ˥ˬ˔˧˔ˡˬ˧ ̃ˠ ̆˪ ̃˧ ̨ ̃ˡ˧ ̨ ̆ʻ ̆˔˟˧ ̨ʽˢˬ˔ˣˣʡ ˌˢ˨˥ˠ ̆˗ ̃˖˔˟ ̨ ̃˦˧ˢ˥ˬ ̃˦˦˧ˢ˥ ̆˗ˢˡˇ ̆˟˔˗ˢ˖ʻ ̆˔˟˧ ̨Ϡ˦ʻʼ˃ʴʴʠ˖ˢˠˣ˟ ̃˔ˡ˧ʟ ̆ˡ˖˥ˬˣ˧ ̆˗ ˖ ̆ˡ˧˥˔˟˦ ̆˥˩ ̆˥ʡʵ ̆ ̇ˢ˥ ̆ ̆˔˖ ̨˩ ̃˦ ̃˧ʟ˧ ̨ ̆˗ˢ˖˧ˢ˥˪ ̃˟˟˥ ̆˩ ̃ ̆˪ˬˢ˨˥ˠ ̆˗ ̃˖˔˟ ̨ ̃˦˧ˢ˥ˬ˪ ̃˧ ̨˔ ˦ˣ ̆˖ ̃Ѓ˖ ̇ˢ˖˨˦ˢˡ˖ ̨˥ˢˡ ̃˖ ̃˟˟ˡ ̆˦˦ ̆˦ʟ˖˨˥˥ ̆ˡ˧ˠ ̆˗ ̃˖˔˧ ̃ˢˡ˦ʟ˔˟˟ ̆˥ ̊ ̃ ̆˦ʟ˔ˡ˗˖ ̨˔ˡ ̊ ̆˦ ̃ˡ ˬˢ˨˥ˠ ̆˗ ̃˖˔˟˖ˢˡ˗ ̃˧ ̃ˢˡʡ ʷ ̆ˣ ̆ˡ˗ ̃ˡ ̊ˢˡ˧ ̨ ̆ˣ˟˔ˡˬˢ˨˥ ̆ˠˣ˟ˢˬ ̆˥ ̃˦ˢˡʟˬˢ˨ˠ˔ˬ˕ ̆˔˕˟ ̆˧ˢ˦ ̆˟ ̆˖˧˔˦ˣ ̆˖ ̃Ѓ˖ ˗ˢ˖˧ˢ˥ ̇ˢ˥ˬˢ˨˥˩ ̃˦ ̃˧ʡʴ˟˟ˇ ̆˟˔˗ˢ˖ʻ ̆˔˟˧ ̨˗ˢ˖˧ˢ˥˦˔˥ ̆˕ˢ˔˥˗ʠ˖ ̆˥˧ ̃Ѓ ̆˗˔ˡ˗˦˧˔˧ ̆ ˟ ̃˖ ̆ˡ˦ ̆˗ʡˇˢ˕ ̆˖ˢˠ ̆˔ˡˢ ̇Ѓ˖ ̃˔˟ˇ ̆˟˔˗ˢ˖ʻ ̆˔˟˧ ̨˗ˢ˖˧ˢ˥ʟ˔˟˟ˣ˥ˢ˩ ̃˗ ̆˥˦ˠ˨˦˧˨ˡ˗ ̆˥ ̊ˢ˔ ˧ ̨ˢ˥ˢ˨ ̊ ̨˖˥ ̆˗ ̆ˡ˧ ̃˔˟ ̃ˡ ̊ˣ˥ˢ˖ ̆˦˦ʡʴ˟˟ˇ ̆˟˔˗ˢ˖ʻ ̆˔˟˧ ̨˗ˢ˖˧ˢ˥˦˔˥ ̆˧ ̨ˢ˥ˢ˨ ̊ ̨˟ˬ˧˥˔ ̃ˡ ̆˗ˢˡ ̨ˢ˪˧ˢˣ˥ˢ˩ ̃˗ ̆˧ ̨ ̆˕ ̆˦˧˩ ̃˥˧˨˔˟˖˔˥ ̆ ̆˫ˣ ̆˥ ̃ ̆ˡ˖ ̆ʡ 28
Chronic Care Connected glucometers, scales, and blood pressure monitors provide real-time feedback and personalized calls to action Health coaches offer ongoing support based on individual conditions, motivations, and lifestyles. These coaches provide 24/7 remote monitoring with emergency outreach Coaches interpret health metrics, social determinants, preferences, clinical needs, and more to trigger realtime, actionable feedback that drives behavior change Empowers members by simplifying and lightening the burden of self management Livongo’s Chronic Care Management programs support the management of individual members’ chronic health conditions. The programs help to minimize healthcare costs with less visits to the ER among individual members diagnosed with diabetes or hypertension, or at risk of developing diabetes. ʵˬ˔˗˗˥ ̆˦˦ ̃ˡ ̊ˠ˨˟˧ ̃ˣ˟ ̆˖ˢˡ˗ ̃˧ ̃ˢˡ˦ ̃ˡ˔˨ˡ ̃Ѓ ̆˗ ̆˫ˣ ̆˥ ̃ ̆ˡ˖ ̆ʟ including underlying lifestyle and behavioral drivers, we can reduce spend while providing wholistic care. 29
How It Works Outcomes Access the service through the HealthJoy Homescreen. The Chronic Care Livongo program includes support for type 1 and type 2 diabetes, hypertension, prediabetes, and weight management. ˃˥ˢ ̊˥˔ˠʠ˦ˣ ̆˖ ̃Ѓ˖ ̆˟ ̃ ̊ ̃˕ ̃˟ ̃˧ˬ˥ ̆ˤ˨ ̃˥ ̆ˠ ̆ˡ˧˦ʢ ̆˫˖˟˨˦ ̃ˢˡ˦˔ˣˣ˟ˬʭ Once registered, members will receive personalized ˣ˥ˢ ̊˥˔ˠˠ ̃ˡ ̊˕˔˦ ̆˗ˢˡ˧ ̨ ̆ ̃˥ˣ˥ ̃ˠ˔˥ˬ˖ˢˡ˗ ̃˧ ̃ˢˡʭ˗ ̃˔˕ ̆˧ ̆˦ʟ hypertension, or prediabetes. Livongo by Teladoc Health ˪ ̃˟˟ˠ˔ ̃˟˔˖ˢˡ˗ ̃˧ ̃ˢˡʠ˦ˣ ̆˖ ̃Ѓ˖˪ ̆˟˖ˢˠ ̆˞ ̃˧˧ˢ ̆˔˖ ̨ program participant that includes the devices and materials they need to manage their condition(s). • Diabetes: Requires type 1 or type 2 diabetes diagnosis, <13 years of age • Hypertension: Must have high blood pressure, <18 years of age • Prediabetes/weight management: Cannot have diabetes; cannot be pregnant; must meet body mass index (BMI) threshold, <18 years of age, weight >440lbs (>200kg), and BMI <25. 9 Point > 100 90% Claims-based ROI analyses with 95% showing positive results at the 1 year mark 1 Higher satisfaction and a greater reduction in HbA1c among members enrolled in both Diabetes and Hypertension programs 2 The testimonials, statements, and opinions presented are applicable to the individuals depicted. Each member’s exact results and experience will be unique and individual to each member. The testimonials are voluntarily provided and are not paid. Testimonial provided is that of a real member. Of members wish to continue after one year 1 ʼ ̨˔˩ ̆˖ˢˡЃ˗ ̆ˡ˖ ̆˧ ̨˔˧ʼ˗ˢˡϠ˧˧ ̨ ̃ˡ˞ʼϠ˩ ̆ ̆˩ ̆˥ ̨˔˗ʡˌ ̆˦ʟ˧ ̨ ̆ˡ˨ˠ˕ ̆˥ˢˡ˧ ̨ ̆ ˦˖˔˟ ̆ ̃˦˔˧ˢˢ˟ʟ˕˨˧ ̃˧˗ˢ ̆˦ˡϠ˧˥˨ˡˠˬ˟ ̃ ̇ ̆˔˦ ̃˧˗ ̃˗˔ˬ ̆˔˥˔ ̊ˢʡϣ EVELYN LIVONGO USER 1 Data from 2019 S1 2 ʷ˔˧˔ˢˡЃ˟ ̆ʛʷˆʠʨʤʫʥʜ
Chronic Care FAQs Who can join? What will I get after I enroll? Do I need to enroll in all programs, or can I choose just one? Will my information be safe? Does unlimited strips really mean unlimited? To enroll in Chronic Care for Diabetes, you must have a diagnosis of type 1 or type 2 diabetes. To enroll in Chronic Care for Hypertension, you must have high blood pressure. To enroll in ʷ ̃˔˕ ̆˧ ̆˦˃˥ ̆˩ ̆ˡ˧ ̃ˢˡʢˊ ̆ ̃ ̊ ̨˧ˀ˔ˡ˔ ̊ ̆ˠ ̆ˡ˧ʟˬˢ˨˖˔ˡˡˢ˧ ̨˔˩ ̆˗ ̃˔˕ ̆˧ ̆˦ʮ˖˔ˡˡˢ˧˕ ̆ˣ˥ ̆ ̊ˡ˔ˡ˧ʮ ˠ˨˦˧ˠ ̆ ̆˧˕ˢ˗ˬˠ˔˦˦ ̃ˡ˗ ̆˫ʛʵˀʼʜ˧ ̨˥ ̆˦ ̨ˢ˟˗ʡ ˊ ̨ ̆ˡˬˢ˨ ̆ˡ˥ˢ˟˟ ̃ˡʿ ̃˩ˢˡ ̊ˢ ̇ˢ˥ʷ ̃˔˕ ̆˧ ̆˦˧ ̨˥ˢ˨ ̊ ̨˧ ̨ ̆ʻ ̆˔˟˧ ̨ʽˢˬ˔ˣˣʟˬˢ˨Ϡ˟˟˥ ̆˖ ̆ ̃˩ ̆˔ connected blood glucose meter that offers automatic data uploading, real-time insights ˔ˡ˗ ̇ ̆ ̆˗˕˔˖˞ˢˡˬˢ˨˥˥ ̆˔˗ ̃ˡ ̊˦ʟ˔˖˖ ̆˦˦˧ˢ ̆˫ˣ ̆˥˧˖ˢ˔˖ ̨ ̆˦ʟ˔ˡ˗ˠˢ˥ ̆ʡˌˢ˨Ϡ˟˟˔˟˦ˢ˥ ̆˖ ̆ ̃˩ ̆ unlimited test strips and lancets shipped right to your door. All are provided at no cost to you. ˊ ̃˧ ̨ʿ ̃˩ˢˡ ̊ˢ ̇ˢ˥ʻˬˣ ̆˥˧ ̆ˡ˦ ̃ˢˡʟˬˢ˨Ϡ˟˟˥ ̆˖ ̆ ̃˩ ̆˔˖ˢˡˡ ̆˖˧ ̆˗˕˟ˢˢ˗ˣ˥ ̆˦˦˨˥ ̆ˠˢˡ ̃˧ˢ˥˧ ̨˔˧˥ ̆˖ˢ˥˗˦ ˕˟ˢˢ˗ˣ˥ ̆˦˦˨˥ ̆˥ ̆˔˗ ̃ˡ ̊˦ʡˌˢ˨Ϡ˟˟˔˟˦ˢ˥ ̆˖ ̆ ̃˩ ̆ˣ ̆˥˦ˢˡ˔˟ ̃˭ ̆˗˧ ̃ˣ˦ʟˡ˨˧˥ ̃˧ ̃ˢˡʟ˔ˡ˗ ̃ˡ ̇ˢ˥ˠ˔˧ ̃ˢˡ˔˕ˢ˨˧ ˦˧˥ ̆˦˦˔ˡ˗ ̆˫ ̆˥˖ ̃˦ ̆˧ˢ ̨ ̆˟ˣˬˢ˨ˠ˔ˡ˔ ̊ ̆ˬˢ˨˥˕˟ˢˢ˗ˣ˥ ̆˦˦˨˥ ̆ʡ ˊ ̨ ̆ˡˬˢ˨˦ ̃ ̊ˡ˨ˣ ̇ˢ˥ʷ ̃˔˕ ̆˧ ̆˦˃˥ ̆˩ ̆ˡ˧ ̃ˢˡʢˊ ̆ ̃ ̊ ̨˧ˀ˔ˡ˔ ̊ ̆ˠ ̆ˡ˧ʟˬˢ˨Ϡ˟˟˥ ̆˖ ̆ ̃˩ ̆˧ ̨ ̆ʿ ̃˩ˢˡ ̊ˢ ˊ ̆˟˖ˢˠ ̆ʾ ̃˧ʡˌˢ˨˥ˊ ̆˟˖ˢˠ ̆ʾ ̃˧ ̃ˡ˖˟˨˗ ̆˦˧ ̨ ̆ʿ ̃˩ˢˡ ̊ˢ˦˖˔˟ ̆ ̇ˢ˥ˬˢ˨˧ˢ˦˧˔˥˧˖ ̨ ̆˖˞ ̃ˡ ̊ˬˢ˨˥ ˪ ̆ ̃ ̊ ̨˧ʡˌˢ˨Ϡ˟˟˔˟˦ˢ˕ ̆˔˕˟ ̆˧ˢ˗ˢ˪ˡ˟ˢ˔˗˔ˡ˗˟ˢ ̊ ̃ˡ˧ˢʿ ̃˩ˢˡ ̊ˢ˧ ̨˥ˢ˨ ̊ ̨˧ ̨ ̆ʻ ̆˔˟˧ ̨ʽˢˬ˔ˣˣʟ where you can personalize your program and see your progress. ˌˢ˨˖˔ˡ˦ ̃ ̊ˡ˨ˣ ̇ˢ˥ ̋˨˦˧ˢˡ ̆ˣ˥ˢ ̊˥˔ˠˢ˥˔˦ˠ˔ˡˬˣ˥ˢ ̊˥˔ˠ˦˔˦ˬˢ˨Ϡ˥ ̆ ̆˟ ̃ ̊ ̃˕˟ ̆ ̇ˢ˥ʡ˂ˡ˖ ̆ˬˢ˨˦ ̃ ̊ˡ ˨ˣʟ˪ ̆Ϡ˟˟˦ ̆ˡ˗ˬˢ˨˔ˊ ̆˟˖ˢˠ ̆ʾ ̃˧ ̇ˢ˥ ̆˔˖ ̨ˢ ̇ˬˢ˨˥ˣ˥ˢ ̊˥˔ˠ˦˧ˢ ̊ ̆˧ˬˢ˨˦˧˔˥˧ ̆˗ʡʼ ̇ˬˢ˨˦˧˔˥˧˪ ̃˧ ̨ one Livongo program, you can always add on another program when you feel ready. ˌˢ˨˥ ̨ ̆˔˟˧ ̨ ̃ˡ ̇ˢ˥ˠ˔˧ ̃ˢˡ ̃˦ˣ˥ˢ˧ ̆˖˧ ̆˗˧ ̨˥ˢ˨ ̊ ̨ ̇ ̆˗ ̆˥˔˟˔ˡ˗˦˧˔˧ ̆˟˔˪˦ʟ ̃ˡ˖˟˨˗ ̃ˡ ̊˧ ̨ ̆ʻ ̆˔˟˧ ̨ ʼˡ˦˨˥˔ˡ˖ ̆˃ˢ˥˧˔˕ ̃˟ ̃˧ˬ˔ˡ˗ʴ˖˖ˢ˨ˡ˧˔˕ ̃˟ ̃˧ˬʴ˖˧ʛʻʼ˃ʴʴʜʟ˔ˡ˗˪ ̃˟˟ˡˢ˧˕ ̆˦ ̨˔˥ ̆˗˪ ̃˧ ̨˔ˡˬ˧ ̨ ̃˥˗ʠˣ˔˥˧ˬ ̃ˡ˔ˠ˔ˡˡ ̆˥˧ ̨˔˧˩ ̃ˢ˟˔˧ ̆˦ ̇ ̆˗ ̆˥˔˟ˢ˥˦˧˔˧ ̆˟˔˪ʡˊ ̆ ̃ˠˣ˟ ̆ˠ ̆ˡ˧ˡ˨ˠ ̆˥ˢ˨˦˦ˬ˦˧ ̆ˠ˦˔ˡ˗˦ ̆˖˨˥ ̃˧ˬ processes for data storage and encryption. ˌ ̆˦ʔˊ ̨ ̆˧ ̨ ̆˥ˬˢ˨˖ ̨ ̆˖˞ˢˡ˖ ̆˔˪ ̆ ̆˞ˢ˥ˢˡ˖ ̆ˣ ̆˥ ̨ˢ˨˥ʟ˪ ̃˧ ̨ʶ ̨˥ˢˡ ̃˖ʶ˔˥ ̆ ̇ˢ˥ʷ ̃˔˕ ̆˧ ̆˦ through Livongo, you receive all the strips you need at no additional cost to you. 31
Reduce Musculoskeletal Costs With Virtual MSK Therapy Musculoskeletal (MSK) is the #1 cost driver of healthcare spending in the U.S. and has doubled over the last decade. On average, employers spend $7,800 and lose 11.4 workdays per year for each employee struggling with back pain or other musculoskeletal disorders (MSDs). On top of that, employees with MSDs suffer greatly both physically and mentally. Unfortunately, typical strategies are extremely expensive and underutilized. HealthJoy’s Virtual MSK Therapy program is an effective exercise therapy program for individuals struggling with back and joint pain. With guidance and support from a personal coach, ̆ˠˣ˟ˢˬ ̆ ̆˦˖˔ˡ˦ ̃ ̊ˡ ̃Ѓ˖˔ˡ˧˟ˬ˥ ̆˗˨˖ ̆ˣ˔ ̃ˡ˔ˡ˗ ̃ˠˣ˥ˢ˩ ̆ functional abilities in just 15 minutes per day for back, neck, shoulder, knee, hip, hand, wrist, elbow, ankle, and/or foot pain. Our program is low-cost, non-invasive, and more convenient than traditional methods like in-person physical therapy and surgery. That translates to lower costs and better health outcomes for you and your employees. 82% Pain reduction 95% Member satisfaction 85% Function improvement $2,572 Claims avoided per participant 32
VIRTUAL MSK THERAPY How it Works . We assign a personal coach to the member, who reaches out to schedule an introductory phone call Introductory Call The member’s coach assigns a care plan with up to 12 weeks of exercises that can be done at home and supports the member throughout the duration of the program Care The member’s coach provides a maintenance program that the member can follow once they’ve completed the program Maintenance Members complete a 15-minute intake survey so we can better understand their unique situation* Intake * 5-10% of people may be ineligible based on medical history indicating structural issues or more serious underlying conditions. Typically 3-7% of an employee population will end up participating in the program after determining eligibility. CORRELATED CARE Chronic pain sufferers also struggle with anxiety and/or depression roughly 50% of the time. JOY and our coaches will remind program participants of the mental health services available to them, particularly ̃ ̇˧ ̨ ̆ ̃˥ ̃ˡ˧˔˞ ̆˦˨˥˩ ̆ˬ ̃ˡ˗ ̃˖˔˧ ̆˦˖˟ ̃ˡ ̃˖˔˟˟ˬ˦ ̃ ̊ˡ ̃Ѓ˖˔ˡ˧˗ ̆ˣ˥ ̆˦˦ ̃ˢˡʡ JOY redirects members who are searching for related providers and facilities to our Virtual MSK Therapy program Steerage 33
VIRTUAL MSK THERAPY Optimized for Adherence Convenient - Our program is more convenient than alternatives, like in-person physical therapy. Members can access the program from home or on-the-go, from their mobile device or a desktop, and it only requires 15 minutes out of their day. Equipment or sensors aren’t needed to complete any of the exercises. 1 Coach-Led - Every program participant is matched with a personal coach who will assign them a personalized program and support them throughout. The coach helps to ensure participant adherence and results. On average, members interact with their coach 40+ times throughout the program. 2 3 Cost-Effective - Our program costs just $800* per participant, which is less than half the cost of a round of in-person physical therapy. Since the employer covers the cost of the program, it’s completely free to employees so they have no barriers to getting the care they need. *1:1 ROI Guarantee: HealthJoy will refund or credit the difference between your estimated Program Savings and Fees if the Total Savings are lower. “My doctor told me that my only option left was surgery. I was losing hope. I’ve gone from 100% getting surgery to 100% NOT getting surgery. I can’t believe I went from ‘I may never run again’ to actually rejoining my running group. I’m just so excited.” 43-YEAR-OLD FEMALE COLLEGE PROFESSOR WHO PARTICIPATED IN THE PROGRAM 34
HealthJoy EAP is here to help with no cost, confidential support. • SHORT-TERM COUNSELING • LEGAL SERVICES PHONE 1-888-731-3EAP (3327) WEB EAP.HEALTHJOY.COM Confidential support 24 hours a day, 365 days a year. • FINANCIAL SERVICES • EXPERT REFERRALS ( PSOR\HH $ VVLVWDQFH 3 URJUDP 35
1-888-731-3327 In-the-moment support from a licensed clinician 24/7/365 Ask the expert !;t†;v|bm=oul-ঞomou resources based on topic or concern Navigator loঞom-ѴC|m;vv assessment and care guidance Short code Text ‘support’ to 51230 Contact the EAP using one of the above access points Clinical assessment and in-the-moment support 1omCulv availability and MHSA network alignment prior to making referral EAP provides “smart” referral to counselor and o@;uv|ov1_;7†Ѵ; |_;Cuv|v;vvbom EAP clinician follows †r-[;u|_;1-v; to assess needs, l;-v†u;v-ঞv=-1ঞom and H&P Digital group support ‚;m7-m-mom‹lo†v group support session Email ";m7-t†;vঞom|o support@mysupportportal.com Textcoach ® Personalized coaching on desktop or mobile Animo Digital behavioral health to improve your ;loঞom-ѴC|m;vv 1-888-731-3327 eap.healthjoy.com loঞom-Ѵ‰;ѴѴ0;bm] resources to keep you -|‹o†u0;v| ;l0;u&v;u Šr;ub;m1; ;-Ѵ|_o‹ o@;uv;Šr;u|]†b7-m1;|o_;Ѵr -77u;vv-m7u;voѴˆ;;ˆ;u‹7-‹bvv†;vĺ11;vvv†rrou| ‰_;m;ˆ;uķ‰_;u;ˆ;ubvlov|1omˆ;mb;m|=ou‹o†ĺ If you are in immediate medical crisis, please call 911. 36
Tip Sheet: Getting To Know Your HealthJoy Benefit Frequently Asked Questions What is HealthJoy EAP? HealthJoy EAP is a free, confidential benefit for employees and their immediate family members to assist with a wide range of personal and professional concerns. Why would someone need HealthJoy EAP? We all experience stress in our lives related to family and relationships, work-life balance, substance abuse or mental health concerns like anxiety and depression. It can be helpful to have a professional to turn to for guidance, support, resources and referrals that we might not come across on our own. What happens when I call the EAP? When you contact HealthJoy EAP, you’ll speak directly to a licensed counselor. The intake process will include an experienced clinician gathering information about you and the nature of your concern. The counselor will then coordinate the most appropriate resources that best meet your needs. These resources can include scheduling short- term counseling with a local provider, work-life resources and/or referrals to community resources or treatment providers through your health insurance plan. 37
GETTING TO KNOW YOUR HEALTHJOY BENEFIT When will I receive my EAP counseling referral? After your intake, we’ll identify an appropriate local counselor to meet your needs. We always confirm that the provider meets your needs and is within your insurance network, just in case longer term care is needed. For routine referrals, this process typically takes no longer than one to two business days. HealthJoy EAP is always available around-the-clock for immediate support. Is HealthJoy EAP confidential? Yes! No one, including your employer, will know that you have used HealthJoy EAP services. If you have been “formally” referred by your supervisor, he/she will only be advised of your follow-through with the recommendations made, not the details of your situation. Exceptions to confidentiality may apply by law if there are concerns regarding your safety or the safety of others. How much does it cost to use the EAP? There is no cost to you or your immediate family members to use the program. If services beyond the EAP are needed, the HealthJoy EAP counselor will provide referrals based on coverage through your health insurance plan or other cost- effective resources in your community. 1-888-731-3EAP (3327) eap.healthjoy.com 38
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ʴ˦ˣ˔˥˧ˢ ̇ˬˢ˨˥ ̆ˠˣ˟ˢˬ ̆˥˕ ̆ˡ ̆Ѓ˧˦ʟˬˢ˨˖˔ˡ˦˖ ̨ ̆˗˨˟ ̆ˬˢ˨˥˦˨˥ ̊ ̃˖˔˟˔ˡ˗ ̃ˠ˔ ̊ ̃ˡ ̊˦ ̆˥˩ ̃˖ ̆˦˔˧ˡˢ˖ˢ˦˧ʡ ˂˨˥ʶ˔˥ ̆ˁ˔˩ ̃ ̊˔˧ ̃ˢˡ˧ ̆˔ˠ˪ ̃˟˟ ̨ ̆˟ˣˬˢ˨˕ˢˢ˞ˬˢ˨˥ˡˢˡʠ ̆ˠ ̆˥ ̊ ̆ˡ˧˦˨˥ ̊ ̆˥ˬ˔ˡ˗ ̃ˠ˔ ̊ ̃ˡ ̊ʡˊ ̃˧ ̨˔ ˡ˔˧ ̃ˢˡ˪ ̃˗ ̆ˡ ̆˧˪ˢ˥˞ˢ ̇ʥʟʣʣʣʞ˟ˢ˖˔˧ ̃ˢˡ˦ʟ˪ ̆Ϡ˟˟ ̨ ̆˟ˣˬˢ˨˖ ̨ˢˢ˦ ̆˔ ̨ ̃ ̊ ̨ʠˤ˨˔˟ ̃˧ˬˣ˥ˢ˩ ̃˗ ̆˥˧ ̨˔˧˕ ̆˦˧Ѓ˧˦ˬˢ˨˥ ˡ ̆ ̆˗˦˔ˡ˗ ̊˨ ̃˗ ̆ˬˢ˨˧ ̨˥ˢ˨ ̊ ̨˧ ̨ ̆ˣ˥ˢ˖ ̆˦˦ ̇˥ˢˠ˥ ̆ ̇ ̆˥˥˔˟˧ˢ˔ˣˣˢ ̃ˡ˧ˠ ̆ˡ˧ʡ Getting Started is Easy: Call: ʶˢˡ˧˔˖˧ʛʫʪʪʜʧʦʫʠʨʧʪʬ˕ ̆ ̇ˢ˥ ̆˦˖ ̨ ̆˗˨˟ ̃ˡ ̊˪ ̃˧ ̨˔ˡ ˢ˨˧˦ ̃˗ ̆ˣ˥ˢ˩ ̃˗ ̆˥ʡ Referral Received: ˉ˔˟ ̆ˡ˭˥ ̆˖ ̆ ̃˩ ̆˦ˬˢ˨˥ˣ˥ˢ˩ ̃˗ ̆˥Ϡ˦ˢ˥˗ ̆˥ ̇ˢ˥ ˥ ̆˩ ̃ ̆˪ʡ C ˢ n Ѓ r ˠ eligi ˕ ility: ˊ ̆Ϡ˟˟˩ ̆˥ ̃ ̇ˬˬˢ˨˥˕ ̆ˡ ̆Ѓ˧˦˔ˡ˗˖ˢˡЃ˥ˠ ˢ˥˗ ̆˥˗ ̆˧˔ ̃˟˦˪ ̃˧ ̨ˬˢ˨˥ˣ˥ˢ˩ ̃˗ ̆˥ʡ Scheduling: ˊ ̆Ϡ˟˟˦˨ ̊ ̊ ̆˦˧ˡ ̆˔˥˕ˬˢˣ˧ ̃ˢˡ˦˖˟ˢ˦ ̆˧ˢˬˢ˨˥ ̨ˢˠ ̆ˢ˥˪ˢ˥˞˔ˡ˗˔˦˦ ̃˦˧ ̃ˡ˦˖ ̨ ̆˗˨˟ ̃ˡ ̊ˬˢ˨˥˔ˣˣˢ ̃ˡ˧ˠ ̆ˡ˧ʡ Receive your voucher: ˊ ̆Ϡ˟˟ ̆ˠ˔ ̃˟ˬˢ˨˔˩ˢ˨˖ ̨ ̆˥˧ˢ˦ ̨ˢ˪ ˧ ̨ ̆ ̇˔˖ ̃˟ ̃˧ˬ ̃ˡ˦˧ ̆˔˗ˢ ̇ˬˢ˨˥ ̃ˡ˦˨˥˔ˡ˖ ̆˖˔˥˗ˢˡ˧ ̨ ̆˗˔ˬˢ ̇ˬˢ˨˥ ˣ˥ˢ˖ ̆˗˨˥ ̆ʡ ˉ͓ len ˭ Surgical ʙ ʼˠ aging: ˄˨˔˟ ̃˧ˬʶ˔˥ ̆ʟʶ˟ˢ˦ ̆˧ˢʻˢˠ ̆˔˧ʗʣʶˢ˦˧ʝ Call (877) 438-5479 to get started ʝʗʣ˂˨˧ʠˢ ̇ʠ˃ˢ˖˞ ̆˧ ̃˦˦˨˕ ̋ ̆˖˧˧ˢˣ˟˔ˡ˖ˢ˩ ̆˥˔ ̊ ̆˥ ̆ˤ˨ ̃˥ ̆ˠ ̆ˡ˧˦ʡˇˢ˥ ̆˖ ̆ ̃˩ ̆˧ ̨ ̆˦ ̆˕ ̆ˡ ̆Ѓ˧˦ʟˠ ̆ˠ˕ ̆˥˦ˠ˨˦˧˦˖ ̨ ̆˗˨˟ ̆˔˧˧ ̨ ̆ˡ˨ˠ˕ ̆˥ˣ˥ˢ˩ ̃˗ ̆˗ʮʻˆʴ˃˟˔ˡ˦˥ ̆ˤ˨ ̃˥ ̆Ѓ˥˦˧ ˗ˢ˟˟˔˥˖ˢ˩ ̆˥˔ ̊ ̆ ̇˥ˢˠˣ˔˧ ̃ ̆ˡ˧˕ ̆ ̇ˢ˥ ̆ˣ˥ˢ˖ ̆˗˨˥ ̆˨ˣ˧ˢʼ˅ˆˀ ̃ˡ ̃ˠ˨ˠʟ˕ ̆ ̇ˢ˥ ̆ˣ˥ˢ ̊˥˔ˠ ̃ˡ˖ ̆ˡ˧ ̃˩ ̆˦˔˥ ̆˥ ̆˖ ̆ ̃˩ ̆˗ʡ ˇ ˇˢ˟ ̆˔˥ˡˠˢ˥ ̆ˢ˥˦˖ ̨ ̆˗˨˟ ̆˔ˣ˥ˢ˖ ̆˗˨˥ ̆ʟ˖ˢˡ˧˔˖˧˨˦˔˧ʭ ˃ ̨ˢˡ ̆ʭʛʫʪʪʜʧʦʫʠʨʧʪʬ ʸˠ˔ ̃˟ʭˡˢ˖ˢ˦˧˖˔˥ ̆ʳ˩˔˟ ̆ˡ˭ ̨ ̆˔˟˧ ̨ʡ˖ˢˠ ˈ˅ʿʭ˦˨˥ ̊ ̃˖˔˟ ̃ˠ˔ ̊ ̃ˡ ̊ʡ˩˔˟ ̆ˡ˭ ̨ ̆˔˟˧ ̨ʡ˖ˢˠ ˊ e Ϡ re here to su ˣˣ ort you every ste ˣ of the ˪ ay ʔ • ʴˡ˞˟ ̆ʙʹˢˢ˧ • ʴ˥˧ ̨˥ˢ˦˖ˢˣˬ • ʶˢ˟ˢˡˢ˦˖ˢˣˬ • ʸˁˇ • ʸ˟˕ˢ˪ • ʺ˔˦˧˥ˢ ̆ˡ˧ ̆˥ˢ˟ˢ ̊ˬ • ʺ ̆ˡ ̆˥˔˟ˆ˨˥ ̊ ̆˥ˬ • ʻ ̆˥ˡ ̃˔˅ ̆ˣ˔ ̃˥ • ʻ ̃ˣ • ʼˠ˔ ̊ ̃ˡ ̊ • Knee • ˆ ̨ˢ˨˟˗ e ˥ • ˆˣ ̃ ne • ˈ˥ˢ˟ˢ ̊ˬ • ˊ˥ ̃˦˧ʙʻ˔ n ˗ • ʴ n ˗ˀˢ˥ e Co ˠˠ on ˃ rocedures: ˻ʥʣʥʨˉ͓˟ ̆ˡ˭̀ʻ ̆˔˟˧ ̨ʴ˟˟˅ ̃ ̊ ̨˧˦˅ ̆˦ ̆˥˩ ̆˗ʿʼˇʥʣʬʨʧ
What is Valenz Surgical and Imaging? As part of your employer funded health plan you have access to affordable imaging and surgery bene Ѓ ts through ˉ alen ˭ʡ ˌ our employer covers the full cost of the procedure so it’s no cost to you! Who is the Program For? Employees and their covered dependents who need ma ̋ or imaging or non ʠ emergent surgery ʡ Must be 18 years or older to qualify for surgery bene Ѓ ts and appro ˫ imately 1 ʣ years or older for imaging bene Ѓ ts ʡ How Does It Work? ˉ alen ˭ uses a nationwide networ ˞ of preferred high ʠ quality providers to ma ˞ e imaging and surgical care more affordable ʡ ˇ o qualify for these imaging and surgical bene Ѓ ts ʟ you must schedule through a ˉ alen ˭ ʶ are ˁ avigator with one of our contracted providers ʡ How Much Does It Cost? It is NO COST to you as your employer provides your imaging and surgical bene Ѓ ts as part of your bene Ѓ ts ʡ How Does This Work With an HSA or HDHP? ˇ here is a special wor ˞ around that occurs with a quali Ѓ ed ʻ igh ʠʷ eductible ʻ ealth ˃ lan that allows your employer to e ˫ tend imaging and surgical bene Ѓ ts at no cost to members ʡ • ˌ ou may be as ˞ ed to pay a portion of the procedure cost ʡ • ˌ our employer would then reimburse you for that amount ʡ What Procedures Are Commonly Covered? How Far Will You need to Travel to a Provider? We believe in a near care model that is designed to give you care options within ʩʣ miles of your home ʡ ˌ ou have access to more than 1 ʟʩʣʣ surgical centers and ʥʟʣʣʣ imaging centers nationally across ʧʩ states ʡ How Do Members Utilize the Program? To Get Started: • Call: ʶ ontact ʛ 8 ʪʪʜ ʧʦ 8 ʠʨʧʪʬ before scheduling with an outside provider ʡ • Referral Received: ˉ alen ˭ receives your provider’s order for review ʡ • Con Ѓ rm eligibility: We’ll verify your bene Ѓ ts and con Ѓ rm order details with your provider ʡ • Scheduling: We’ll suggest nearby options close to your home or wor ˞ and your appointment ʡ • Receive your voucher: We’ll email you a voucher to show the facility instead of your insurance card on the day of your procedure ʡ FAQs ˇ ˇˢ˟ ̆˔˥ˡˠˢ˥ ̆ˢ˥˧ˢ˦˖ ̨ ̆˗˨˟ ̆˔ˣ˥ˢ˖ ̆˗˨˥ ̆˖ˢˡ˧˔˖˧˨˦˔˧ʭ ˃ ̨ˢˡ ̆ʭʛʫʪʪʜʧʦʫʠʨʧʪʬ ʸˠ˔ ̃˟ʭˡˢ˖ˢ˦˧˖˔˥ ̆ʳ˩˔˟ ̆ˡ˭ ̨ ̆˔˟˧ ̨ʡ˖ˢˠ ˈ˅ʿʭ˦˨˥ ̊ ̃˖˔˟ ̃ˠ˔ ̊ ̃ˡ ̊ʡ˩˔˟ ̆ˡ˭ ̨ ̆˔˟˧ ̨ʡ˖ˢˠ V ͓ lenz Surgical ʙ Imaging FAQs ˌ our partner for ˁ˂ ʶ˂ˆˇʟ high ʠ quality imaging and surgical care • An ˞ le ʙ ʹ oot • Arthroscopy • ʶ olonoscopy • E ˁˇ • Elbow • Gastroenterology • General ˆ urgery • ʻ ernia ˅ epair • ʻ ip • Imaging ʛ M ˅ I ʟ ʶˇʟ ˃ E ˇʜ • Knee • ˆ houlder • ˆ pine • Urology • Wrist ʙ ʻ and • And More ˻ʥʣʥʨˉ͓˟ ̆ˡ˭̀ʻ ̆˔˟˧ ̨ʴ˟˟˅ ̃ ̊ ̨˧˦˅ ̆˦ ̆˥ ˩ ̆˗ʿʼˇʥʣʬʧʫ
+1 877 640 9610 MPP^d]c\M]MURab̓PM]PRaPMaR_a^UaM\͙P^\ PM]PRaPMaR_a^UaM\͙P^\ Day One Help We are available to help you from the day of your diagnosis and beyond. You can register for the program at any point in your cancer journey to gain access to our resources and support. Registration is available through our website or by phone. Personalized Care Once you are part of the program, a dedicated nurse will be with you every step of the way. This nurse will be available to answer any questions you might have as well as make sure you are receiving ideal treatment for your diagnosis. National Resources Through CancerCARE, you will have access to some of the best doctors, hospitals, and technology nationwide. We will work with your local oncologist to make sure all treatment options are considered, not just local ones. Expert Medical Team Our medical staff has decades of experience treating cancer and we pride ourselves on staying up-to-date with the latest cancer treatments and technology. Each medical staffer has unique cancer expertise and background. The CancerCARE Program is an additional benefit, provided by your health plan, that focuses on helping members diagnosed with cancer. Our passionate medical team will oversee your cancer treatment and ensure the optimal treatment path with proven results is being followed. We are your cancer advocates and will strive to lead you and your dependents to survivorship! A Benefit Specialized In Dealing with Cancer CancerCARE DWUVc4MaR͙DWUVcFW\R͙DWUVcBZMPR͙ What is CancerCARE?
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H^Zd]cMah>WSRDMcRbͼ 2QQWcW^]MZ5RcMWZb;@F:6 @6JFB286E ͔ ͔ K^d\MhW]PaRMbRh^daOR]RSWcc^d_c^Ά ͜S^aR\_Z^hRRM\^ d]c͝MQQWcW^]MZ _aR\Wd\bMeMWZMOZRW]h^daR]a^ZZ\R]c_^acMZ͛BMhZ^PWch͙P^\ 2\^d]cΧ 6\_Z^hRR Ʈ Ʈ ή͕ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά͜ Ά͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά ͔͔͜ Ά ͙ Ά ͙ Ά͙ 2\^d]cΧ E_^dbR Ʈ Ʈ ή͕ Ά ͜ Ά ͙ Ά͙ Ά ͙ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά͜ Ά ͙ Ά͙ Ά ͙ Ά͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά͙ γ Ʈ Ʈ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ 4aWcWPMZ;ZZ]Rbb Ͳ 8dMaQWM]@^]F^OMPP^ ER\W?^]cVZhaMcRb 4VWZQ4^bcWbW]PZdQRQfWcV6\_Z^hRRRZRPcW^] γ Ʈ Ʈ E_^dbROR]RSWcM\^d]cd_c^ ̈́^SR\_Z^hRRM\^d]cc^M\MgW\d\ ^SΆ ͜ ͝ MQQWcW^]MZ_aR\Wd\bMeMWZMOZRW]h^daR]a^ZZ\R]c_^acMZ͛BMhZ^P Wch͙P^\ 4aWcWPMZ;ZZ]RbbDMcRb D2F6;@7AD?2F;A@ 4
H^Zd]cMah >WSR 4^bc ;ZZdbcaMcW^]͛ F^QRcRa\W]RcVR\^bcM__a^_aWMcRZReRZ^SP^eRaMUR͜MbMadZR ^ScVd\O͜h^dbV^dZQP^]bWQRaMO^dc cW\Rbh^da M]]dMZW]P^\R͜SMPc^aW]UW]_a^XRPcRQP^bcbc^VRZ_\MW]cMW]h^ daSM\WZhͭbPdaaR]cZWSRbchZR͙ B^ZWPh 6ZRPcW^] 2\^d]c ER\W\^]cVZh _aR\Wd\b QWb_ZMhRQ͙ 4^bc ^S 25̿5 Wb W]PZdQRQ͙ B^ZWPh 6ZRPcW^] 4^bc BRa 2UR 3aMPYRc 6\_Z^hRR γ ͼ ͼ ͼ ͼ ͼ ͼ ͼ ͕ Ά͜ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά ͜ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͜ Ά ͙ Ά ͙ Ά͙ Ά͙ Ά͜ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͜ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͜ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͜ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά͜ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά͙ Ά͙ Ά ͙ Ά ͜ Ά͙ Ά͙ Ά͙ Ά ͙ Ά ͜ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά͜ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ ͼ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά ͙ Ά͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ 4
H^Zd]cMah >WSR 4^bc ;ZZdbcaMcW^] P^]cW]dRQ ͼ ͼ ͼ ͼ ͼ ͼ ͼ ͕ γ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ ͼ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ B^ZWPh 6ZRPcW^] 2\^d]c E_^dbR Ά͜ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά ͙ Ά ͜ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͜ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͜ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά͙ Ά ͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά͙ Ά ͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ 4
H^Zd]cMah >WSR 4^bc ;ZZdbcaMcW^] P^]cW]dRQ γ ͼ ͼ ͼ ͼ ͼ ͼ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά͙ Ά͙ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά͜ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά͜ Ά ͙ Ά ͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά ͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά͜ Ά ͙ Ά ͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά͜ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͜ Ά ͙ Ά͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά͜ Ά ͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͜ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ ͼ ͼ ͕ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙
H^Zd]cMah >WSR 4^bc ;ZZdbcaMcW^] P^]cW]dRQ γ ͼ ͼ ͼ ͼ ͼ ͼ ͼ ͕ Ά ͜ Ά͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ ͼ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͜ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͜ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά͙ Ά ͙ Ά ͙ Ά ͙ Ά͙ Ά͙ Ά ͜ B^ZWPh 6ZRPcW^] 2\^d]c 4VWZQ͈aR]͉ Ά ͜ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά ͜ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά ͜ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͜ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͜ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ Ά͙ DRSRac^8dMaM]cRR;bbdRa^f^]_MURMO^eRS^aH^Zd]cMah>WSR8;M\^d]cb͙ BaR\Wd\bS^aH^Zd]cMah>WSR;]PaRMbRW]SWeRhRMaW]PaR\R]cb E_^dbR P^eRaMUR _aR\Wd\ Wb OMbRQ ^] 6\_Z^hRR MUR͙ ͕ 3R]RSWcaRQdPcW^]bM__Zh͙ >;?;F2F;A@E 2@5 6J4>GE;A@E͛ 2 EG??2DK A7 B>2@ >;?;F2F;A@E 2@5 6J4>GE;A@E 7AD >;76 2@5 25̿5 4AH6D286͛ K^d\dbcORf^aYW]USdZZcW\R^]cVRRSSRPcWeRQMcR^Sh^daP^eRaMUR͝ ^cVRafWbR͜h^daP^eRaMURORP^\RbRSSRPcWeRMScRah^dVMeRP^\_Z RcRQM b_RPWSWPfMWcW]U_RaW^Q͙6\_Z^hRRb\dbcORZRUMZZhf^aYW]UW]c VRG]WcRQEcMcRb W]^aQRac^ORRZWUWOZRS^aP^eRaMUR͙G]QRafaWcW]U\dbcM__a^eR P^eRaMURS^a R\_Z^hRRb^]cR\_^aMahMbbWU]\R]c͈͛M͉RgPRRQW]U^]RhRMa͝^a͈ O͉W]M]MaRM d]QRacaMeRZfMa]W]UOhcVRGE5R_Mac\R]c^SEcMcR͙EdOXRPcc^ bcMcRb_RPWSWP eMaWMcW^]b͙6eWQR]PR^S;]bdaMOWZWchWbaR`dWaRQ^]MZZZMcRR] a^ZZRRb͙FVWb P^eRaMURfWZZ]^cORRSSRPcWeRd]cWZM__a^eRQOhM8dMaQWM]d]QRafaWcRa͙FVWb _a^_^bMZWbVRQURQbdOXRPcc^bMcWbSMPc^ahSW]M]PWMZReMZdMcW^]͙BZRMbRaRSRac^ PRacWSWPMcR^SP^eRaMURS^aSdZZ_ZM]QRbPaW_cW^]͙ 5R_R]QR]cZWSRW]bdaM]PRfWZZ]^ccMYRRSSRPcWSMQR_R]QR]c͜^ cVRacVM]M ]RfO^a]͜WbP^]SW]RQc^cVRV^b_WcMZ^a^cVRaVRMZcVPMaRSMPWZ Wch^aWbd]MOZR c^_RaS^a\cVR]^a\MZMPcWeWcWRb^Sb^\R^]R^SZWYRMURM]QbRg͙ 2PPRZRaMcRQ>WSR3R]RSWcWb]^c_MWQc^M]R\_Z^hRRd]QRacVRS^ZZ^fW]U PWaPd\bcM]PRb͛^]RfV^WbaR`dWaRQOhZMfc^dbRcVROR]RSWcc^ _MhPaRQWc^ab͝Wb aR`dWaRQOhP^dac^aQRac^_MhcVROR]RSWcc^M]^cVRa_Rab^]͝W baR`dWaRQOhM U^eRa]\R]cMUR]Phc^dbRcVR_Mh\R]cc^aRPRWeRMU^eRa]\R]cOR]RSWc͝^a Z^bRbVWb^aVRaUa^d_P^eRaMURORS^aRM]MPPRZRaMcRQOR]RSWcWb_MWQ͙ H^Zd]cMah >WSR A]Zh͛ IR_Mh]^OR]RSWcbWScVRW]bdaRQͭbQRMcVWbQdRc^bdWPWQRfWc VW]cf^hRMab Sa^\cVRW]bdaRQͭb^aWUW]MZRSSRPcWeRQMcR͙FVWbcf^hRMaZW\Wc McW^]MZb^M__ZWRb c^M]hW]PaRMbRW]OR]RSWc͙FVWbRgPZdbW^]\MheMahMPP^aQW]Uc ^bcMcRZMf͙>McR R]caM]cbM]QOR]RSWcW]PaRMbRbaR`dWaRd]QRafaWcW]UM__a^eMZ͙ 8BD>3͜8BD6ABF 8dMaM]cRR;bbdRΧ4^]QWcW^]MZ;bbdRM\^d]cb\MheMahOMbRQ^]MURM]QPMbR bWjR͙ERRh^daBZM]2Q\W]WbcaMc^aS^aQRcMWZb͙>McRR]caM]cbM] QOR]RSWc W]PaRMbRbaR`dWaRd]QRafaWcW]UM__a^eMZ͙ 7^a 25̿5͛ IR_Mh]^OR]RSWcbS^aM]hZ^bbPMdbRQ͛ OhfWZZSdZbRZSW]Xdah ͝ bWPY]Rbb͜QWbRMbR^a\RQWPMZcaRMc\R]c͝ Oh_MacWPW_McW]U W]MP WeWZQWb^aQRa^a P^\\WccW]UMSRZ^]h͝FaMeRZW]U^]M]hch_R^SMWaPaMScfVWZRVM eW]UQdcWRb^] cVMcMWaPaMSc͝ OhQRPZMaRQ^ad]QRPZMaRQMPc^SfMa^aMa\RQMU UaRbbW^]͝fVWZRM \R\ORa^SM]hMa\RQS^aPR͈?MheMahOhbcMcR͉͝fVWZRQaWeW]UM \^c^aeRVWPZR fWcV^dcMPdaaR]c͜eMZWQQaWeRaͭbZWPR]bR͝ OhZRUMZW]c^gWPMcW^ ]͝^a Ohe^Zd]cMaWZh dbW]UM]^]_aRbPaW_cW^]P^]ca^ZZRQbdObcM]PR͙4^]caMPć8BD 254>Rc MZ͙IRf^]ͨc_Mh\^aRcVM]̈́^ScVR;]bdaM]PRM\^d]cS^aMZZ Z^bbRbQdRc^ cVRbM\RMPPWQR]c͜RgPR_cMbbcMcRQ͙FVRZ^bb\dbc^PPdafWcVW] Mb_RPWSWRQ _RaW^Q^ScW\R^ScVRMPPWQR]c͙BZRMbRbRRP^]caMPcS^ab_RPWSW PQRSW]WcW^]͝ QRSW]WcW^]^SZ^bb\MheMahQR_R]QW]U^]cVROR]RSWc_MhMOZR͙ 6]VM]PRQ 25̿5͛ 2Z^bb\MhORQRSW]RQMbQRMcV͜`dMQaW_ZRUWM͜Z^bb^S b_RRPVM]QVRMaW]U͜Z^bb^SP^U]WcWeRSd]PcW^]͜P^\Mc^bRbcMcR W]RgPRbb^S ^]R \^]cV͜VR\W_ZRUWM^a_MaM_ZRUWM͙FVRZ^bb\dbc^PPdafWcVW] Mb_RPWSWRQ _RaW^Q^ScW\R^ScVRMPPWQR]c͙BZRMbRbRRP^]caMPcS^ab_RPWSW PQRSW]WcW^]͝ QRSW]WcW^]^SZ^bb\MheMahQR_R]QW]U^]cVROR]RSWc_MhMOZR͙ 4
Snellings Walters Insurance Agency Welfare Benefit Plan Summary Plan Description Wrap Document Adopted In 202 6 This document together with the applicable insurance contracts, carrier plan documents and certificate insurance booklets which are incorporated herein by reference, constitute the Summary Plan Description /written plan document for the Snellings Walters Insurance Agency Employer Welfare Benefit Plan.
2 TABLE of C ONTENT S INTRODUCTION ................................ ................................ ................................ ....................... 3 GENERAL TERMS AND CONDITIONS ................................ ................................ ......................... 3 PLAN INFORMATION ................................ ................................ ................................ ............... 4 PLAN ADMINISTRATION ................................ ................................ ................................ .......... 13 PLAN CONTACT INFORMATION ................................ ................................ ............................... 15 CLAIMS AND APPEALS ................................ ................................ ................................ ............ 17 MISCELLANEOUS RULES ................................ ................................ ................................ .......... 25 SECTION 125 PLAN ................................ ................................ ................................ .................. 28 ELIGIBILITY AND PARTICIPATION REQUIREMENTS ................................ ................................ ... 29 COBRA ................................ ................................ ................................ ................................ .... 32 BENEFIT PLAN PROVISIONS ................................ ................................ ................................ ..... 40 STATUTORY PROVISIONS ................................ ................................ ................................ ........ 40 BENEFIT CONTINUATION PROVISIONS FOR NON - STATUTORY LEAVE OF ABSENCE ................... 42 AMENDMENT OR TERMINATION OF THE PLAN ................................ ................................ ........ 43 HIPAA PRIVACY AND SECURITY STANDARDS ................................ ................................ ........... 44 HIPAA NOTICE OF SPECIAL ENROLLMENT RIGHTS ................................ ................................ .... 46 STATEMENT OF ERISA RIGHTS ................................ ................................ ................................ . 47 PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) ................................ ................................ ................................ ................................ ..... 50 ENFORCE YOUR RIGHTS ................................ ................................ ................................ .......... 59 DEFINITIONS ................................ ................................ ................................ ........................... 60 ASSISTANCE WITH YOUR QUESTIONS ................................ ................................ ...................... 63 QUALIFIED MEDICAL CHILD SUPPORT ORDERS ................................ ................................ ........ 64
3 INTRODUCTION This document (the Summary Plan Description ( SPD ) Wrap Document ) constitutes the governing plan document and SPD for Snellings Walters Insurance Agency Welfare Benefit Plan and presents information about all the health and welfare benefit plans maintained by Snellings Walters Insurance Agency (Employer ) , and your rights and benefits as a Plan P articipant. Please refer to the “Subsidiary Contracts” ( i.e., applicable certificate of coverage, subscriber agreement, or evidence of coverage booklet , which are incorporated herein by reference as described below ) for more details on specific items such as benefit coverage, definitions, coordination of benefits, claims procedures and exclusions and limitations. The actual terms and conditions of the Subsidiary Contracts offered under this Plan are contained in separate, written documents governing each re spective benefit. I n the event of a conflict between this SPD and a Subsidiary Contract, the terms of the Subsidiary Contract shall govern . E ach separate Subsidiary Contract, as amended or subsequently replaced, is hereby incorporated by reference as if fully recited herein. This Wrap Document and the incorporated Subsidiary Contracts have been prepared for Plan Participants , and together constitute the Summary Plan Description for your Welfare Benefit Plan . This is intended to comply with the disclosure requirements set forth in regulations issued by the U.S. Department of Labor under the Employee Retirement Income Security Act (ERISA) of 1974. Please read this SPD carefully and keep it along with your other benefit plan information for future reference. This Wrap Document contains a summary in English of your rights and benefits under the Snellings Walters Insurance Agency Welfare Benefit Plan. If you have difficulty understanding any part of this Wrap Document, contact the Plan Administrator for assistance. GENERAL TERMS AND CONDITIONS This Welfare Benefit Plan is established for the purpose of providing the employee welfare benefits listed here in for the benefit of eligible Employees and D ependents. This Plan d ocument , together with the Adoption A greement and Governing D ocuments described herein constitutes the written plan document required by ERISA § 402(a), and is an employee Welfare Benefit Plan (within the meaning of ERISA § 3(l)). The Plan , also provides benefits in accordance with the applicab le requirements of federal laws such as , Consolidated Omnibus Budget Reconciliation Act (COBRA), Health Insurance Portability Accountability Act (HIPAA), Newborns’ and Mothers’ Health Protection Act (NMHPA), Mental Health Parity Act (MHPA), and the Women’s Health and Cancer Rights Act (WHCRA) and the Genetic Information Non - Discrimination Act (GINA) . In addition, some of the Welfare Program s are offered on a pre - tax basis through the Section 125 Plan in accordance with the Internal Revenue Code.
4 PLAN INFORMATION The name of the Medical Carrier that insures benefits under the Plan is: Meritain Health Benefit Program Plan Name: Meritain - Aetna $4000 100% HDHP POS Plan Year January 01 through December 31 Benefit Funding Type: Self Insured Policy Number: 16316 Insurance Carrier Address: 1044 Eastbury Drive Lansing , MI 48917 Insurance Carrier Phone: 888 - 324 - 5789 Insurance Carrier URL: www.meritain.com Dental is Included in this Plan Yes Vision is included in this Plan Yes Pharmaceutical is included in this Plan Yes Eligible Employee: Employees working at least 30 hours per week Excluded Classes: Part Time;Seasonal Workers;Seasonal Employees;Interns Benefit Waiting Period: 1st of Month following 30 Days Benefit Termination Date: End of Month Eligible Dependents: Spouse and Dependents up to the age of 26 Employee Coverage Only Contributions: Yes - Employee and Employer contribute Employee and Spouse ( o r Domestic Partner ) Coverage Contributions: Yes - Employee and Employer contribute Employee and Dependents Contributions: Yes - Employee and Employer contribute Employee and Family Contributions: Yes - Employee and Employer contribute If Employee contributes to premium, is that contribution collected Pre - Tax Yes Grandfathered: No
5 The name of the Dental Carrier that insures benefits under the Plan is: Guardian Benefit Program Plan Name: Vol. Dental $2000 Value/NAP Plan Plan Year January 01 through December 31 Benefit Funding Type: Fully Insured Policy Number: 547925 Insurance Carrier Address: P.O. Box 14319 Lexington , KY 40512 Insurance Carrier Phone: 888 - 600 - 1600 Insurance Carrier URL: www.guardiananytime.com Eligible Employee: Employees working at least 30 hours per week Excluded Classes: Part Time;Seasonal Workers;Seasonal Employees;Interns Benefit Waiting Period: 1st of Month following 30 Days Benefit Termination Date: End of Month Eligible Dependents: Spouse and Dependents up to the age of 26 Employee Coverage Only Contributions: Yes - Employee contributes 100% Employee and Spouse (or Domestic Partner) Coverage Contributions: Yes - Employee contributes 100% Employee and Dependents Contributions: Yes - Employee contributes 100% Employee and Family Contributions: Yes - Employee contributes 100% If Employee contributes to premium, is that contribution collected Pre - Tax Yes
6 The name of the Vision Carrier that insures benefits under the Plan is: Guardian Benefit Program Plan Name: Vol. Vision Plan Year January 01 through December 31 Benefit Funding Type: Fully Insured Policy Number: 547925 Insurance Carrier Address: P.O. Box 14319 Lexington , KY 40512 Insurance Carrier Phone: 888 - 600 - 1600 Insurance Carrier URL: www.guardiananytime.com Eligible Employee: Employees working at least 30 hours per week Excluded Classes: Part Time;Seasonal Workers;Seasonal Employees;Interns Benefit Waiting Period: 1st of Month following 30 Days Benefit Termination Date: End of Month Eligible Dependents: Spouse and Dependents up to the age of 26 Employee Coverage Only Contributions: Yes - Employee contributes 100% Employee and Spouse (or Domestic Partner) Coverage Contributions: Yes - Employee contributes 100% Employee and Dependents Contributions: Yes - Employee contributes 100% Employee and Family Contributions: Yes - Employee contributes 100% If Employee contributes to premium, is that contribution collected Pre - Tax Yes
7 The name of the Group Life Carrier that insures benefits under the Plan is: Guardian Benefit Program Plan Name: Basic Life & AD&D Plan Year January 01 through December 31 Benefit Funding Type: Fully Insured Policy Number: 547925 Insurance Carrier Address: P.O. Box 14319 Lexington , KY 40512 Insurance Carrier Phone: 888 - 600 - 1600 Insurance Carrier URL: www.guardiananytime.com Eligible Employee: Employees working at least 30 hours per week Excluded Classes: Part Time;Seasonal Workers;Seasonal Employees;Interns Benefit Waiting Period: 1st of Month following 30 Days Benefit Termination Date: End of Month Eligible Dependents: Spouse and Dependents up to the age of 26 Employee Coverage Only Contributions: Yes - Employer only contributes Employee and Spouse (or Domestic Partner) Coverage Contributions: Yes - Employer only contributes Employee and Dependents Contributions: Yes - Employer only contributes Employee and Family Contributions: Yes - Employer only contributes If Employee contributes to premium, is that contribution collected Pre - Tax No
8 The name of the Voluntary Life/ADD Carrier that insures benefits under the Plan is: Guardian Benefit Program Plan Name: Vol. Life and AD&D $500,000 max Plan Year January 01 through December 31 Benefit Funding Type: Fully Insured Policy Number: 547925 Insurance Carrier Address: P.O. Box 14319 Lexington , KY 40512 Insurance Carrier Phone: 888 - 600 - 1600 Insurance Carrier URL: www.guardiananytime.com Eligible Employee: Employees working at least 30 hours per week Excluded Classes: Part Time;Seasonal Workers;Seasonal Employees;Interns Benefit Waiting Period: 1st of Month following 30 Days Benefit Termination Date: End of Month Eligible Dependents: Spouse and Dependents up to the age of 26 Employee Coverage Only Contributions: Yes - Employee contributes 100% Employee and Spouse (or Domestic Partner) Coverage Contributions: Yes - Employee contributes 100% Employee and Dependents Contributions: Yes - Employee contributes 100% Employee and Family Contributions: Yes - Employee contributes 100% If Employee contributes to premium, is that contribution collected Pre - Tax Yes
9 The name of the Group Short Term Disability Carrier that insures benefits under the Plan is: Guardian Benefit Program Plan Name: STD max $2000 Plan Year January 01 through December 31 Benefit Funding Type: Fully Insured Policy Number: 547925 Insurance Carrier Address: P.O. Box 14319 Lexington , KY 40512 Insurance Carrier Phone: 888 - 600 - 1600 Insurance Carrier URL: www.guardiananytime.com Eligible Employee: Employees working at least 30 hours per week Excluded Classes: Part Time;Seasonal Workers;Seasonal Employees;Interns Benefit Waiting Period: 1st of Month following 30 Days Benefit Termination Date: End of Month Employee Coverage Only Contributions: Yes - Employer only contributes If Employee contributes to premium, is that contribution collected Pre - Tax No
10 The name of the Group Long Term Disability Carrier that insures benefits under the Plan is: Guardian Benefit Program Plan Name: LTD max $12,000 Plan Year January 01 through December 31 Benefit Funding Type: Fully Insured Policy Number: 547925 Insurance Carrier Address: P.O. Box 14319 Lexington , KY 40512 Insurance Carrier Phone: 888 - 600 - 1600 Insurance Carrier URL: www.guardiananytime.com Eligible Employee: Employees working at least 30 hours per week Excluded Classes: Part Time;Seasonal Workers;Seasonal Employees;Interns Benefit Waiting Period: 1st of Month following 30 Days Benefit Termination Date: End of Month Employee Coverage Only Contributions: Yes - Employer only contributes If Employee contributes to premium, is that contribution collected Pre - Tax No
11 The name of the Voluntary Critical Care Carrier that insures benefits under the Plan is: Guardian Benefit Program Plan Name: Critical Illness $5k - $50k - $5k increments Plan Year January 01 through December 31 Benefit Funding Type: Fully Insured Policy Number: 547925 Insurance Carrier Address: P.O. Box 14319 Lexington , KY 40512 Insurance Carrier Phone: 888 - 600 - 1600 Insurance Carrier URL: www.guardiananytime.com Eligible Employee: Employees working at least 30 hours per week Excluded Classes: Part Time;Seasonal Workers;Seasonal Employees;Interns Benefit Waiting Period: 1st of Month following 30 Days Benefit Termination Date: End of Month Eligible Dependents: Spouse and Dependents up to the age of 26 Employee Coverage Only Contributions: Yes - Employee contributes 100% Employee and Spouse (or Domestic Partner) Coverage Contributions: Yes - Employee contributes 100% Employee and Dependents Contributions: Yes - Employee contributes 100% Employee and Family Contributions: Yes - Employee contributes 100% If Employee contributes to premium, is that contribution collected Pre - Tax Yes
12 The name of the Voluntary Accident Carrier that insures benefits under the Plan is: Guardian Benefit Program Plan Name: Vol. Accident Insurance Plan Year January 01 through December 31 Benefit Funding Type: Fully Insured Policy Number: 547925 Insurance Carrier Address: P.O. Box 14319 Lexington , KY 40512 Insurance Carrier Phone: 888 - 600 - 1600 Insurance Carrier URL: www.guardiananytime.com Eligible Employee: Employees working at least 30 hours per week Excluded Classes: Part Time;Seasonal Workers;Seasonal Employees;Interns Benefit Waiting Period: 1st of Month following 30 Days Benefit Termination Date: End of Month Eligible Dependents: Spouse and Dependents up to the age of 26 Employee Coverage Only Contributions: Yes - Employee contributes 100% Employee and Spouse (or Domestic Partner) Coverage Contributions: Yes - Employee contributes 100% Employee and Dependents Contributions: Yes - Employee contributes 100% Employee and Family Contributions: Yes - Employee contributes 100%
13 PLAN ADMINISTRATION The Plan Administrator shall be responsible for the general administration of the Plan , including the H ealth Benefit P rograms referenced above , and shall be the “Plan A dministrator” and “named fiduciary” within the meaning o f ERISA under the Plan and the Benefit P rograms (except to the extent another person or entity is specifically d esignated ; ) p rovid ed, however, for Fully Insured Benefit P rograms, unless specifically provided otherwi se in the Governing D ocuments, the Insurer shall be the “named fiduciary,” and claims fiduciary responsible for administering and determining benefits unde r such Benefit P rogram, and shall have full authority and discretion to interpret the terms of the Benefit P rogram for those purposes. With resp ect to the Plan , including the Welfare Benefit P rograms identified in this document , the Plan Administrator shall have, without limitation, the following discretionary authority, duties and powers: 1) To make and enforce such rules and regulations as it deems necessary or proper for the efficient administration of the Plan , including the establishment of any claims procedures that may be required by applicable provisions of law; 2) Except to the extent reserved to the Insurer w ith respect to a F ully Insured Benefit P rogram, to interpret the provisions of the Plan , make findings of fact, and correct errors in, supply omissions from, and resolve inconsistencies or ambiguities in the language of the Plan , and to decide all claims and appeals arising under the Plan ; 3) To decide all questions concerning the Plan and the eligibility of any person to participate in the Plan ; 4) To appoint such agents, counsel, accountants, consultants and other persons as may be required to assist in administering the Plan ; and 5) To allocate and delegate its fiduciary and administrative responsibilities under the Plan and to designate other persons to carry out any of its responsibilities under the Plan , any such allocation, delegation, or designation to be in writing. Without limitation, the Plan Administrator may designate other organizations or persons (who also may be employed by an Employer) to carry out the following: a. pursuant to an administrative services or claims administration agreement, the responsibility fo r administering and managing a Welfare Benefit P rogram or p rograms, including the processing and payment of claims under the Welfare Benefit Program and the recordkeeping related thereto; b. the responsibility to prepare, report, file and disclose any forms, documents and other information required to be reported and filed by law with any government agency or to be prepared and disclosed to Employees, Participants or other persons entitled to disclosure u nder the Benefit P rograms; and c. the responsibility to review cla ims or claim denials under the Benefit P rograms, including discretionary authority to act as claims fiduciary to determine adverse claims determinations within the meaning of Department of Labor Regulation § 2560.503 - 1.
14 Subject to applicable law, any interpretation of the provisions of the Plan and the Welfare Benefit P rograms and any decisions on any matter within the discretion of the Plan Administrator made by the Plan Administrator in good faith shall be binding on all persons. A misstatement or other mistake of fact shall be corrected when it becomes known, and the Plan Administrator shall make such adjustment on account thereof as it considers equitable and practicable. The Plan Administrator shall not be liable in any manner for any determination of fact made in good faith.
15 PLAN CONTACT INFORMATION Plan S ponsor & Plan A dministrator : The name, address and telephone number of the Plan Sponsor is: Snellings Walters Insurance Agency 5 Concourse Parkway, Suite 2700 Atlanta , GA 30328 Phone: 4705144868 The name, address and telephone number of the Plan Administrator is: Snellings Walters Insurance Agency 5 Concourse Parkway, Suite 2700 Atlanta , GA 30328 Phone: 4705144868 Plan F iduciary : The name, address and telephone number of the Plan Fiduciary is: Snellings Walters Insurance Agency 5 Concourse Parkway, Suite 2700 Atlanta , GA 30328 Phone: 4705144868 Agent for S ervice of L egal P rocess : The name and address of the Agent for Service of Legal Process is: Brannon Johnston Snellings Walters Insurance Agency 5 Concourse Parkway, Suite 2700 Atlanta , GA 30328 Phone: 4705144868 Important Disclaimer: Plan benefits are provided under contracts between the Employer and the carriers. If the terms of this Summary Plan Description document conflict with the terms of the Welfare Program Subsidiary Contract, the terms of the Welfare Program Subsidiary Contrac t will control, unless superseded by applicable law.
16 Identification numbers: The Federal Employer Identification Number of the Plan Sponsor listed above is: 58 - 0970646 Plan Number is 501 PLAN AMENDMENT OR TERMINATION Amendment The Employer reserves the right to amend an y part or all of the Plan or a Welfare Benefit P rogram at any time or from time to time by written instrument. Termination The Employer reserves the ri ght to terminate the Plan or a Welfare B enefit P rogram at any time by wr itten instrument. The Plan or Welfare Benefit P rogram , as applied to any single Employer, may be terminated at any time by such Employer, subject to consent of the Employer . Sources of Plan Contributions Plan Year – January 1st through December 31st Plan Contributions - Contributions for coverage may be made solely by the Plan Sponsor, solely by Participants , or by a combination of the Plan Sponsor and Participants . Employee con tributions will be paid through payroll deduction. Eligible plan premiums may be deducted on a Pre - Tax basis (subject to IRS Code § 125 rules) . Actual contribution r ates will be published during the Employer ’ s open enrollment p eriod in each year. Carrier documentation and/or your open enrollment guide provide the specific contribution information for each Health Benefit Program .
17 CLAIMS AND APPEALS Claims All claims for benefits under the Plan and any assignment of benefits to a provider shall be made, processed and paid , in accordance with Department of Labor Regulations § 2560.503 - 1 and other applicable law, and the terms and conditions of the applicable Benefit P rogram (referenced in the tables above) and the related provisions of the Summary Plan Description for each Benefit P rogram. The Claims Administrator shall be the claims fiduciary unless this function is delegated to another perso n or entity under this Section . No Estoppel of Plan No person is entitled to any benefit under the Plan except and to the extent expressly provided under the terms an d conditions of the applicable Benefit P rogram . The fact that payments have been made from the Plan in connection with any claim for benefits does not (a) establish the validity of the claim; (b) provide any right to have such benefits continue for any period of time; or (c) prevent the Plan from recovering the benefits paid to the extent that the Claims Administrator determines that there was no right to payment of the benefits under the Plan . Thus, if a benefit is paid and it is thereafter determined that such benefit should not have been paid (whether or not attributable to an error by the Participant or any other person), then the Claims Administrator may take such action as it deems necessary or appropriate to remedy such situation, including without limitation, by deducting the amount of any prior overpayment theretofore made to or on behalf of such Participant from any succeeding payments to or on behalf of such Participant under the Plan or from any amounts due or owing to such Participant by the Employer or under any other plan, program , or arrangement benefiting the Employees or former Employees of the Employer , or otherwise recovering such overpayment from whomever has benefited from it. If the Claims Administrator determines that an underpayment of benefits has been made, then the Claims Administrator shall take such action as it deems necessary or appropriate to remedy such situation. Claims Procedures The sp ecific guidelines for filing a c laim or a request for a review of a denied claim shall be set out in the Subsidiary Contracts for each Welfare Benefit P rogram. Such procedures shall comply with the general provisions of this Section and shall be designed to ensure the independence and impartiality of the persons involv ed in making decisions on such claims. A c laimant must follow all internal claims and appeal procedures and, where applicable, all external review procedures before a c laimant can file a lawsuit to contest the decision. For d isability claims made on or after April 1, 2018, i f a plan participant has been denied a benefit based on an adverse determination of disability and the new procedures established by (DOL Regulation §2560.503 - 1) are not strictly followed, then the claimant will be deemed to have exhausted administrative remedies and may seek action in court. Definitions For purposes of this S ection , the following terms shall have the meanings set forth below:
18 1. “ Adverse Benefit Determination ” means a total or partial denial of a C laim. For a Non - Grandfathered Plan, a retroactive rescission of coverage due to fraud or misrepresentation shall be treated as an Adverse Benefit Determination . 2. “Appeal” means a c laimant’s written request for review of an Adverse Benefit Determination in accordance with the Appeal Section below . 3. “Claim” means any request for a benefit under a Welfare Benefit P rogram, made by a c laimant or representative that complies with the reasonable procedures for making benefit c laims under such Benefit P rogram. 4. “ Concurrent Care Claim” means a c laim for an ongoing course of treatment to be provided over a period of time or number of treatments. Any reduction or termination by a Benefit P rogram of the course of treatment (other than by plan amendment or termination) before the end of the period of time or number of treatments origin ally approved is considered an Adverse Benefit Determination . 5. “Final Adverse Benefit Determination” means an Adverse Benefit Determination issued in connection with the last stage of Appeal as set forth in the Appeal Section below . 6. “Non - Gran dfathered Plan” means a Welfare Benefit P rogram that is (1) subject to Title I of the Patient Protection and Affordable Care Act of 2010, as amended, and (2) does not meet the requirements for “grandfathered status” within the meaning of that Act. 7. “Post - Service Claim” means any Claim that is not a Pre - Service Claim, an Urgent Care Claim or a Concurrent Care Claim . 8. “ Pre - Service Claim ” means any claim for a benefit under a Health Benefit P rogr am that conditions receipt of the benefit, in whole or in part, on approval in advance of obtaining medical care. 9. “Urgent Care Claim ” means a special type of Pre - Service Claim for medical care or treatment with respect to which the time frame for a non - urgent care determination could seriously jeopar dize the life or health of the c laimant; or the ability of the c laimant to regain maximum function; or in the opinion of the attending or consultin g physician, would subject the c laimant to severe pain that could not be adequately managed without the care or treatm ent that is the subject of the c laim. A physician wit h knowledge of the c laimant’s medica l conditi on may determine if a C laim is one involving urgent c are. If there is no such physician, an individual acting on behalf of the Health Benefit P rogram applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine may make the determination.
19 Notice to Claimant of Adverse Benefit Determination s Initial Claims Except with respect to Urgent Care C laims (the notification for which may be oral followed by written or electronic notification within three days of the oral notification), upon its initial determination of a C laim, the Claims Administrator shall provide written or electronic notification of any Adverse Benefit Determination . The notice will state, in a manner calculated to be understood by the c laimant: a. The specific reason or reasons for the adverse determination , including for Non - Grandfathered Plans, the denial code and its corresponding meaning, and a description of the Non - Grandfathered Plan’s standard, if any, that was used i n denying the C laim. b. Reference to the specific Welfare P rogr am provisions on which the determination was based. c. A description of any additional material or information necessary f or the claimant to perfect the C l aim and an explanation of why such material or information is necessary. d. A description of the Welfare P rogram’s appeal procedures, including any voluntary appeal pr ocedures offered by the Welfare P rogram and for Non - Grandfathered Plans, any external review procedures, and the time limits applicable to such procedures. This w ill include a statement of the c laimant's right to bring a civil action under ERISA S ection §502 . e. If the Adverse Benefit Determination was based on an internal rule, guideline, protocol, or other similar criterion, the specific rule, guideline, protocol, or criterion will be provided free of charge, or a statement will be included that such a rule, guideline, protocol, or criterion was relied upon in making the Adverse Benefit Determination and a copy will be provided free of charge to the c laimant upon request. f. If the Adverse Benefit Determination is based on a medical necessity or experimental or investigational treatment or similar exclusion or limit, an explanation of the scientific or clinical judgment for the determination, applying the terms of the Health Benefit P rogram to the c laimant's medical circumstances, will be provided, or a statement will be included that such explanation will be provided free of charge, upon request. g. For Non - Grandfathered Plans, infor mation sufficient to allo w the claimant to identify the C laim involved (including date of service , the healthcare provider, the C laim amount, if applicable, the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning). h. For Non - Grandfathered Plans, information about the availability of and contact information for, any applicable office of health insurance consumer assistance or ombudsman established under applicable federal law to assist individuals with the internal clai ms and appeals procedures and external review process.
20 Appeals The Claims Administrator shall also provide written or electronic notice of an Adverse Benefit Determination on Appeal. This notice shall contain the informat ion listed i n subsections Initial Claims (a) through (h ) above , as well as: 1) A statement that the c laimant is entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records and oth er information relevant to the C laim. 2) In the case of a Final Adverse Benefit Determination for a Non - Grandfathered Plan, a discussion of the decision. When a c laimant receives an Adverse Benefit Determination , the c laimant has 180 days following receipt of the notification in which to request a review of the decision, unless a short er time is permitted by law. A c laimant may submit written comments, documents, records, and oth er information relating to the C laim. If the c laimant so requests, they will be provided, free of charge, reasonable access to, and copies of, all documents, records, and oth er information relevant to the C laim. A document, record, or other information sha ll be considered relevant to a C laim if it: a. w as relied upon in making the benefit determination; b. was submitted, considered, or generated in the course of making the benefit determination, without regard to whether it was relied upon in ma king the benefit determination; c. demonstrated compliance with the administrative processes and safeguards designed to ensure and to verify that benefit determinations are made in accordance with Welfare P rogram documents and Welfare P rogram provisi ons have been applied consistently with respe ct to all c laimants; or d. constituted a statement of policy or guidance with respect to the Welfare P rogram concerning the denied treatment option or benefit. For Non - Grandfathered Plans, the Claims Ad ministrator shall provide the cl aimant any new or additional evidence that is relied upon, considered , or generated by or at the direction of the Non - Grandfathered Plan. This new evidence shall be provided free of charge and must be provided to c laimant as soon as possible and sufficiently in advance of the time within which a Final Adverse Benefit Determination is required, to allow the c laimant time to respond. I f a F inal Adverse Benefit Determination will be based on a ne w or additional rationale, the cl aimant must be provided with this rationale as soon as possible and sufficiently in ad vance of the date on which the F inal Adverse Benefit Determination must be provided, in order to give the c laimant a reasonable opportunity to respond prior to that date. The Claims Administrator’s review shall take into account all comments, documents, records, and othe r information submitted b y the claimant relating to the C laim, without regard to whether such information was submitted or considered in the i nitial Adverse Benefit Determination . The review will not afford deference to the initial Adverse Benefit Determination and will be conducted by a
21 fiduciary of the Welfare Benefit P rogr am who is neither the i ndividual who made the Adverse Benefit D etermination nor a subordinate of that individual. If the Adverse Benefit D etermination was based on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, the Claims Administrator shall consult with a health care professional who was not involved in the original Adverse Benefit D etermination, nor a subordinate of any individual involved in the original Adverse Benefit D etermination. This health care professional will have appropriate training and experience in the field of medicine involved in the medical judgment. Additionally, medical or vocational experts whose advice was obtained on behalf of the Health Benefit P rogram in connection with the initial Adverse Benefit D etermination will be identified. I f specifically provided under the Health Benefit P rogram, a c laimant may bring a second a ppeal, which shall be subject to the terms of this S ection . Voluntary Appeals If a Welfare B enefit P rogram provides for a voluntary appeal process, the terms of this section shall apply. During voluntary dispute resolution, any statute of limitations or other defense based on timeliness is tolled during the time any voluntary appeal is pending. The Benefit P rogram wai ves any right to assert that a c laimant has failed to exhaust administrative remedies because they did not elect to submit a benefit dispute to the voluntary appeal provided by the Benefit P rogram. A c laimant may elect a voluntary appeal after exhaustion of appeals of an Adverse Benefit Determination as explained in the section above, entitled, "Appeals." The B enef it P rogram will provide to the c laimant, at no cost and upon request, sufficient information about the voluntary appeal to enable the c laimant to make an informed judgment about whether to submit a benefit dispute to the voluntary level of appeal. This information will include a statement that the decis ion will have no effect on the c laimant's rights to any other benefits under the Benefit P rogram; will list the rules of the appeal; state the c laimant's right to representation; enumerate the process for selecting the decision maker; and give circumstances, if any, that may affect the impartiality of the decision maker. No fees o r costs will be imposed on the c laimant as part of the voluntary level of appeal. Time for Responses Upon receipt of a C laim or an Appeal of an Adverse Benefit Determination , the Claims Administrator (or its delegate) shall make its determination and provide any required notice within the following time periods. Urgent Care Claims - The Claims Administrator shall decide the c laim as soon as feasible, but no later than 72 hours following receipt of the C laim. For Non - Grandfathered Plans, this time should be as soon as possible . If additional information is needed in order to decide the C laim, the Claims Administrator will notify the c laimant w ithin 24 hours and the c laimant shall have at least 48 hours to provide the required information. The Claims Administrator will notify c laimant of its benefit
22 determination within 48 hours after the earlier of: (i) receipt of the required information, or (ii) the expira tion of the period afforded to c laimant to provide the information. In the case of an Adverse Benefit Determination , c laimant will be provided a description of the expe dited claim review process for urgent care c laims. Appeal of an Adverse Benefit Determination shall be decided as soon as feasible, but no later than 72 hours after the Claims Administrator receives the request for review or Appeal. Pre - Service Claim s - A Pre - Service Claim shall be decided within 15 days after the Claims Administrator receives the C laim, although the review period may be extended an additional 15 days if necessary due to circumstances beyond the Claims Administrator ’s control. The c laimant will be notified within the original 15 - day period of the reason for the extension and the date the Claims Administrator expects to render its decision. If the C laimant does not follow a Health Benefit P ro gram’s procedures for filing a Pre - Service Claim , the Claims Administrator must notify the claimant within 5 days of the proper procedures for the claimant to complete the c laim. If the Claims Administrator cannot render a d ecision within 15 days because the c laimant has not provided suffic ient information to review the c laim, the notice of extension must describe the specific info rmation needed to complete the c laim. The c laimant will be given at least 45 days from receipt of this notice to provide the required information. The Claims Administrator has 15 days after it receives the information to render its decision. The Claims Administrator wil l decide an appeal of a denied Pre - Service Claim within 30 days after receiving the request for review; provided, if a Health Benefit P rog ram provides for two levels of a ppeal, the Claims Administrator shall decide each level of a ppeal within 15 days. Concurrent Care Claims - An Adverse Benefit Determination involvi ng Concurrent C are Claim will be made sufficiently in advance of any reduction in or ter mination of treatment to allow the claimant to appeal the Adverse Benefit Determination . If a course of t reatment involves Urgent C are, the c laimant’s request to extend the course of treatment will be decided as soon as possible, but not later than 24 hours after the Claims Administrator receives the request, provided that the request is made at least 24 hours prior to the expiration of treatment. Post - Service Claim s - A Post - Service Claim shall be decided within 30 days after the Claims Administrator receives the C laim. The Claims Administrator may extend the review period for an additional 15 days if necessary due to circumstances beyond the control of the Claims Administrator . The Claims Administrator will notif y the c laimant within the original 30 - day period of the reason for the extension and the date by which the Claims Administrator expects to render its decision. If the Claims Administrator cannot render a d ecision within 30 days because the c laimant has not provided sufficient information to determine whether, or to what extent, benefits are covered or payable under the Health Benefit P rogram, the notice of extension will describe the specific info rmation needed to complete the Claim. The c laimant will be given at least 45 days from receipt of the notice to provide the required information. The Claims Administrator has 15 days from the date of receiving such information to render its decision.
23 An appeal involving a Post - Service Claim shall be decided by the Claims Administrator within 60 days after receiving the request for review; provided, if a Health Benefit P rog ram provides for two levels of a ppeal, the Claims Administrator shall decide each level of Appeal within 30 days. External Review Process For Non - Grandfathered Plans, upon exhaustion of the internal C laims and Appeal procedures, a c laimant may request that the C laim be reviewed under the Non - Grandfathered Plan’s external review process. The Non - Grandfathered Plan shall comply with the applicable s tate external review process, if any, and if none, the federal external review process. If the federal external review process applies, the following guidelines shall apply. The c laimant must file their request for external review within 4 months after receipt of the Final Adverse Benefit Determination . The Claims Administrator will determine whether the C laim is eligible for review under the external review process. This determination is based on whether: 1. The c laimant is or was covered under the Non - Gran dfathered Plan at the time the C laim was made or incurred; 2. The c laimant has exhausted the Non - Grandfathered Plan’s internal Claims and A ppeal procedures; and 3. The c laimant has provided all the information required to process an external review. Within one business day after completion of this preliminary review, the Claims Administrator will provide written notification to the claimant of whether the C laim is eligible for external review. If the request for review is complete but not eligible for external review, th e Claims Administrator will notify the claimant of the reasons for its ineligibility. The notice will include contact information for the Employee Benefits Security Administration at its toll - free number. If the request is not complete, the notice will describe the informati on needed to complete it. The c laimant will have 48 hours or until the last day of the 4 - month filing period, whichever is later, to submit the additional information. If the request is eligible for the external review process, the Claims Administrator will assign it to a qualified Independent Review O rganization (“IRO”). The IRO is responsible for notifying the c laimant, in writing, that the request for external review has been accepted. The notice shoul d include a statement that the c laimant may submit in writing, within 10 business days, additional information the IRO must consider when conducting the review. The IRO will share this information with the Non - Grandfathered Plan. The Non - Grandfathered Plan may consider this information and decid e to reverse its denial of the C laim. If the denial is reversed, the external review process will end. If the Non - Grandfathered Plan does not reverse the denial, the IRO will make its decision on the basis of its review of all of the information in the record, as well as additional information where appropriate and available, such as: 1. The c laimant’s medical records;
24 2. The attending health care professional’s recommendation; 3. Reports from appropriate health care professionals and other documents su bmitted by the Plan or issuer, claimant, or the c laimant’s treating provider; 4. The terms of the Non - Grandfathered Plan; 5. Appropriate practice guidelines; 6. Any applicable clinical review criteria developed and used by the Health Benefit Plan ; and 7. The opinion of the IRO’s clinical reviewer. The IRO must provide written notice to the Non - Grandfathered Plan and the c laimant of its final decision within 45 days after the IRO receives the request for the external review. The IRO’s decision notice must contain: 1. A general description of the reason for the external review, including informat ion sufficient to identify the C laim; 2. The date the IRO received the assignment to conduct the review and the date of the IRO’s decision; 3. References to the evidence or documentation the IRO considered in reaching its decision; 4. A discussion of the principal reason(s) for the IRO’s decision; 5. A statement that the determination is binding and that judicial review may be available to the c laimant; and 6. Contact information for any applicable office of health insurance consumer assistance or ombudsman established under federal guidelines. Generally, a c laimant must exhaust the Non - Grandfathered Plan’s claims and appeal procedures in order to be eligible for the external review process. However, an expedited external review is available if: 1. The c laimant receives an Adverse Benefit Determination that involves a medical condition for which the time for completion of the Non - Grandfathered Plan’s internal claims and appeal procedures would seriously jeopardize the c laimant’s life , health or ability to r egain maximum function and the c laimant has filed a request for an expedited internal review; or 2. The c laimant receives a Final Adverse Benefit Determination that involves a medical condition where the time for completion of a standard external review process would seriously jeopardize the c l aimant’s life , health or the c laimant’s ability to regain maximum function, or if the Final Adverse Benefit Determination concerns an admission, availability of care, continued stay, or health care item or service for which the c laimant received emergency services, but has not been discharged from a facility. I mmediately upon receipt of a request for expedited external review, the Non - Grandfathered Plan must determine and notify the c laimant whether the request satisfies the requirements for expedited review, including the eligibility requirements for external review listed above. If the request qualifies for expedited review, it will be assigned to an IRO. The IRO must make its dete rmination and provide a notice of the de cision as expeditiously as the c laimant’s medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request for an expedited external review. If the original notice of its decision is not in writing, the IRO must provide written confirmati on of the decisi on within 48 hours to both the c laimant and the Non - Grandfathered Plan.
25 MISCELLANEOUS RULES Information to be Furnished by Participants Participants under the Health Benefit Plan must furnish the Plan Administrator with such evidence, data or information, as the Plan Administrator considers necessary or desirable to administer the Health Benefit Plan s . A fraudulent or knowing misstatement or omission of fact made by a p articipant or d epe ndent in an enrollment form, a C l aim for benefits or similar matt er may result in cancellatio n of coverage and/or denial of C laims for benefits. Records As a condition of receiving benefits payable under a Benefit P rogram, a P articipant may be required to provide the Plan A dministrator with any evidence and records of expenses incurred by such Participant and each of such Participant’s Dependents in such form as the Plan Administrator shall from time to time specify. Rescission The Health Benefit P lan s, as Welfare Benefit Pla n s , may not rescind a p articipant's coverage (that is, terminate that coverage retroactively) except in the case of fraud or the individual's intentional mis representation of a material fact, as prohibited by the Plan terms. In such cases of fraud or intentional misrepresentation the Plan will rescind coverage by providing a 30 - day notice of such action. The P lan must provide at least 30 days ’ advance written notice to each participant who would be affected before any coverage may be rescinded. Separately, the P lan may cancel coverage, even retroactively, if the termination of coverage is due to a failure to pay required premiums or contributions toward the cost of coverage on a timely basis . Uniform Rules The Plan Administrator shall administer the Health Benefit Plan s and the Benefit P rograms on a reasonable and nondiscriminatory basis and shall apply uniform rules to all persons in similar situations. No Vested Interest No person shall have any right, title or interest in or to any contributions made under the Health Benefit Plan s and the Benefit P rograms, such contributions being made for the sole purpose of providing benefits under the Benefit P rograms in accordance with their t erms. Neither the Employer , the Plan Administrator , nor any Insurer shall in any way guarantee the payment of any benefit that may be or become due to any person under the Plan or the Benefit P rog rams. Employment Rights Employment r ights of an Employee shall not be deemed to be enlarged or diminished by reason of establishment of, or participation in , the Health Benefit Plan s or any Benefit P rogram , nor shall
26 establishment of the Plan and the Benefit P rograms confer upon any Employee any right to be retained in the service of an Employer. Cost of Plan and Program Administration The costs and expenses incurred in the administration of the Plan and the Benefit P rograms shall be paid, in the discretion of the Plan Administrator , (i) from assets accumulated under the Plan and the Benefit P rograms , if any; (ii) from Employee contribu tions; or (iii) by the Employer and Employee in such proportion as the Employer or the Plan Administrator shall determine. Evidence Evidence required of anyone under the Plan and the Benefit P rograms may be by certificate, affidavit, document , or other information the Plan Administrator considers pertinent and reliable, and signed, made or presented by the proper party or parties. Physical Examination and Autopsy In addition to any rights and privileges granted under a Benefit P rogram , the Plan Administrator , at its own expense, shall have the right and opportunity to have a physician, designated by the Plan Administrator , examine any individual whose injury or sickness is the basis of a claim under the Plan and the Benefit P rograms, when and as often as it may reasonably require during the pendency of a claim or any period of benefits under the Plan and the Benefit P rogra ms and to make an autopsy in case of death, provided it is not otherwise pr ohibited by law. Notwithstanding the foregoing, a Benefit P rogram that is not an excepted Benefit P rogram under ERISA § 732(b), (c) or (d), shall not request or require an individual to undergo a genetic test. Recovery of Benefits If, because of fraud, mistake or any other reason, a person receives a benefit payment under the Plan or a Benefit P rogram that exceeds the benefit payment that should have been made, the Plan Administrator shall have the right to recover the amount of such excess from such person. However t he Plan Administrator may, at its option, deduct the amount of such excess from any subsequent benefits payable to, or for, the Participant or such Participant’s Dependents to whom or on whose behalf the excess payment was made. Lawsuits Concerning Benefits No lawsuit may be brought by any person or entity to recover benefits under the Plan more than three year s from the date P lan benefits are finally denied. Workers’ Compensation Not Affected The Plan is not in lieu of, and does not affect any requirement for, coverage under Workers’ Compensation. Severability In case any provisions of the Plan or any Benefit P rogram shall be held illegal or invalid for any reason, such illegality or invalidity shall not affect the remaining provisions of the Plan or any Benefit P rogram, and the Plan and all Benefit P rograms shall be construed and enforced as if such illegal and invalid provisions had never been set forth in the Plan or Benefit P rogram .
27 Failure to Enforce Failure to enforce any provision of the Plan shall not affect the Employer’s or Plan Administrator ’s right thereafter to enforce such provision, nor shall suc h a failure affect the Employer s ’ or Plan Administrator ’s right to enforce any other provision of the Plan . Indemnification The Employer shall indemnify and hold harmless any person serving as the Plan Administrator (and its delegate) from all claims, liabilities, losses, damages and expenses, including reasonable attorneys' fees and expenses, incurred by such persons in connection with their duties hereunder to the extent not covered by insurance, exce pt when the same is due to such person's own gross negligence, willful misconduct, lack of good faith, or breach of its fiduciary duties under the Plan or ERISA. Acquisition All eligible Employees (including eligible Dependents) of a company acquired by Snelling Walters Insurance Agency are eligible for coverage under this Plan effective on the date of the acquisition, or the termination date of the prior company’s coverage un der, whichever is later. The waiting period will be wived provided the Employee and eligible Dependents were covered under the prior plan on the date of the acquisition. All other provisions of this Plan will apply.
28 SECTION 125 PLAN General If elected in an A doptio n A greement, the Welfare P rograms shall include a Section 125 Plan , which shall permit Employees to choose between cash (or other taxable benefits) and the Health Benefit P r ograms on a non - taxable basis, subject to the requirements of Code § 125 and the regulations thereunder. Eligibility Notwithstanding anything to the contrary contained in any document governing the Section 125 Plan , participation in the Section 125 Plan shall be restricted to E mploy ees, which may include former Employees if permitted in the g overning d ocuments. Irrevocable Elections An Employee’s election under the Section 125 Plan shall be effective for the Plan year, and shall be irrevocable, except to the extent permitted unde r the Governing D ocuments and Treasury Regulation § 1.125 - 4. Additional Required Terms Additional terms required under Code § 125 shall be set forth in the g overning d ocuments for the Section 125 P lan .
29 ELIGIBILITY AND PARTICIPATION REQUIREMENTS Special Enrollment Period Once you are enrolle d , you may make changes to your Benefit Program E lections only during open enrollment or if you have a change in status that affects the eligibility of you or your dependents, and the requested election change corresponds (e.g. if an employee gets married they may add their spouse to the plan) w ith the effect on your eligibility. A Qualified Change in Status includes: • A change in your Legal Marital Status such as marriage, death of a spouse, divorce, legal separation or annulment. • A change in your n umber of d ependents such as birth, a , placement for adoption, or death of a child. • A change in e mployment s tatus such as commencement or termination of employmen t for you, your spous e , or your d ependent. • A change in work s chedule such as a reduction or increase in hours including a switch between part - time and full - time, a strike or lockout, or commencement or return from an unpaid leave of absenc e for you, your spouse , or your d ependent. • If your d ependent satisfies or ceases to satisfy the requirements for u nmarried if applicable . • Dependents due to factors such as age or dependent status . • A change in residence or w orksite for you, your spouse , or your D ependent. • The receipt of a Qualified Child Support Order . • A change in Entitlement to Medicare or Medicaid for you, your spouse or your d ependent. • A change in Eligibility for COBRA for you, your spouse or your d ependent while you are still an active employee. • HIPAA Special Enrollment Opportunities : o Special enrollment opportunities when a current employee or a current employee’s dependent loses other coverage (coverage loss special enrollments) o Special enrollment opportunities due to birth, adoption, or placement for adoption of a child with a current employee or a participant who is not a current employee, or marriage of a current employee or a participant who is not a current employee (new depe ndent special enrollments) o Special enrollment opportunities when a current employee or a current employee’s dependent loses Medicaid or CHIP coverage or becomes eligible for Medicaid or CHIP premium assistance (Medicaid and CHIP special enrollments ) • Health Insurance Premium Payment (HIPP) is also an allowed change . U nder limited circumstances, your Employer may permit you to make a mid - year election change that correspond s to ch anges made by your spouse’s or D ependent’s employer plan (i.e. during the other plan’s open enrollment period ). However, all election changes must be requested within 30 days of the event in question , with the exception of Me dicare/Medicaid change (which must be requested within 60 days of the event in question ) unless stipulated differently by state regulations or by carrier contract .
30 Employee Benefit Eligibility Beginning in 2015, the Affordable Care Act (ACA) imposes a penalty on applicable large employers (ALEs) that do not offer health insurance coverage to substantially all full - time employees and dependents. F ull - Time employees will be measured using the Monthly Measurement Method - The monthly measurement method involves a month - to - month analysis where full - time employees are identified based on their hours of service for each calendar month. This method is not based on averaging hours of service over a prior measurement period. Month - to - month measuring may cause practical difficulties for employers, particularly if there are employees with varying hours or employment schedules, and it could result in employees moving in and out of health plan coverage on a monthly basis Part - Time or Variable Hour employees will be measured using the Look - back Measurement Method - Under the look - back measurement method, an employer counts an employee's hours of service during one period (called a measurement period) to determine their full - time status for a future period (called the stability period). The compan y’s Look - back Measurement Method is defined below. Look - Back Measurement Method The Employer offers coverage under its medical plan (s) to Full - Time Employees. A Full - Time Employee is an E mployee who is employed, on average, for at least 30 hours of service per week or 130 hours of ser vice in a calendar month. Full - Time E mployees may also elect coverage for their spouse, (or domestic partner if allowed) and dependent children up to age 26. T he Employer will use a Look - Back Measurement Method to dete rmine whether an employee is a Full - Time E mployee for purposes of Medical P lan coverage. The Look - Back Measurement Method is based on Internal Revenue Service (IRS) final regulations under the Affordable Care Act (ACA). Its purpose is to provide greater predictability for Medical Plan coverage determinations. The Look - Back Measurement Method applies to E mployees enrolled in a medical plan offered by the Employer . The Look - Back Measurement Method involves three different periods: o A Measurement Period for counting an E mployee’s hours of service (also called a S tandard Measurement Period or an I nitial Measurement Period ); o A Stability Period when the E mployee is either treated as full - time or non - full - time for Plan eligibility purposes; and o An Administrative Period that allows time for Plan enrollment and disenrollment. The Employer establishes how long these periods will last, subject to specified IRS parameters. An ongoing employee is one who has been employed by the Employer for at least one complete S tandard Measurement Period (SMP). If an ongoing employee was employed, on average, for at least 30 hours of service per week (or 130 hours per month) during the SMP, the employee is
31 treated as a full - time employee for a set period into the future, known as the S tability P eriod. This means that, as a general rule, the employee is eligible for Plan coverage during the S tability P eriod, regardless of the employee’s number of hours of service during the S tability P eriod, as long as they remain an employee. Snellings Walters Insurance Agency ’s Initial Measurement Period is : 12 Months Snellings Walters Insurance Agency ’s Initial Administrative Period is : 1 Month Snellings Walters Insurance Agency ’s Initial Stability Period : 12 Months Snellings Walters Insurance Agency ’s Ongoing Measurement Period : 12 Months Snellings Walters Insurance Agency ’s Ongoing Administrative Period : 1 Month Snellings Walters Insurance Agency ’s Ongoing Stability Period : 12 Months Employee Eligibility Due to Status Change from Part - Time to Full - Time In addition to utilizing the Look - Back Measurement Method to determine eligibility for health benefits (described above), there is an additional opportunity for an employee to become eligible under the Medical P lan. Specifically, employees who are deemed part - time under the Look - Back Measurement Method but who are formally promoted into a permanent, full - time position will be eligible to enroll in medical benefits under the Plan p er the eligibi lity criteria set forth in the M edical Plan Information Section of the Document. Employee Eligibility Due to Status Change from Full - Time to Part - Time Medical Plan benefits for an employee who has a change in status from full - time to part - time will remain qualified for benefits for the remaining portion of the current stability period. Benefits should not be cancelled in this situation until the end of the stabilit y period in which the employee moves into the part - time position. However, t he employer is allowed to switch to the monthly measurement method for an employee for a period of 3 months, during which time they cannot exceed 30 hours per week for any week, moving to part - time starting with the first day of the 4th full month after th e employee moves to a part - time position Proof of Dependent Eligibility The Employer reserves the right to verify that your dependent is eligible or continues to be eligible for coverage under the Plan’s Benefit Programs. If you are asked to verify a dependent’s eligibility for coverage, you will receive a notice describing the documents that you need to submit. To ensure that coverage for an eligible dependent continues without interruption, you must submit the required proof within the designated timeframe. To make an election ch ange, contact your Plan Administrator .
32 COBRA Continuation of benefits under COBRA Qualified Beneficiaries shall have all continuation rights required by the Consolidated Omnibus Budget Reconciliation Act (“COBRA”) for group health plan benefits offered under Welfare Program s . To the extent a Welfare Program offering health benefits does not specify COBRA Continuation Coverage rights in accordance with Code Section 4980B, the Plan shall be administered in accordance with Code Section 4980B and 29 CFR Part 2590.606 - 1 through 2590.606 - 4, with respect to the final COBRA notice rules and regulations for group health plans. In addition, the Plan Administrator shall adopt such policies and provide such forms, as it deems advisable to implement the rights contemplated by this Section. Other Options You may have other options available to you when you lose group health plan 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, y ou 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. Election of COBRA COBRA Continuation Coverage for Terminated Participants In the event a Covered Employee, Qualified Dependent or Qualified Beneficiary experiences a Qualifying Event, the Plan Administrator shall provide notice of COBRA Continuation Coverage that shall inform such individual of their rights and obligations with respect to COBRA Continuation Coverage under the Plan . A Qualified Beneficiary who is a Covered Employee may elect COBRA Continuation Coverage, at their own expense, if their participation under the Plan would terminate as a result of either of the following Qualifying Events: a. termination of employment (other than for gross misconduct); or b. reduction of hours of employment with the Employer. COBRA Continuation Coverage for Qualifying Dependent A Qualified Beneficiary who is a Qualifying Dependent of a Covered Employee may elect COBRA Continuation Coverage, at their own expense : • Qualifying Events for Spouses o Voluntary or involuntary termination of the covered employee's employment for any reason other than gross misconduct. o Reduction in the hours worked by the covered employee below plan eligibility requirements.
33 o Covered employee becoming entitled to Medicare. o Divorce or legal separation of the covered employee. o Death of the covered employee. • Qualifying Events for Dependent Children o Loss of dependent child status under the plan rules. o Voluntary or involuntary termination of the covered employee's employment for any reason other than gross misconduct. o Reduction in the hours worked by the covered employee below plan eligibility requirements. o Covered employee becoming entitled to Medicare. o Divorce or legal separation of the covered employee. o Death of the covered employee A Qualified Beneficiary (or a third party on behalf of the Qualified Beneficiary) must complete and return the required COBRA election enrollment materials within a maximum of sixty (60) days from the later of: a. loss of coverage; or b. the date the Plan Administrator sends notice of eligibility for COBRA Continuation Coverage. The Employer shall, in the event of a Qualifying Event that is either a Termination of Employment (other than for gross misconduct) or a reduction of hours, notify the Plan Administrator (or its designee) within thirty (30) days of the later of the date of the Qualifying Event or the date tha t coverage under the Plan ends. Such notice shall be given in a form and manner as determined by the Plan Administrator, in its sole discretion, in compliance with applicable law. The Plan Administrator shall then notify the Covered Employee and all covered Dependents of their right to elect COBRA Continuation Coverage within fourteen (14) days of such notice from the Employer. Failure to enroll for COBRA Continuation Coverage during this maximum sixty (60) day period will terminate all rights to COBRA Continuation Coverage under this Plan and such right to COBRA Continuation Coverage shall not be reinstated. A separate election as to what health coverage, if any, is desired may be made by or on behalf of each Qualified Beneficiary. However, an affirmative election of COBRA Continuation Cov erage by a Covered Employee or their Spouse shall be deemed to be an election for that Covered Employee’s Qualifying Dependents who would otherwise lose coverage under the Plan , unless the election specifically provides to the contrary. Elections for COBRA Continuation Coverage may be made by the Qualified Beneficiary or on their behalf by a third party (including a third party that is not a Qualified Beneficiary). In the event the Plan Administrator determines that a Covered Employee, Qualified Dependent or Qualified Beneficiary who has furnished a notice of Qualifying Event, second Qualifying Event or disability determination is not entitled to COBRA Continuation Coverage, the Plan Administrator shall provide a notice of unavailability of COBRA Continuation Coverage to such affected individual in accordance with 29 CFR Part 2590.606 - 4(c).
34 Period of COBRA Coverage A Qualified Beneficiary who qualifies for COBRA Continuation Coverage as a result of Termination of Employment (other than for gross misconduct) or reduction in hours of employment, may elect COBRA Continuation Coverage for up to eighteen (18) months (Federal COBRA) , ( thirty - six (36) months in the State of New York ) , measured from the date of the Qualifying Event. With respect to all other Qualifying Events, a Qualified Beneficiary who is a Qualifying Dependent may continue COBRA Continuation Coverage for up to thirty - six (36) months from the date of the Qualifying Eve nt. A Qualified Beneficiary who properly elects and renders payment for the initial Continuation Coverage Contribution shall have such COBRA Continuation Coverage effective on the date of the Qualifying Event. Coverage under this Section may be terminated early and may not continue beyond certain deadlines based on : a. the date on which the Employer ceases to maintain a group health plan; b. the last day of the month for which premium payments have been made, if the individual fails to make premium payments on time, in accordance with this Plan; c. the date the Qualified Beneficiary, after the date they elect COBRA Continuation Coverage, first becomes enrolled in Medicare; d. the date the Qualified Beneficiary, after the date they elect COBRA Continuation Coverage , first becomes covered under another group health plan and is no longer subjected to a pre - existing condition exclusion or limitation under the Qualified Beneficiary’s other coverage or new employer plan; or e. in the case of a disabled Qualified Beneficiary (and their disabled or non - disabled family members) receiving COBRA Continuation Coverage under the eleven (11) month extended coverage extension , the first day of the month that begins more than thirty (30) days after the date the Qualified Beneficiary is determined by the Social Security Administration to no longer be “disabled” within the meaning of the Social Security Act. In the event the Plan Administrator terminates COBRA Continuation Coverage of a Qualified Beneficiary prior to the end of the maximum available Continuation Coverage Period, the Plan Administrator shall provide a notice of such termination to each affected Qualified Beneficiary in accordance with 29 CFR Part 2590.606 - 4(d). Contribution Requirements for Coverage Qualified Beneficiaries who elect COBRA Continuation Coverage as a result of a Qualifying Event (or third parties on behalf of a Qualified Beneficiary) will be required to pay Continuation Coverage Contributions. Qualified Beneficiaries (or third parties on behalf of a Qualified Beneficiary) must make the Continuation Coverage Contributions monthly on or prior to the first day of the month of such coverage. However, a Qualified Beneficiary has forty - five (45) days from the date of an affirmative election to pay the Continuation Coverage Contributions for the first month plus the cost for the period between the date health coverage would otherwise have terminated due to the Qualifying Event and the date the Qualified Beneficiary actually elect s COBRA Continuation Coverage. If the Qualified Beneficiary fails to make the Continuation
35 Coverage Contribution for the first month’s premium, coverage will either terminate or will be retroactively cancelled. The Qualified Beneficiary shall have a thirty (30) day grace period from the due date (the first of each month) to make the Continuatio n Coverage Contributions due for such m onth. Continuation Coverage Contributions must be postmarked on or before the end of the thirty (30) day grace period. The thirty (30) day grace period shall not apply to the forty - five (45) day perio d for payment of COBRA premiums as applicable to initial elections. If Continuation Coverage Contributions are not made on a timely basis, COBRA Continuation Coverage will terminate as of the last day of the month for which such premiums were made on a timely basis. Once terminated, COBRA Continuation Coverage shall not be reinstated. The Continuation Coverage Contribution shall be on e hundred percent (100%) of the cost of coverage plus a two percent (2%) administrative fee for a total contribution of one hundred two percent (102%) of the cost of coverage. If timely payment of the Continuation Coverage Contribution is made to the Plan in an amount that is not significantly less than the amount due for a period of coverage, then the amount paid is deemed to satisfy the Plan ’s requirement for the amount that must be paid for Continuation Coverage Contribution, unless the Plan notifies the Qualified Beneficiary of the amount of the deficiency and grants a reasonable period of time (thirty (30) days) for payment of the deficiency to be made. For purposes of this Section of this Plan, an amount not significantly less than the amount the Plan requires to be paid shall be defined as the lesser of fifty dollars ($50) or ten percent (10%) of the required payment amount. Limitation on Qualified Beneficiary's Rights to COBRA Continuation Coverage If a Qualified Beneficiary loses, or will lose health coverage under the Plan as a result of divorce, legal separation or ceasing to be a Dependent, such Qualified Beneficiary or the Covered Employee must notify the Plan Administrator within a maximum of sixty (60) days of the divorce, legal separation or loss of Dependent status. Such notice shall be required to comply with the Plan ’s notice procedures as contemplated by this Plan, in accordance with applicable law. Failure to make timely notification shall result in a termination of the Qualified Beneficiary’s rights to COBRA Continuation Coverage under this Plan ; such right shall not be reinstated. A Qualified Beneficiary must notify the Plan Administrator of the birth to, adoption or placement for adoption of a child with a Covered Employee receiving COBRA Continuation Coverage. The notice must be provided within a maximum of thirty (30) days of the child’s birth, adoption or placement for adoption with the Qualified Beneficiary, subject to the Plan ’s notice procedures . Extension of COBRA Continuation Coverage Period If a second Qualifying Event that is not a Termination of Employment or reduction in hours occurs during an eighteen (18) month extension period explained above , coverage may be continued for a maximum of thirty - six (36) months from the date of the first Qualifying Event for the affected Qualifying Dependent. A second Qualifying Event will result in an extension of the initial Continuation Coverage Period if such Qualifying Event would have resulted in a loss of coverage under the Plan had the first Qualifying Event not occurred. Such extension of COBRA Continuation Coverage applies only to Qualifying Dependents. Therefore, such extension would apply to a child
36 adopted by or placed for adoption with a Qualified Beneficiary, but would not apply to a Spouse who was added to a Qualified Beneficiary’s COBRA Continuation Coverage as a result of the Qualified Beneficiary’s becoming married after commencement of the ini tial eighteen (18) month continuation period. Notwithstanding the foregoing, terminating employment after a Qualifying Event that is a reduction in hours of employment does not extend the maximum Continuation Coverage Period beyond eighteen (18) months of COBRA Continuation Coverage. The maximum COBRA Continuation Coverage Period is extended up to eleven (11) months for Qualified Beneficiaries (and their disabled or non - disabled family members receiving COBRA Continuation Coverage due to the same Qualifying Event) for up to twenty - nine (29) months in total (measured from the date of the Qualifying Event), provided the following requirements are met: a. the Social Security Administration determines that the Qualified Beneficiary was “disabled” on the date of the Qualifying Event or anytime within the first sixty (60) days of COBRA Continuation Coverage ; and b. the disabled Qualified Beneficiary provides evidence to the Plan Administrator of such Social Security Administration determination within sixty (60) days of the date of such determination but not later than the last day of the initial eighteen (18) month period of COBRA Continuation Coverage in a manner consistent with the Plan ’s reasonable notice procedures as contemplated by this Plan. Failure to notify the Plan Administrator of such determination within the time period stated above will result in the loss of the Qualified Beneficiary’s right to an extension of the initial eighteen (18) month period of COBRA Continuation Coverage and such right will not be reinstated. In such event, if the disabled Qualified Beneficiary is receiving COBRA Continuation Coverage, the Continuation Coverage Contribution shall be one hundred fifty percent (150%) of the cost of coverage for the nineteenth (19th) through twenty - ninth (29th) month of COBRA Continuation Coverage. Otherwise, the Continuation Coverage Contribution shall continue to be one hundred two percent (102%) of the cost of coverage for the nineteenth (19th) through twenty - n inth (29th) months of coverage. However, if a Qualified Beneficiary who meets the above requirements receives a final determination from the Social Security Administration that they are no longer disabled, the Qualified Beneficiary must notify the Plan Administrator within thirty (30) days of the date of that determination in a manner consistent with the Plan ’s notice procedures as contemplated by this Plan . Such a final determination shall end the disability extension of COBRA coverage for all Qualified Beneficiaries as of the later of either: (i) the first day of the month following thirty days (30) from the final determination date or (ii) the end of the Continuation Coverage Period without regard to the disability extension. Responses to Informati on Regarding Qualified Beneficiary’s Right to Coverage If a provider of health care (such as a physician, hospital, or pharmacy) contacts the Plan to confirm coverage of a Qualified Beneficiary during the COBRA Continuation Coverage election period, the Plan will give a complete response to the health care provider about the Qualified Beneficiary’s COBRA Continuation Coverage rights during the election period, and his right to retroactive coverage if COBRA Continuation Coverage is elected. If a provider of he alth care (such as a
37 physician, a hospital or pharmacy) contacts the Plan to confirm coverage of a Qualified Beneficiary with respect to whom the required payment has not been made for the current period, but for whom any applicable grace period has not expired, the Plan will inform the health care provider of all of the details of the Qualified Beneficiary’s right to pay for such coverage during the applicable grace period. Coordination of Benefits - Medicare and COBRA For purposes of this Section , “Medicare Entitlement” means being entitled to Medicare due to either: (1) enrollment (automatically or otherwise) in Medicare Parts A or B, or (2) being medically determined to have end - stage renal disease ("ESRD"), and (a) having applied for Medicare P art A; (b) having satisfied any waiting period requirement and (c) being either (i) insured under Social Security, (ii) entitled to retirement benefits under Social Security or (iii) a spouse or dependent of a person satisfying either (i ) or (ii). Such Medicare entitlement is a COBRA terminating event. If you already have COBRA when you enroll in Medicare , your COBRA coverage usually ends on the date you enroll in Medicare. Your spouse and dependents may keep COBRA for up to 36 months, regardless of whether you enroll in Medicare during that time. If you already have Medicare when you become eligible for COBRA , you will be allowed to enroll in COBRA subjec t to specific language in the Governing Documents . Relocation and COBRA Coverage If a Qualified Beneficiary moves outside the service area of a region - specific group health benefit package, alternative coverage, if available to similarly situated active Employees, will be made available to the Qualified Beneficiary no sooner than the date of the Qualified Beneficiary’s relocation, or if later, the first day of the month following the month in which the Qualified Beneficiary requests the alternative coverage. COBRA Coverage and HIPAA Special Enrollment Rules Once a Qualified Beneficiary is receiving COBRA Continuation Coverage, the Qualified Beneficiary has the same right to enroll family members under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) rules as if the Qualified Beneficiary were an Employee or Participant in the Plan , provided that such family members do not become Qualified Beneficiaries, and who are therefore eligible to elect COBR A Continuation Coverage in their own right. Election of COBRA Continuation Coverage by a Qualified Beneficiary may serve to bridge coverage between this Plan and any future coverage under another group health plan . Procedures for Providing Notices The Plan Administrator shall establish procedures for the furnishing of notices required by a Covered Employee, Qualifying Dependent or Qualified Beneficiary to the Employer and/or Plan Administrator including Qualifying Event notices, notice of disability determination or Medicare entitlement, change in disability determination, and Medicare entitlement. Such procedures may: be described in the Plan ’s Summary Plan Description ; specify the individual or entity designated to receive such notices; specify the form and means of delivery of such notices (including requiring the use of certain forms when submitting such notices); describe the information required by the Plan to provide COBRA Continuation Coverage rights; and shall comply with
38 applicable federal laws regarding requirements for timing and content of such notices. Moreover, the Plan Administrator may select or appoint another entity or individual to handl e COBRA administration, where applicable. COBRA Definitions For purposes of this Section only, the following definitions shall apply: (a) “COBRA” means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended. (b) “COBRA Continuation Coverage” means the coverage elected by a Qualified Beneficiary as of the date of a Qualifying Event. This coverage shall be the same as the health coverage provided to Similarly Situated Beneficiaries who have not experienced a Qualifying Event as of the date the Qualified Beneficiary experiences a Qualifying Event. If the provisions of this Plan are modified for Similarly Situated Beneficiaries, such coverage shall also be modified in the same manner for all Qualified Beneficiaries as of the same date. Open enrollment rights extended to active Employees will also be extende d to Similarly Situated Qualified Beneficiaries. (c) “Continuation Coverage Contribution” means the amount of premium contribution required to be paid by or on behalf of a Qualified Beneficiary for COBRA Continuation Coverage. (d) “Continuation Coverage Period” means the applicable time period for which Continuation Coverage may be elected. (e) “Covered Employee” means an Employee covered under this Plan on the day prior to the Qualifying Event. If an individual who otherwise would be a Covered Employee is denied coverage under the Plan in violation of applicable law, including HIPAA, the individual is considered a Covered Employee. (f) “Annual Enrollment Period” means a period during which an Employee covered under the Plan can choose to be covered under another Plan or under another benefit option within the same plan, or add or eliminate coverage of family members. (g) “Qualified Beneficiary” means a Covered Employee or Qualifying Dependent. (h) “Qualifying Dependent” means: i. a Covered Employee’s Spouse or Dependent child covered under this Plan on the day prior to the Qualifying Event; or ii. a Dependent child who is born to, adopted by or placed for adoption with a Covered Employee during the Covered Employee’s period of COBRA Continuation Coverage. (i) “Qualifying Event” means any of the following events which would otherwise result in a Covered Employee’s or a Qualifying Dependent’s loss of health coverage in the absence of this provision: i. a Covered Employee’s Termination of Employment, for any reason other than gross misconduct;
39 ii. a Covered Employee’s reduction in work hours resulting in a change of status such that the Covered Employee is no longer eligible to be a Covered Employee; iii. a Covered Employee’s divorce or legal separation; iv. a Qualified Dependent ceasing to qualify as a Dependent under the provisions of this Plan; v. a Covered Employee’s entitlement to benefits under Medicare; vi. the death of a Covered Employee; or vii. the failure of a Covered Employee to return from FMLA leave. Loss of coverage includes any increase in the premium or contribution that must be paid by the Covered Employee (or Spouse or Dependent) for coverage under the Plan that results from the occurrence of one of the events listed above in subsections (i) – (vii). The loss of coverage need not occur immediately after the event, so long as the loss of coverage occurs before the end of the maximum COBRA Continuation Coverage period. If coverage is reduced or eliminated in anticipation of an event, such reduction or elimination is disregarded in determining whether the event causes a loss of coverage. (j) “Similarly Situated Beneficiaries” means Employees or their Dependents, as applicable, who are Participants in this Plan .
40 BENEFIT PLAN PROVISIONS All documents relating to th e Snellings Walters Insurance Agency Welfare Benefit Plan , including the Evidence/Certificate of Coverage for each plan, Listing of Network Providers, Contribution Rates, General COBRA Notice , General HIPAA , Medicare Creditable Coverage Notice and any other relevant Plan Documents or Notices, are available to employees and their dependents . Plan participants may receive a paper copy of any of the above documents free of charge by contacting the Plan Administrator . In addition to this Wrap Document p lease refer to the applicable Subsidiary Contract and any other applicable plan document for each Welfare Program’s specific details. These documents will include the description of benefits, cost - sharing provisions, requirements for use of network providers and circumstances by which benefits may be excluded or denied . STATUTORY PROVISIONS Family and Medical Leave Act (FMLA) To be eligible for FMLA leave, employees must have worked for covered employers for a total of 12 months (which do not need to be consecutive) and for at least 1,250 hours in the previous 12 months , immediately preceding the leave . The 1,250 - hour threshold can be met whether employees work full - time or part - time. Employers with multiple worksites are covered by FMLA if the worksites are within a 75 - mile radius of each other and the number of employees equals 50 or more by counting employees at all worksites. The 75 - mile radius is measured in surface miles, rather than linear miles. If you go on a qualified unpaid leave under the Family and Medical Leave Act of 1993 (FMLA), the following rules will apply. Only to the extent required by FMLA (among other things, this means only for the duration of a qualifying leave), the employer will continue to maintain your health plan benefits on the same terms and conditions as though you were still an active employee. Except as otherwise provided by FMLA, your Plan participation will cease when the Plan Administrator learns that you do not intend to return to work after your leave. Y our Plan participation will immediately cease upon expiration of your FMLA leave, if you fail to return to work at such time , unless otherwise required by federal, state , or local law . Except as otherwise provided in the FMLA, if you fail to return to work after the FMLA leave, you will be required to reimburse the Employer for the cost of the coverage provided to you while you were on FMLA leave (the cost equals the COBRA premium, without a 2% add - on, and minus any employee contribution you already made). For more information on FMLA, please contact the Employer, where you may obtain a summary of your rights under FMLA without charge. The Employer has the responsibility to provide you with prior written notice of the terms and conditions under which payment must be made. Failure to make payment within 30 days of the due date established by your Employer will result in the termination of coverage. If coverage is terminated for failure to make payments while you are on an approved F amily or Medical L eave of A bsence, coverage for you and your eligible dependents will be automatically reinstated on the date you return to employment if you and your dependents are otherwise eligible
41 under the Plan . Any waiting period for pre - existing conditions or other waiting periods will not apply. However, all accumulated annual and lifetime maximums will apply. The Plan intends to comply with all existing FMLA regulations. If , for some reason , the information presented differs from actual FMLA regulations, the Plan reserves the right to administer the FMLA in accordance with such actual regulations. Military Leave Coverage The Uniformed Services Employment and Reemployment Rights Act (USERRA) establishes requirements that employers must meet for certain employees who are involved in the uniformed services . As used in this provision, “Uniformed Services” means: o The Armed Forces; o The Army National Guard and the Air National Guard when engaged in active duty for training, inactive duty training, or full - time National Guard duty (pursuant to orders issued under federal law); o The commissioned corps of the Public Health Service; and o Any other category of persons designated by the President in time of war or national emergency. As used in this provision, “Service in the Uniformed Services” or “Service” means the performance of a duty on a voluntary or involuntary basis in a Uniformed Service under competent authority and includes: o Active duty; o Active duty for training; o Initial active duty training; o Inactive duty training; o Full - time National Guard duty ; o A period for which you are absent from your job for purpose of an examination to determine your fitness to perform any such duties; o A period for which you are absent from your job for the purpose of performing certain funeral honors duty; and o Certain service by intermittent disaster response appointees of the National Disaster Medical System (NDMS). If you were covered under this Plan immediately prior to taking a leave for Service in the Uniformed Services, you may elect to continue your coverage under USERRA for up to 24 months from the date your leave for uniformed service began, if you pay any req uired contributions toward the cost of the coverage during the leave. This USERRA continuation coverage will end earlier if one of the following events takes place: o You fail to make a premium payment within the required time;
42 o You fail to report to work or to apply for reemployment within the time period required by USERRA following the completion of your service; or o You lose your rights under USERRA, for example, as a result of a dishonorable discharge. If the leave is 30 days or less, your contribution amount will be the same as for active employees. If the leave is longer than 30 days, the required contribution will not exceed 102% of the cost of coverage. Coverage continued under this provision runs c oncurrently with coverage described above under the section entit led “COBRA ”. If your coverage under the Plan terminated because of your Service in the Uniformed Services, your coverage will be reinstated on the first day you return to employment if you are released under honorable conditions and you return to employment within the time period(s) required by USER RA. When coverage under the Plan is reinstated, all of the Plan ’s provisions and limitations will apply to the extent that they would have applied if you had not taken military leave and your coverage had been continuous. This waiver of limitations does not provide coverage for any illness or injury caused or aggrava ted by your military service, as determined by the V eterans A dministration (VA) . ( For complete information regarding your rights under USERRA, contact your Employer . ) The Plan intends to comply with all existing regulations of USERRA. If , for some reason , the information presented in the Plan differs from the actual regulations of USERRA, the Plan reserves the right to administer the Plan in accordance with such actual regulations. Leave o f Absence Mandated Under State And Local Laws The Plan may be required to maintain coverage for an employee based on the provisions of applicable state or local laws. Such laws may allow employees protected leave for various reasons such as sick leave, family leave, parental leave, domestic violence l eave or other reasons mandated by state and local statutes. BENEFIT CONTIN UATION PROVISIONS FOR NO N - STATU TORY LEAVE OF ABSENCE Coverage under the plan may be continued under the provisions of applicable company policy. The Plan may allow an employee to remain covered when a leave of absence is needed for personal or medical reasons and when the employee does not qualify for leave under statute such as FMLA or USERRA or state /local statu t e as noted above. There may be limits to the amount of time the employee may remain on the plan as an active participant and after such time, the employee may be offered continuation of coverage under federal COBRA or state continuation of coverage provisions. Please refer to the c ompany’s Employee Handbook for specific provisions related to such non - statutory leaves of absence. AFFORDABLE CARE ACT The Plan will also comply with stability rules under the Affordable Care Act (ACA), where the employee may still be able to maintain coverage under the plan outside of a leave of absence provided for under statute or under applicable company policy.
43 AMENDMENT OR TERMINATION OF THE PLAN As Plan Sponsor, the Employer has the right to amend or terminate the Plan at any time. You have no vested or permanent rights or benefits under the Plan . Plan benefits will typically change from year - to - year and you should examine all materials provided to you each year to determine the benefits of the Plan . No Contract of Employment The Plan is not intended to, and does not, either directly or indirectly constitute any form of employment contract or other employment arrangement between you and Employer. Other Materials The Certificate of Coverage (including the Member Payment Summary, and the Provider & Facility Directory) issued by Plans are part of the Summary Plan Description . Please refer to these materials for other important provisions regarding your participation in the Plan .
44 HIPAA PRIVACY AND SECURITY STANDARDS General If a Health Benefit P rogram is not exempt from the requirements of the Privacy Standards and the Security Standards of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) , then this Section shall apply. The Plan also intends to comply with any applicable state laws relating to privacy and security. Privacy and Security Standards The Plan shall not disclose Protected Health Information (PHI) to any member of an Employer’s workforce unless each of the conditions set out in this Section are met. PHI shall have the same definition as set forth in the Privacy Standards but generally shall mean individually identifiable information about the past, present or future physical or mental health or condition of an individual, including information about trea tment or payment for treatment. PHI shall include “genetic information,” as defined in the Privacy Standards. “Electronic Protected Health Information” shall have the same definition as set out in the Security Standards, but generally shall mean Protected Health Information that is transmi tted by or maintained in electronic media. PHI disclosed to members of the Employer’s workforce shall be used or disclosed by the Employer only for purposes of Plan administrative functions. The Plan ’s administrative functions shall include all Plan treatment, payment functions and health care operations. The terms “treatment,” “payment” and “health care operations” shall have the same definitions as set out in the Privacy Standards, but the term “pa yment” shall include activities taken to determine or fulfill Plan responsibilities with respect to eligibility, coverage, provision of benefits, or reimbursement for health care. Genetic information shall not be used or disclosed for “underwriting” purpos es, as defined in the Privacy Standards. The Plan shall disclose PHI only to members of the Employer’s workforce who are authorized to receive such PHI , and only to the extent and in the minimum amount necessary for that person to perform their duties with respect to the Plan . “Members of the Employer’s workforce” shall refer to all employees and other persons under the control of the Employer. The Employer shall keep an updated list of those authorized to receive PHI . 1) An authorized member of the Employer’s workforce who receives Protected Health Information shall use or disclose the Protected Health Information only to the extent necessary to perform their duties with respect to the Plan . 2) In the event that any member of the Employer’s workforce uses or discloses Protected Health Information other than as permitted by this Section and the Privacy Standards, the incident shall be reported to the Plan ’s Privacy Officer. The Privacy O fficer shall take appropriate action, including: a) investigation of the incident to determine whether the breach occurred inadvertently, through negligence or deliberately , whether there is a pattern of breaches , and the degree of harm caused by the breach;
45 b) appropriate sanctions against the persons causing the breach which, depending upon the nature of the breach, may include oral or written reprimand, additional training, or termination of employment; c) mitigation of any harm caused by the breach, to the extent practica l ; and documentation of the incident and all actions taken to resolve the issue and mitigate any damages. 3) By executing the Welfare Benefit Plan Adoption A greement that accompanies this document , the Employer and all affiliated Employers agree to: a) Not use or further disclose the PHI other than as permitted or required by the Plan documents or as required by law; b) Implement reasonable and appropriate administrative, physical and technical safeguards to protect the confidentiality, integrity and availability of Electronic Protected Health Information that the Employer creates, maintains or transmits on behalf of the Plan ; c) Ensure that any agent or subcontractor, (i) to whom it provides Protected Health Information received from the Plan , agrees to the same restrictions and conditions that apply to the Employer with respect to such information, and/or (ii) to whom it provides Electronic Protected Health Information shall agree, in writing, to implement reasonable and appropriate security measures to protect the Electronic Protected Health Information ; d) Not use or disclose PHI for employment - related actions and decisions or in connection with any other benefit or employee benefit plan of the Employer; e) Report to the Plan any use or disclosure of the PHI of which it becomes aware that is inconsistent with the uses or disclosures permitted by this Section, or required by law; f) Make available PHI to individual Plan members as required by Section 164.524 of the Privacy Standards; g) Make available PHI for amendment by individual Plan members and incorporate any amendments to Protected Health Information as required by Section 164.526 of the Privacy Standards; h) Make available the PHI required to provide an accounting of disclosures to individual Plan members as required by Section 164.528 of the Privacy Standards; i) Make its internal practices, books and records relating to the use and disclosure of PHI received from the Plan available to the Department of Health and Human Services for purposes of determining compliance by the Plan with the Privacy Standards; j) If feasible, return or destroy all PHI received from the Plan that the Employer still maintains in any form, and retain no copies of such information when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible; and
46 k) Ensure the adequate separation between the Plan and members of the Employer’s workforce, as required by Section 164.504(f)(2)(iii) of the Privacy Standards and set out in (d) above, and to use reasonable and appropriate security measures to comply with this provision. HIPAA 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 elig ibility 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 you 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, o r placement for adoption. To request special enrollment or obtain more information, contact: Snellings Walters Insurance Agency 5 Concourse Parkway, Suite 2700 Atlanta , GA 30328 Phone: 4705144868
47 STATEMENT OF ERISA RIGHTS As a participant in the Plan (which is a type of E mployee Welfare Benefit Plan called a “group health plan”) you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all group health plan participants shall be entitled to: Receive Information About Your Plan and Benefits Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as worksites and union halls, all documents governing the Plan , including insurance contracts and if applicable, collective bargaining agreements, and a copy of the latest A nnual R eport (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan , including insurance contracts and if applicable, collective bargaining agreements, and copies of the latest A nnual R eport (Form 5500 Series) and updated Summary Plan Description . The Plan Administrator may make a reasonable charge for the copies. Medical Loss Ratio (MLR) In certain circumstances under the Medical Loss Ratio Standards in section 2718 of the Patient Protection and Affordable Care Act of 2010 (PPACA), rebates may be paid to this Plan. The federal law requires that the issuer of the rebate (the insurance company) provide you a written notice of a rebate, at the time the rebate is paid to the Plan . The rebate will be prorated between the amount attributable to Plan costs paid by the Plan Sponsor and Plan costs paid by participants. The participant portion of the rebate will be used for the benefit of the Plan participants. This can be done by a number of actions, including but not limited to lowering the Plan costs for the participants for the next Plan Year, applied towards the cost of administering the Plan , paid as taxable income to the participants, or in any manner that allocates the rebate to Participants based on each Participant’s actual contributions, or to apportion it on any other reasonable basis . Continue Group Health Plan Coverage To c ontinue health care coverage for yourself, legal spouse defined by Federal and State Law , or dependents if there is a loss of coverage under the Plan as a result of a Qualifying Event. You or your dependents may have to pay for such coverage. Review this Summary Plan Description Wrap Document and the documents governing the Plan on the rules governing your COBR A C ontinuation C overage R ights. Qualified Medical Child Support Order Procedures If a Health Benefit P rogram is subject to ERISA § 609(a), then this Section shall apply. Such Health Benefit P rogram shall provide benefits in accordance with the terms of a Q ualified M edical C hild S upport O rder that meets the requirements of ERISA § 609(a). Each Health Benefit P rogram shall establish reasonable written procedures to determine whether a medical child support order is a Q ualified M edical C hild S upport O rder . Such procedures shall be made av ailable upon request of a p articipant at no charge .
48 Medicaid If a Health Benefit P rogram is subject to ERISA § 609(b), then this Section shall apply. Payment for benefits with respect to a p articipant under a Health Benefit P rogram will be made in accordance with any assignment of rights made by or on behalf of such participant or a beneficiary of the participant as required by a state plan for medical assistance approved under title XIX of the Social Security Act pursuant to Section 1912(a)(1)(A) of such Act (as in effect on the date of the enactment of the Omnibus Budget Reconciliation Act of 1993). a. The fact that a p articipant is eligible for or is provided medical assistance under a State plan for medical assistance approved under title XIX of the Social Security Act will not be taken into account in enrolling such Participant or in determining or making benefit paym ents for such Participant. b. To the extent that payment has been made under a State plan for medical assistance approved under title XIX of the Social Security Act in any case in which a Health Benefit P rogram has a legal liability to make payment for items or services con stituting such assistance, payment for benefits under such program will be made in accordance with any State law which provides that the State has acquired the rights with respect to a Participant to such payment for such items or services. Newborn and Mothers Health Protection Act Group H ealth P lans 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 fol lowing 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 issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). Mental Health Parity and A ddiction E quity A ct A Health Benefit P rogram that provides both medical and surgical benefits and mental health and/or substance abuse benefits shall not impose any limits on mental health or substance abuse benefits that violate the requirements of ERISA § 712. Women ’ s Health and Cancer Rights Act If a Health Benefit P rogram is subject to ERISA § 713 and provides medical and surgical benefits with respect to a mastectomy, then this Section shall apply. Such Health Benefit P rogram shall, with respect to a participant who is receiving benefits in connection with a mastectomy, and who elects breast reconstruction in connection with such mastectomy, provide coverage for the following (subject to applicable ded uctibles, copayments and other H ealth B enefit P rogram limitations): 1) reconstruction of the breast on which the mastectomy has been performed; 2) surgery and reconstruction of the other breast to produce a symmetrical appearance;
49 3) prostheses ; and 4) treatment of physical complications for all stages of mastectomy, including lymphedemas; in a manner determined in consultation with the attending physician and the patient. This Plan complies with these requirements. Benefits for these items generally are comparable to those provided under this Plan for similar types of medical services and supplies. Of course, the extent to which any of these items is appropriate following mastectomy is a matter to be determined by consultation between the attending physician and the patient. The Plan neither imposes penalties (for example, reducing or limiting reimbursements) nor provides incentives to induce attending providers to provide care inconsistent with these requirements . Patient Protection and Affordable Care Act Notice If a Health Benefit P rogra m is not exempt under ERISA § 732 from the requirements of Title I of the Patient Protection and Affordable Care Act of 2010, the Health Benefit P rogr am shall be operated in accordance with such requirements. If the Plan s and issuers require or allow for the designation of primary care providers b y participants or beneficiaries : Employer ’ s medical plan requires/allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accep t you or your family members. If the Plan or health insurance coverage designates a primary c are provider automatically, u n til you make this designation, the G roup H ealth P lan or health insurance issuer will designate one for you. For information on how to select a primary care provider, and for a list of the participating prima ry car e providers, contact the Plan A dministrator or issuer. If the Plan s and issuers require or allow for the designation of a primary care provider for a child ; you may designate a pediatrician as the primary care provider. If the Plan s and issuers that provide coverage for obstetric or gynecological care and require the designation by a participant or beneficiary of a primary care provider : You do not need prior authorization from the Group Health Plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre - approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who special ize in obstetr ics or gynecology, contact the Plan A dministra tor or issuer.
50 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 enro llment” 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 J uly 31, 202 5 . 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
51 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 Health Insurance Buy - In Program (HIBI): https://www.mycohibi.com/ HIBI Customer Service: 1 - 855 - 692 - 6442 Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecove ry.com/hipp/index.html Phone: 1 - 877 - 357 - 3268 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 Health Insurance Premium Payment Program All other Medicaid Website: https://www.in.gov/medicaid/ http://www.in.gov/fssa/dfr/ Family and Social Services Administration Phone: 1 - 800 - 403 - 0864 Member Services Phone: 1 - 800 - 457 - 4584 IOWA – Medicaid and CHIP (Hawki) KANSAS – Medicaid Medicaid Website: https://hhs.iowa.gov/programs/welcome - iowa - medicaid Medicaid Phone: 1 - 800 - 338 - 8366 Hawki Website: https://hhs.iowa.gov/programs/welcome - iowa - medicaid/iowa - health - link/hawki Hawki Phone: 1 - 800 - 257 - 8563 HIPP Website https://hhs.iowa.gov/programs/welcome - iowa - medicaid/fee - service/hipp HIPP Phone: 1 - 888 - 346 - 9562 Website: https://www.kancare.ks.gov/ Phone: 1 - 800 - 792 - 4884 HIPP Phone: 1 - 800 - 967 - 4660
52 KENTUCKY – Medicaid LOUISIANA – Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI - HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.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/?language=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 - 3739 Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573 - 751 - 2005 MONTANA – Medicaid NEBRASKA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP 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
53 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 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/s ervices/ dhs/apply - for - medicaid - health - insurance - premium - payment - program - hipp.html Phone: 1 - 800 - 692 - 7462 CHIP Website: https://www.pa.gov/en/agencies/dhs/resources/chip.html 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)
54 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/ VERMONT – Medicaid VIRGINIA – Medicaid and CHIP Website: https://dvha.vermont.gov/members/medicaid/hipp - program 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/programs - and - eligibility/ Phone: 1 - 800 - 251 - 1269
55 To see if any other states have added a premium assistance program since J uly 31, 202 5 , 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 Genetic Information Nondiscrimination Act (“G INA ”) “GINA” shall mean the Genetic Information Nondiscrimination Act of 2008 (Public Law No. 110 - 233), which prohibits Group H ealth P lans , issuers of individual health care policies, and employers from discriminating on the basis of genetic information. GINA prohibits a G roup H ealth P lan from adjusting group premium or contribution amounts for a group of similarly situated individuals based on the genetic information of members of the group. The term “genetic information” means, with respect to any individual, information about: 1) Such individual’s genetic tests; 2) The genetic tests of family members of such individual; and 3) The manifestation of a disease or disorder in family members of such individual. The term “genetic information” includes participating in clinical research involving genetic services. Genetic tests would include analysis of human DNA, RNA, chromosomes, proteins, or metabolite that detect genotypes, mutations, or chromosomal changes. Genetic information is a form of Protected Health Information (PHI) as defined by and in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and is su bject to applicable Privacy and Security Standards. “Family members” include dependents, plus all relatives to the fourth degree, without regard to whether they are related by blood, marriage, or adoption. “Underwriting” includes any rules for determining eli gibility, computing premiums or contributions, and applying preexisting conditions. Offering reduced premiums or other rewards for providing genetic information would be impermissible underwriting. Subrogation and Recovery If a Participant incurs covered expenses or receives benefits under a Benefit Program with respect to an injury or illness for which a third party (or its insurer) may be liable, the Plan retains all rights of subrogation, recovery and reimbursement as se t out more specifically in the governing d ocuments for each Benefit P rogram . Prudent Actions by Plan Fiduciaries In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the Plan . The people who operate the Plan , called “fiduciaries” of the Plan , have a duty to do so prudently and in the interest of you and other Plan participants and
56 beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA.
57 Your Rights and Protections Against Surprise Medical Bills When you get emergency care or get treated by an out - of - network provider at an in - network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. 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, such as a copayment, coinsurance, and/or a deductible. You may have other 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” describes p roviders and facilities that haven’t signed a contract with your health plan . Out - of - network providers may be permitted to bill you for the difference between what your plan agreed to pay 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 annual out - of - pocket limit . “ Surprise billing ” is a n 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. You are protected from balance billing for: Emergency services If you have an emergency medical condition and get emergency services from an out - of - network provider or facility, the most the provider or facility may bill you is your plan’s in - network cost - sharing amount (such as copayments and coinsurance) . You can’t be balance bill ed 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. Certain services at an in - network hospital or ambulatory surgical center W hen 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 may 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 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 care out - of - network. You can choose a provider or facility in your plan’s network.
58 When balance billing isn’t allowed, you also have the following protections: • You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in - network). Your health plan will pay out - of - network providers and facilities directly. • Your health plan generally must: o Cover emergency services without requiring you to get approval for services in advance ( 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 deductible and out - of - pocket limit. If you believe you’ve been wrongly billed , you may contact the applicable entity responsible for enforcing the federal and/or state balance or surprise billing protection laws. Visit www.dol.gov for more information about your rights under federal law.
59 ENFORCE YOUR RIGHTS If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest A nnual R eport from the Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the Plan ’s decision or lack thereof concerning the qualified status of a medical child support order, you may file suit in Federal court. If it should happen that Plan fiduciaries misuse the Plan ’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are succe ssful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. Receive a summary of the Plan ’s annual financial report. Should the Employer be required to file a Form 5500 the Plan Administrator is required by law to furnish each Participant with a copy of the Summary Annual Report (SAR) that provides a financial summary of the Plan.
60 DEFINITIONS The following terms, where capitalized, shall have the meanings set forth below unless otherwise specified herein: (a) “Adoption Agreement ” means a written document signed by a corporate officer adopting the Plan on the part of the organization. (b) “Beneficiary” means a Beneficiary under the Plan as defined under the terms of the respective Welfare Program. (c) “Benefit Program and Health Benefit Program ” means the Welfare Benefit Plan s being offered to the employees. (d) “Claims Administrator” means the insurance Employer , third party administrator or other entity designated by the Plan Administrator to determine benefit eligibility and availability and/or pay claims for benefits under this Plan or a Welfare Program under this Plan. (e) “Code” means the Internal Revenue Code of 1986, as amended. (f) “Company” means Snellings Walters Insurance Agency . In the event of a reorganization, merger or similar transaction affecting the Company, any successor entity may adopt the Plan for the benefit of Employees of such successor, in which event, the Plan shall continue without any gap or lapse in coverage. (g) “Dependent” means a covered Dependent under the Plan as defined under the terms of the respective Welfare Program. (h) “Effective Date” means January 1st . (i) “Employee” means, unless otherwise specified in a Welfare Program incorporated herein, any person currently employed by the Employer who is receiving compensation for services performed and who is classified by the Employer as a salaried or hourly full - time employee regularly scheduled the amount of hours per week as noted in the Eligible Employee Section of the Plan Information Section of this document. Employees on certain leaves of absence are also eligible to participate, subject to additional terms and conditions as specified in this P lan . “Employee” shall not include any person classified on the Employer’s records as other than an employee. For example, “Employee” shall not include anyone classified on the Employer’s records as an independent contractor, agent, leased employee, contract employee, temporary employee or similar classifications, regardless of any subsequent or retroactive reclassification or determination by a governmental agency that any such person is a common law employee of an Employer. Notwithstanding anything to the contrary contained herein or in the Welfare Programs, Employees who are non - resident aliens and who receive no earned income (within the meaning of Code Section 911(d)(2)) from an Employer that constitutes income from sources within the United States (within the meaning of Code Section 861(a)(3)) shall not be eligible to participate in the Plan . (j) “Employer” means the Company, and any other entity that participates in the Plan with the approval of the Plan Administrator. The Plan Administrator shall have the right to terminate
61 any Employer’s adoption of the Plan at any time. If an Employer merges or is otherwise consolidated with any affiliate, the successor shall, as to the group of Employees covered by the Plan immediately before such merger or consolidation, be the Employer as defined hereunder, unless the Plan Administrator specifies to the contrary. In case of any other merger or consolidation, the successor shall not be the Employer except to the extent that it acts to adopt the Plan . (k) “ERISA” means the Employee Retirement Income Security Act of 1974, as amended. (l) “Former Employee” means any person formerly employed as an Employee of the Employer. (m) “Fully Insured Benefit Programs” means a plan where the E mployer contracts with another organization to assume financial responsibility for the enrollees’ medical claims and for all incurred administrative costs. (n) “Independent Review Organization” (IRO) means a third - party organization contracted to collaborate in the decision - making process on claims. (o) “Insurer” means Insurance Company that issues a particular insurance policy to an insured . (p) “Governing Document(s)” means the various carrier p lan document s and this Summary Plan Description Wrap Document required by ERISA that include the Plan ’s terms for a number of items including eligibility, benefits, exc lusions, a named fiduciary and P lan A dministrator, claims and appeals procedures, funding information, and other items. (q) “Participant” means an Employee or Former Employee of the Employer who meets the requirements for eligibility as set forth in this P lan and who properly enrolls in the Plan . A person shall cease to be a Participant when they no longer meets the requirements for eligibility . (r) “Participant Contribution” means the P re - T ax or Post - T ax contribution required to be paid by a Participant, if any, as determined under each Welfare Program. The term “Participant Contribution” includes contributions used for the provision of benefits under a S elf - F unded arrangement of the Company or an Employer as well as contributions used to purchase insurance contracts or policies. (s) “Plan” means this Plan, the Snellings Walters Insurance Agency Welfare Benefit Plan , which consists of this document, and each Welfare Program incorporated hereunder by reference, as amended from time to time. (t) “Plan Administrator” shall have the same meaning as set forth in ERISA Section 3(16). The Plan Administrator for the Plan shall be the Employer , unless another entity or person is appointed by the Employer . (u) “Plan Fiduciary“ means the C ompany (v) “Plan Sponsor” means the C ompany (w) “Plan Year” means the twelve (12) consecutive month period commencing on January of such year .
62 (x) “Subsidiary Contracts” means any description of benefits, certificate of coverage, subscriber agreement, or evidence of coverage booklet , referenced by this SPD. These documents provide more details on specific items such as benefit coverage, definitions, coordination of benefits, claims procedures , exclusions and limitations . (y) “ Summary Plan Description ( SPD ) ” means any Summary Plan Description , Summary of Material Modifications or other Employee communication that describes the benefits under a Welfare Program, and has been included by the Employer and/or Employer as part of this Plan by reference . (z) “Spouse” means the legal spouse (as defined by state law, as applicable) of a Participant. (aa) “ Welfare Benefit Plan ” means a type of employer - sponsored employee Welfare Benefit Plan . 419(e) Welfare Benefit Plan s qualify under paragraph (e) of Section 419 of the Internal Revenue Code . They provide a range of benefits to employees, such as life, health, disability, long - term care and post - retirement medical. (bb) “Welfare Program” means a Welfare Program incorporated into this Plan that is offered by the Company and/or an Employer that provides any Employee a benefit that would be treated as an “employee Welfare Benefit Plan ” under Section 3(1) of ERISA if offered separately. (cc) “Welfare Program Document” means a written arrangement, including any contract between an Employer and an insurance company, health maintenance organization (“HMO”), administrative service organization (“ASO”) or other similar organization to provide benefits, a plan document or other instrument under which a Welfare Program is established and operated.
63 ASSISTANCE WITH YOUR QUESTIONS If you have any questions about the Plan , you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or: Division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by contacting the Employee Benefits Security Administration.
64 Q UALIFIED M EDICAL C HILD S UPPORT O RDERS Under the Employee Retirement Income Security Act (ERISA), A qualified medical child support order (QMCSO) is a court decree that orders an alternate beneficiary, such as a plan participant's child or step - child, is entitled to be covered by the participan t's group health plan. Status of Order The Plan Administrator or its designee shall recognize the Order as a Qualified Medical Child Support Order if the Order clearly satisfies all of the following requirements: o The Order discloses the name and last known mailing address, if any, of the employee member and each Alternate Recipient covered by the Order, except that, to the extent provided in the Order, the name and mailing address of an official of a state or a pol itical subdivision thereof (hereafter "governmental official") may be substituted for the mailing address of any such Alternate Recipient; provided, however, that an Order shall not fail to be a Qualified Medical Child Support Order merely because the Orde r does not specify the address of the employee member or an Alternate Recipient, if the Plan Administrator or its designee is otherwise aware of the address of such employee member or Alternate Recipient. o The Order specifies a reasonable description of the type of coverage to be provided by the Plan to each Alternate Recipient, or the manner in which such type of coverage is to be determined. o The Order identifies the period to which such Order applies. o The Order does not require any type or form of benefits or any opinion that is not otherwise provided under the Plan except to the extent necessary to meet the requirements of a law relating to medical child support described in Section 1908 of the Social Security Act, as added by Section 13822 of the Omnibus Budget Reconciliation Act of 1993. Procedural Requirements o Notice of Receipt and Copy of Procedure Order. Upon receipt by the Plan of any Medical Child Support Order, the Plan Administrator or its designee shall promptly notify the employee member and each Alternate Recipient that it has received such Order and the Plan Administrator or its designee shall pro vide the employee member and each Alternate Recipient with a copy of this Procedure. o Notification Following Qualification Determination. Within a reasonable time after receipt by the Plan Administrator or its designee of a Medical Child Support Order, or within such time period as shall be established under any applicable regulations issued by the Secretary of Labor or the Secretary of the Treasury, the Plan Administrator or its designee shall determine whether the Order is a Qualified Medical Child Support Order and shall notify the employee member and each Alternate Recipient of such determination. If the Plan Administrator or its designe e determines that an Order is not a Qualified Medical
65 Child Support Order, such notice shall advise that Alternate Recipient that he or she may have a right to petition the issuing court to amend the Order. Notifications shall be sent to the addresses specified in the Order, or if the Order does not specify a ddresses, to the last known address of the employee member and the Alternate Recipient. o National Medical Support Notice. In the case of a National Medical Support Notice that is deemed a Qualified Medical Child Support Order, the Plan Administrator or its designee shall within 40 business days after the date of the Notice: (i ) notify the state agency issuing the Notice whether coverage of the child is available under the terms of the Plan and, if so, whether such child is covered under the Plan and either the effective date of the coverage or, if necessary, any steps to be tak en by the custodial parent (or governmental official) to effectuate the coverage, and (ii) provide the custodial parent (or governmental official) a description of the coverage available and any forms or documents necessary to effectuate such coverage. o Designation of Representative. The Alternate Recipient shall be permitted to designate in writing a representative for receipt of copies of notices that are sent to the Alternate Recipient with respect to a Medical Child Support Order. Such written designation shall be provided to the Plan Administrator or its designee. o Payment for Benefits. Any payment for benefits made by the Plan pursuant to a Medical Child Support Order in reimbursement for expenses paid by an Alternate Recipient or an Alternate Recipient's custodial parent or legal guardian shall be made to the Alternate Recipient or the Alternate Recipient's custodial parent or legal guardian. Payments to a governmental official whose name and address have been substituted for the address of an Alternate Recipient shall be treated as payment of benefits to the Alternate Recipient. Actions Taken by the Plan Administrator If the Plan Administrator or its designee acts in accordance with Part 4 of Title I of the Employee Retirement Income Security Act of 1974, as amended ("ERISA"), in treating a Medical Child Support Order as being (or not being) a Qualified Medical Child Su pport Order, then the Plan's obligation to the employee member and each Alternate Recipient shall be discharged to the extent of any payment made pursuant to such act of the Plan Administrator or its designee.
66 Treatment of Alternate Recipients o A person who is an Alternate Recipient under a Qualified Medical Child Support Order shall be considered a beneficiary under the Plan for purposes of any applicable provisions of ERISA. o A person who is an Alternate Recipient under any Medical Child Support Order shall be considered a participant under the Plan for purposes of the reporting and disclosure requirements of Part 1 of Title I of ERISA. Modification of Procedure This Procedure may be modified from time to time by the Plan Administrator or its designee in its discretion to conform to regulations promulgated by the Secretary of Labor or Secretary of the Treasury or any other applicable guidance thereunder.
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