2-City of Westerville 2026 Benefits Guide.pdf

CONFIDENTIAL AND PROPRIETARY: This document and the information contained herein is confidential and proprietary information of USI Insurance Services, LLC ("USI"). Recipient agrees not to copy, reproduce or distribute this document, in whole or in part, w ithout the prior written consent of USI. Estimates are illustrative given data limitation, may not be cumulative and are subject to change based on ca rrier underwriting. © 2025 USI Insurance Services. All rights reserved.

Benefits Guide

City of Westerville 2026 Benefits Guide

Table of Contents

Welcome

Eligibility

Medical and Pharmacy Insurance

Virtual Visits

Type 2 Diabetes

Dental Insurance

Vision Insurance

Health Savings Account (HSA)

Dependent Care Flexible Spending Account

Basic Life and Accidental Death & Dismemberment

Employee Assistance Plan (EAP)

Contact Information

REQUIRED NOTIFICATIONS

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

Please see page 26 for more details.

Welcome

At City of Westerville, we recognize our ultimate success depends on our talented and dedicated workforce.

We understand the contribution each employee makes to our accomplishments. Our goal is to provide a comprehensive program of competitive benefits to attract and retain the best employees available. Through our benefit programs we strive to support the needs of our employees and their dependents by providing a benefit package that is easy to understand and easy to access for all our employees. This Benefits Guide provides an overview of your benefit options to help you choose the type of plan and level of coverage that is right for you. This guide is filled with valuable health and wellness information.

Whether you are a long-standing employee or a newly hired employee, this is your chance to review and update any medical, dental, and vision plan that is best for you.

Where to go for care

Selecting your benefits is an important decision you’ll make for yourself and your family. Insurance benefits provide a healthy lifestyle and essential coverage for many of life’s unexpected health events, offering financial protection even when out-pocket costs arise.

This benefit guide will help you understand what the City offers our employees and how these benefits can work for you. This guide provides important information to make informed decisions that safeguard your health, finances and future.

Typically, the Open Enrollment period is the only time during which you can elect benefits and make any life updates. We understand that life can change, and so should you have a Qualifying Life Event, you have 30 days from the date of the event to adjust your coverage.

The newly elected benefits will begin January 1, 2026, and will last the entire year, ending December 31, 2026.

Eligibility

Eligible Employees:

If you are an active, full-time employee, you are eligible to participate in the City of Westerville’s Employee Benefits Program.

Eligible Dependents:

The following is the City of Westerville’s eligible dependent guidelines.

Spouse

The City of Westerville has a spousal eligibility provision in the benefits program. This policy ONLY applies to spouses who have access medical coverage through an employer– sponsored plan.

If your spouse is offered health insurance coverage through an employer or employer sponsored retirement program, they are unable to enroll as a spouse on the City of Westerville medical plan. This policy does not apply to dental or vision. The objective of this policy is to require employers to be the primary payer of their employees’ health claims. It is not the objective to remove your spouse from the City’s plan. The spouse may remain on your plan and receive secondary coverage through coordination of benefits, as applicable.

It is important to note that this City of Westerville policy creates a qualifying event for working spouses, which allows them to enroll in their employer health plan, even if it is outside of the normal open enrollment period.

Children

Up to age 26, removed at the end of the year.

Benefit Highlights Eligibility

QUALIFYING LIFE EVENT

Changes in Household

• Marriage

• Birth of a baby, legal adoption or foster care

• Child turning 26*

• Judgement, decree or court order allowing you to add or drop cove rage for dependent child

• Divorce

• Death of a family member enrolled your health plan

Loss of Health Coverage

• Losing existing health coverage, including job-based, individual and student plan

Medical and Pharmacy Insurance

The City of Westerville offers medical coverage through United Healthcare. The medical plan provides coverage both in and out-of-network services. Keep in mind, your out-of-pocket expense will be lower when using an in-network provider. However, if you wish to seek services outside of the network, you will still receive comprehensive benefits. Please review the chart below for more detail.

To learn more, click on United Healthcare.

UnitedHealthcare Insurance Company High-Deductible Health Plan

Benefits Coverage In-Network Benefits Out-of-Network Benefits

Annual Deductible

Individual $2,000 $4,000

Family $4,000 $8,000

Coinsurance 100% 80%

Maximum Out-of-Pocket

Individual $2,000 $8,000

Family $4,000 $16,000

Physician Office Visit

Primary Care 100% after deductible 80% after deductible

Specialty Care 100% after deductible 80% after deductible

Preventive Care

Adult Periodic Exams 100% 80% after deductible

Well-Child Care 100% 80% after deductible

Diagnostic Services

X-ray and Lab Tests 100% after deductible 80% after deductible

Complex Radiology 100% after deductible 80% after deductible

Urgent Care Facility 100% after deductible 80% after deductible

Emergency Room Facility Charges* 100% after deductible 100% after deductible

Inpatient Facility Charges 100% after deductible 80% after deductible

Outpatient Facility and Surgical Charges 100% after deductible 80% after deductible

Mental Health

Inpatient 100% after deductible 80% after deductible

Outpatient 100% after deductible 80% after deductible

Substance Abuse

Inpatient 100% after deductible 80% after deductible

Outpatient 100% after deductible 80% after deductible

Other Services

Chiropractic (24 visits per calendar year) 100% after deductible; 80% after deductible

Where to go for care Know Your Benefits City of Westerville 2026 Benefits Guide https://member.uhc.com/myuhc?deeplink=paperless

Pharmacy Benefits

Retail Pharmacy (30 Day Supply)

Generic (Tier 1) 100% after deductible 80% after deductible

Preferred (Tier 2) 100% after deductible 80% after deductible

Non-Preferred (Tier 3) 100% after deductible 80% after deductible

Mail Order Pharmacy (90 Day Supply)

Generic (Tier 1) 100% after deductible Not covered

Preferred (Tier 2) 100% after deductible Not covered

Non-Preferred (Tier 3) 100% after deductible Not covered

Employee Contributions (Monthly)

Employee $109.82

Employee & Spouse $241.61

Employee & Child(ren) $219.65

Family $384.38

NOTES:

1. The Out-of-Pocket maximum includes all cost sharing, deductible, coinsurance and copays.

2. All Out-of-Network services are subject to deductible, coinsurance and balance billing.

Virtual Visits

Type 2 Diabetes

Dental Insurance

Your dental insurance is administered through Delta Dental. The dental plan is a PPO that offers coverage in and out-of-network. There is also a third provider tier called the Premier network. It is similar to in-network in that you cannot be balanced-billed. You just won’t receive the full cost savings for services as you would receive with a true in-network provider. If you choose to go out-of-network, you will be responsible for any cost exceeding Delta Dental negotiated fees, plus any deductible and coinsurance associated with your procedure.

To find a Delta Dental provider in your area, visit the website by clicking here.

When you scroll down and select your network, ensure you click on Delta Dental PPO and Delta Dental Premier.

Select the specialty and network. Search both the PPO and Premier dentists as both are considered in -network.

To achieve the greatest cost savings, ensure you are seeing a PPO or Premier provider. For the greatest discounts on all services, visit the providers and specialists in the PPO network.

The chart below is a brief outline of the plan. Please refer to the summary plan description for complete plan details. To learn more, click on Delta Dental.

Delta Dental Insurance Company

Dental Plan

Benefits Coverage In-Network Benefits Out-of-Network Benefits

Annual Deductible

Individual $0 $50

Family $0 $150

Waived for Preventive Care? Yes Yes

Annual Maximum

Per Person / Family $1,000 $1,000

Preventive 100% 100%

Basic 90% 80%

Major 60% 50%

Orthodontia

Benefit Percentage 50% 50%

Adults Covered (up to age 20) Covered (up to age 20)

Dependent Child(ren) Covered (up to age 20) Covered (up to age 20)

Lifetime Maximum $1,500 $1,500

Dental contributions are 100% covered by the City of Westerville.

Employee $0.00

Employee & Spouse $0.00

Employee & Child(ren) $0.00

Family $0.00 https://www.deltadentaloh.com/Member/Using-Your-Benefits/Find-a-Dentist?Global_Member https://www.deltadental.com/us/en/login.html

Vision Insurance

The City offers a vision program administered through VSP Vision Care. VSP has thousands of locations, including private practice doctors, Visionworks®, and Eye Mart Express retail locations nationwide. network. To learn more, click on VSP Vision Care.

The chart below is a brief outline of the plan. Please refer to the summary plan description for complete plan details.

Vision Service Plan (VSP)

Vision Plan

Benefits Coverage In-Network Out-of-Network

Vision Exam

Routine Exams $0 copay Reimbursement

Up to $32

Vision Materials

Lenses

Single Bifocal Trifocal

$10 copay; 100% covered

Covered every 12 months

Reimbursement

Up to $25 Up to $40 Up to $55

Covered every 12 months

Frames

$10 copay then $150 allowance 20% off balance over $120

Covered every 24 months

Reimbursement Up to $45

Covered every 24 months

Elective Contacts*

$10 copay then $150 allowance;

15% off balance

Contact Lens Fitting: Up to $60

Reimbursement Up to $105

Contact Lens Fitting: Included in reimbursement cost above

VSP LightCare Allows those that do not wear prescription glasses to use the frame allowance for non-prescription eyewear

N/A

*Covered in lieu of frames. Medically necessary contacts may be covered at a higher benefit level.

Vision contributions are 100% covered by the City of Westerville.

Employee $0.00

Employee & Spouse $0.00

Employee & Child(ren) $0.00

Family $0.00 https://www.vsp.com/benefits/how-to-use-vsp-benefits

Health Savings Account (HSA)

An HSA is a tax-sheltered bank account that you own to pay for eligible health care expenses for you and/or your eligible dependents for current or future healthcare expenses. The Health Savings Account (HSA) is yours to keep, even if you change jobs or medical plans. There is no “use it or lose it” rule; your balance carries over year to year.

Plus, you get extra tax advantages with an HSA because:

◼ Money you deposit into an HSA is exempt from federal income taxes

◼ Interest in your account grows tax free; and

◼ You don’t pay income taxes on withdrawals used to pay for eligible health expenses. (If you withdraw funds for non-eligible expenses, taxes and penalties apply).

◼ You also have a choice of investment options which earn competitive interest rates, so your unused funds grow over time.

Are you eligible to open a Health Savings Account (HSA)?

Although everyone is able to enroll in the Qualified High-Deductible Health Plan, not everyone is eligible to open and contribute to an HSA. If you do not meet these requirements, you cannot open an HSA.

◼ You must be enrolled in a Qualified High-Deductible Health Plan (QHDHP)

◼ You must not be covered by another non-QHDHP health plan, such as a spouse’s PPO plan.

◼ You are not enrolled in Medicare.

◼ You are not in the TRICARE or TRICARE for Life military benefits program.

◼ You have not received Veterans Administration (VA) benefits within the past three months.

◼ You are not claimed as a dependent on another person’s tax return.

◼ You are not covered by a traditional health care flexible spending account (FSA). This includes your spouse’s FSA. (Enrollment in a limited purpose health care FSA is allowed).

2026 HSA Contributions

The City does offer a medical plan that is a qualified high-deductible health plan, allowing you the opportunity to open HSA. You can contribute to your HSA on a pre-tax basis through payroll deductions up to the IRS statutory maximums. The City also contributes money into your established bank account of your choice at either CME Federal Credit Union or Heartland Bank. It is the responsibility of the employee to open an account at either financial institution.

Your contributions plus the City’s contribution cannot exceed the IRS limit . The IRS has established the following maximum HSA contributions:

If you are age 55 and over, you may contribute an extra $1,000 catch up contribution.

Coverage Level

City of Westerville HSA Contribution

Employee Max Contribution

2026 Annual Contribution Limit

Employee Only $1,700 $2,700 $4,400

Employee + Family $3,400 $5,350 $8,750

Spending Accounts City of Westerville 2026 Benefits Guide

Where can I use my HSA funds?

You can use HSA funds for IRS-approved items such as, but not limited to:

◼ Doctor’s office visits

◼ Prescription drugs and some over the counter medications

◼ Hospital services, surgery, lab fees

◼ Dental services to include orthodontia, dental, cleanings, and fillings

◼ Eye exams, eyeglasses, laser surgery, contact lenses and solution

◼ Hearing aids

◼ Physical therapy, speech therapy and chiropractic expenses

More information about approved items, plus additional details about the HSA is available at irs.gov.

As an HSA account holder, you will be required to file a Form 8889 with the IRS each year. This form identifies any contributions, distributions or earned interest associated with your account.

What services do not qualify for HSA funds?

◼ Advance payment for future medical care

◼ Babysitting, childcare

◼ Cosmetic surgery (unless due to trauma or disease)

◼ Massage (unless a prescription is presented)

◼ Nutritional supplements

◼ Teeth whitening

How to pay for my eligible expenses?

To pay for qualified medical expenses, choose the option that’s most convenient for you:

◼ Use your Debit Card from your designated HSA bank

◼ Use online bill pay

◼ Pay out-of-pocket and then distribute funds from your HSA to reimburse yourself

Keep your receipts! You must be able to prove that you were reimbursing yourself for an eligible expense in the event that you are audited.

If you use your HSA funds for non-eligible expenses, you will be charged a 20% penalty tax (if under age 65) as well as federal income taxes.

https://www.irs.gov/publications/p969

*Or $3,750 for married individuals filing separate tax returns

Dependent Care Flexible Spending Account

The Dependent Care FSA plan is an optional benefit that allows you to set aside pre-tax dollars to cover qualified expenses you would normally pay out of pocket with post-tax dollars. You pay no federal or state income taxes on the money you place in a Dependent Care FSA.

The money you contribute to a Dependent Care FSA is not subject to payroll taxes, so you end up paying less in taxes and taking home more of your paycheck.

Flores HR will administer your DCFSA account and process claims.

How do I use my Dependent Care FSA funds?

◼ Care for dependent who is under age 13

• Before and after school care

• Babysitting and nanny expenses

• Daycare, nursery school, and preschool

• Summer day camp

◼ Care for your spouse or a relative who is physically or mentally incapable of self-care and lives in your home.

◼ To view a full list of eligible DCFSA claims, click here FSAFEDS.gov

For the 2026 plan year, the IRS Dependent Care FSA (DCFSA) contribution limit will increase to $7,500 per household and $3,750 for married individuals filing separately. This increase, made possible by the One Big Beautiful Bill Act (OBBBA), provides more tax-advantaged savings for families' dependent care expenses, such as childcare or adult daycare, compared to the previous 2025 limit of $5,000.

How to save:

◼ Choose a specific amount of money to be automatically deducted each pay period, pre-tax, for the entire year.

◼ The amount is automatically deducted from your pay at the same level each pay period.

◼ Submit the appropriate paperwork in order to be reimbursed by the plan.

Important rules to keep in mind:

◼ The IRS has a strict “use it or lose it” rule. If you do not use the full amount in your FSA, you will lose any remaining funds.

◼ Once you enroll in the FSA, you cannot change your contribution amount during the year unless you experience a qualifying life event.

◼ You cannot transfer funds from one FSA account to another FSA account.

Maximum Annual Election

Dependent Care FSA $7,500*

City of Westerville 2026 Benefits Guide https://www.google.com/search?sca_esv=1720fa6fb76a49fc&rlz=1C1GCEB_enUS999US1017&q=One+Big+Beautiful+Bill+Act&sa=X&ved=2ahUKEwj_4ZSA_N2PAxXBmYkEHYq3PHQQxccNegQINhAB&mstk=AUtExfCOyAfLFWQ1vKBP0zai1pc5VNb5ss3f1SQvk367AG2oZDfbqxOoWQmYhVrRNPmtWfQRAW7k6KQOR8cuRmc4GgXhyLhwY-7VZVM2Yn-gpPy4SZcvSg95AXDxJjzBR4yfIFU&csui=3 https://www.google.com/search?sca_esv=1720fa6fb76a49fc&rlz=1C1GCEB_enUS999US1017&q=One+Big+Beautiful+Bill+Act&sa=X&ved=2ahUKEwj_4ZSA_N2PAxXBmYkEHYq3PHQQxccNegQINhAB&mstk=AUtExfCOyAfLFWQ1vKBP0zai1pc5VNb5ss3f1SQvk367AG2oZDfbqxOoWQmYhVrRNPmtWfQRAW7k6KQOR8cuRmc4GgXhyLhwY-7VZVM2Yn-gpPy4SZcvSg95AXDxJjzBR4yfIFU&csui=3

Please plan your FSA contributions carefully, as any funds not used by the end of the year will be forfeited.

Re-enrollment is required each year.

Basic Life and Accidental Death & Dismemberment

Employer sponsored Basic Life and Accidental Death & Dismemberment (AD&D) is available to eligible employees, at no cost to you, and is administered through Equitable Plan Services.

Basic Life: Term life that pays a benefit in the event of an employee’s death due to illness or injury. The life insurance benefit will be paid to your designated beneficiary in the event of death while covered under the plan.

Accidental Death & Dismemberment (AD&D): AD&D coverage pays a benefit in the event of an employee’s death or dismemberment resulting from an accident. The amount payable is determined by the loss. The AD&D benefit will be paid at the time of loss of life or limb, by accident, while covered under the plan.

Equitable Plan Services Basic Life

Equitable Plan Services

AD&D

Employee

Benefit Maximum $100,000 $100,000

Guaranteed Issue $100,000 $100,000

Spouse

Benefit Maximum $10,000 N/A

Guaranteed Issue $10,000 N/A

Dependent Child

Benefit Maximum $5,000 N/A

Guaranteed Issue $5,000 N/A

Disability Insurance City of Westerville 2026 Benefits Guide

Employee Assistance Plan (EAP)

Life does not always go smoothly. All of us experience times when a personal problem or crisis affects the way we function at work or home. Your Employee Assistance Program (EAP) is a problem-solving resource available to you and your household members. A professional counselor will assist you in assessing your situation, finding options, making choices or locating further help. You have access to six coaching and counseling sessions either in person or virtually with a provider in Optum’s large network – at no cost.

It’s free...The City of Westerville covers the cost of initial assessment, additional problem-solving sessions and referral services. If there is a need for further counseling or treatment, your counselor will help you explore various options.

It’s confidential...Your EAP has been set up with Optum, an outside counseling resource to assure confidentiality. No one at work will know you have chosen to seek help unless you choose to tell them.

Nothing concerning your use of EAP will appear in your personnel file.

Employee Assistance Plan Wellness Program EAP Resource

NOW AVAILABLE

FREE

Coaching & Counseling Sessions

Contact Information

Have Questions? Need Help?

The City of Westerville is excited to offer access to the USI Benefit Resource Center (BRC), which is designed to provide you with a responsive, consistent, hands-on approach to benefit inquiries. Benefit Specialists are available to research and solve elevated claims, unresolved eligibility problems, and any other benefit issues with which you might need assistance. The Benefit Specialists are experienced professionals, and their primary responsibility is to assist you.

The Specialists in the Benefit Resource Center are available Monday through Friday 8:00am to 5:00pm Eastern & Central Standard Time at 855-874-0829 or via e-mail at BRCMidwest@usi.com. If you need assistance outside of regular business hours, please leave a message and one of the Benefit Specialists will promptly return your call or e-mail message by the end of the following business day.

Carrier Customer Service

CARRIER PHONE NUMBER WEBSITE

Medical PPO UnitedHealthcare (800) 357-0978 www.uhc.com

Dental PPO Delta Dental (800) 524-0149 www.deltadentaloh.com

Vision Vision Service Plan (800) 877-7195 www.vsp.com

Health Savings Account

CME Federal Credit Union

(614) 224-8890 www.cmefcu.org

Heartland Bank (614) 839-2265 www.heartland.bank

Flexible Spending Account Flores & Associates (888) 586-3997 www.flores247.com

Life and AD&D Equitable (888) 274-9887 www.equitable.com

Short Term Disability (STD) Equitable (888) 274-9887 www.equitable.com

Employee Assistance Program (EAP) Optum (866) 248-4094 www.liveandworkwell.com

Flexible Spending Account Flores & Associates (888) 586-3997 www.flores247.com

Know Who to Call City of Westerville 2026 Benefits Guide

This brochure summarizes the benefit plans that are available to City of Westerville, Ohio eligible employees and their dependents. Official plan documents, policies and certificates of insurance contain the details, conditions, maximum benefit levels and restrictions on benefits. These documents govern your benefits program. If there is any conflict, the official documents prevail. These documents are available upon request through the Human Resources

Department. Information provided in this brochure is not a guarantee of benefits.

REQUIRED NOTIFICATIONS

Important Legal Notices Affecting Your Health Plan Coverage

If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

• All stages of reconstruction of the breast on which the mastectomy was performed;

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

• Prostheses; and

• Treatment of physical complications of the mastectomy, including lymphedema.

These benef its will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benef its provided under this plan. Therefore, the following deductibles and coinsurance apply: $2,000/$4,000/100%

Group health plans and health insurance issuers generally may not, under Federal law, restrict benef its for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days af ter your or your dependents’ other coverage ends (or af ter 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 af ter the marriage, birth, adoption, or placement for adoption.

Further, if you decline enrollment for yourself or eligible dependents (including your spouse) while Medicaid coverage or coverage under a State CHIP program is in effect, you may be able to enroll yourself and your dependents in this plan if :

• coverage is lost under Medicaid or a State CHIP program; or

• you or your dependents become eligible for a premium assistance subsidy f rom the State.

In either case, you must request enrollment within 60 days from the loss of coverage or the date you become eligible for premium assistance.

To request special enrollment or obtain more information, contact the person listed at the end of this summary.

THE WOMEN’S HEALTH CANCER RIGHTS ACT OF 1998 (WHCRA)

NEWBORNS ACT DISCLOSURE − FEDERAL

NOTICE OF SPECIAL ENROLLMENT RIGHTS

Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by dif ferent means. Contact Human Resources.

Under the ACA, dependent children are covered by the group health plan until age 26. City of Westerville’s group health plan extends dependent coverage beyond the ACA requirements, to age 26, so long as the child is covered as a student.

If your child has extended coverage as a student but loses their student status because they take a medically necessary leave of absence from school your child may continue to be covered under the plan for up to one year from the beginning of the leave of absence. This is available if, immediately before the first day of the leave of absence, your child was (1) covered under the plan and (2) enrolled as a student at a post-secondary educational institution (includes colleges and universities).

To obtain more information, contact person listed at the end of this summary.

As a participant in the Plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (“ERISA”). ERISA provides that all participants shall be entitled to:

Receive Information about Your Plan and Benefits

• Examine, without charge, at the Plan Administrator’s office and at other specif ied locations, the Plan and Plan documents, including the insurance contract and copies of all documents f iled by the Plan with the U.S.

Department of Labor, if any, such as annual reports and Plan descriptions.

• Obtain copies of the Plan documents and other Plan information upon written request to the Plan Administrator.

The Plan Administrator may make a reasonable charge for the copies.

• Receive a summary of the Plan’s annual f inancial report, if required to be furnished under ERISA. The Plan

Administrator is required by law to furnish each participant with a copy of this summary annual report, if any.

Continue Group Health Plan Coverage If applicable, you may continue health care coverage for yourself, spouse, or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You and your dependents may have to pay for such coverage. Review the summary plan description and the documents governing the Plan for the rules on COBRA continuation of coverage rights.

Prudent Actions by Plan Fiduciaries In addition to creating rights for participants, ERISA imposes duties upon the people who are responsible for the operation of the Plan. These people, called “fiduciaries” of the Plan, have a duty to operate the Plan prudently and in the interest of you and other Plan participants.

No one, including the Company or any other person, may fire you or discriminate against you in any way to prevent you f rom obtaining welfare benef its or exercising your rights under ERISA.

Enforce your Rights If your claim for a welfare benefit is denied in whole or in part, you must receive a written explanation of the reason for t he denial. You have a right to have the Plan reviewed and reconsider your claim.

Under ERISA, there are steps you can take to enforce these rights. For instance, if you request materials f rom the Plan Administrator and do not receive them within 30 days, you may f ile suit in federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 per day, until you receive the materials, unless the materials were not sent due to reasons beyond the control of the Plan Administrator. If you have a claim for benef its which is denied or ignored, in whole or in part, and you have exhausted the available claims procedures under the Plan, you may file suit in a state or federal court. If it should happen that Plan fiduciaries misuse the Plan’s money, o r 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 successful, the court may order the person you have sued to pay these costs and fees. If you lose (for example, if the court finds your claim is f rivolous) the court may order you to pay these costs and fees.

Assistance with your Questions

MICHELLE’S LAW DISCLOSURE

STATEMENT OF ERISA RIGHTS

If you have any questions about your Plan, this statement, or your rights under ERISA, you should contact the nearest of fice of the Employee Benefits and Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits and Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210.

Questions regarding any of this information can be directed to:

Stacy Hathaway

City of Westerville 614-901-6838 stacy.hathaway@westerville.org

CONTACT INFORMATION

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Contact information for questions or complaints is available at the end of the notice.

Your Rights You have the right to:

• Get a copy of your health and claims records

• Correct your health and claims records

• Request conf idential communication

• Ask us to limit the information we share

• Get a list of those with whom we’ve shared your information

• Get a copy of this privacy notice

• Choose someone to act for you

• File a complaint if you believe your privacy rights have been violated

Your Choices You have some choices in the way that we use and share information as we:

• Answer coverage questions f rom your family and f riends

• Provide disaster relief

• Market our services and sell your information

Our Uses and Disclosures We may use and share your information as we:

• Help manage the health care treatment you receive

• Run our organization

• Pay for your health services

• Administer your health plan

• Help with public health and safety issues

• Do research

• Comply with the law

• Respond to organ and tissue donation requests and work with a medical examiner or funeral director

• Address workers’ compensation, law enforcement, and other government requests

• Respond to lawsuits and legal actions

Your Rights When it comes to your health information, you have certain rights.

This section explains your rights and some of our responsibilities to help you.

Get a copy of health and claims records

• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request.

We may charge a reasonable, cost-based fee.

Ask us to correct health and claims records

• You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing, usually within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a dif ferent address.

• We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations.

• We are not required to agree to your request.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for up to six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information at the end of this notice.

• You can f ile a complaint with the U.S. Department of Health and Human Services Off ice for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/hipaa/f iling-a-complaint/index.html.

• We will not retaliate against you for f iling a complaint.

https://www.hhs.gov/hipaa/filing-a-complaint/index.html

Your Choices For certain health information, you can tell us your choices about what we share.

If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close f riends, or others involved in payment for your care

• Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

• In these cases, we never share your information unless you give us written permission:

Marketing purposes Sale of your information

Our Uses and Disclosures How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Help manage the health care treatment you receive We can use your health information and share it with professionals who are treating you.

Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.

Pay for your health services We can use and disclose your health information as we pay for your health services.

Example: We share information about you with your dental plan to coordinate payment for your dental work.

Administer your plan We may disclose your health information to your health plan sponsor for plan administration.

Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.

Run our organization

• We can use and disclose your information to run our organization and contact you when necessary.

• We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long-term care plans.

Example: We use health information about you to develop better services for you.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html.

Help with public health and safety issues We can share health information about you for certain situations such as:

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone’s health or safety

City of Westerville 2026 Benefits Guide https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html

Do research We can use or share your information for health research.

Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests and work with a medical examiner or funeral director

• We can share health information about you with organ procurement organizations.

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you:

• For workers’ compensation claims

• For law enforcement purposes or with a law enforcement of f icial

• With health oversight agencies for activities authorized by law

• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html.

Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site (if applicable), and we will mail a copy to you.

Other Instructions for Notice

1/1/2026 Stacy Hathaway City of Westerville 614-901-6838 stacy.hathaway@westerville.org

MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE FOR USE ON OR AFTER APRIL

1, 2011

If you are receiving a copy of this notice electronically, you are responsible for providing a copy of it to any Part -D eligible dependents covered under the group health plan.

Important Notice from City of Westerville About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with City of Westerville and about your options under Medicare’s prescription drug coverage.

This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

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

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by

Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. City of Westerville has determined that the prescription drug coverage offered by the UHC High Deductible Health Plan for the plan year [insert plan year] is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

When Can You Join a Medicare Drug Plan?

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

December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens to Your Current Coverage If You Decide to Join a Medicare Drug Plan?

If you decide to join a Medicare drug plan, the following options may apply:

• You may stay in the UHC High Deductible Health Plan and not enroll in the Medicare prescription drug coverage at this time. You may be able to enroll in the Medicare prescription drug program at a later date without penalty either:

o During the Medicare prescription drug annual enrollment period, or o If you lose UHC High Deductible Health Plan creditable coverage.

• You may stay in the UHC High Deductible Health Plan and also enroll in a Medicare prescription drug plan. The

UHC High Deductible Health Plan will be the primary payer for prescription drugs and Medicare Part D will become the secondary payer.

• You may decline coverage in the UHC High Deductible Health Plan and enroll in Medicare as your only payer for all medical and prescription drug expenses. If you do not enroll in the UHC High Deductible Health Plan you are not able to receive coverage through the plan unless and until you are eligible to reenroll in the plan at the next open enrollment period or due to a status change under the cafeteria plan or special enrollment event.

When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with City of Westerville and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a

Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information About This Notice or Your Current Prescription Drug Coverage…

Contact the person listed below for further information.

NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through City of Westerville changes. You also may request a copy of this notice at any time.

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

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:

• Visit www.medicare.gov

• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help

• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

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

1213 (TTY 1-800-325-0778).

Date: 1/1/2026

Name/Entity of Sender: City of Westerville

Contact Position/Office: Human Resources

Address: 21 State St., Westerville, OH 43081

Phone Number: 614-901-6400

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

http://www.medicare.gov/

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

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or

CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace.

For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your

State Medicaid or CHIP office to find out if premium assistance is available.

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

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

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2025. 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 http://www.healthcare.gov/ http://www.insurekidsnow.gov/ http://www.askebsa.dol.gov/ http://myalhipp.com/ http://myakhipp.com/ mailto:CustomerService@MyAKHIPP.com https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fhealth.alaska.gov%2Fdpa%2FPages%2Fdefault.aspx&data=05%7C01%7CBerman.Nathaniel%40dol.gov%7Ca5722ebf007e4847fe8808da69a45fb9%7C75a6305472044e0c9126adab971d4aca%7C0%7C0%7C637938452103798639%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=A5Fggwg0lR2c%2FOwofWNVpVk8b5%2FFX1kaOQNuuEwAAAE%3D&reserved=0 http://myarhipp.com/ http://dhcs.ca.gov/hipp mailto:hipp@dhcs.ca.gov

COLORADO – Health First Colorado

(Colorado’s Medicaid Program) & Child Health

Plan Plus (CHP+)

FLORIDA – Medicaid

Health First Colorado Website:

https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center:

1-800-221-3943/State Relay 711 CHP+: https://hcpf.colorado.gov/child-health-plan-plus CHP+ Customer Service: 1-800-359-1991/State Relay 711

Health Insurance Buy-In Program (HIBI): https://www.mycohibi.com/ HIBI Customer Service: 1-855-692-6442

Website:

https://www.flmedicaidtplrecovery.com/flmedicaidtplrecover y.com/hipp/index.html

Phone: 1-877-357-3268

GEORGIA – Medicaid INDIANA – Medicaid

GA HIPP Website:…