Appendix_A_-_Employee_Benefits_Guide_2026.pdf

Employee Benefits Guide January 1, 2026 - December 31, 2026

Contents

WELCOME 3

BENEFITS ELIGIBILITY 4

DEFINITION OF TERMS 5-6

EMPLOYEE RATES 7

MEDICAL BENEFITS SCHEDULE - FHCP 8

FHCP RESOURCES 9-11

FHCP FITNESS PROGRAM 12

WELLNESS INITIATIVE 2026 13

HEALTH SAVINGS ACCOUNTS 14

DENTAL BENEFITS 15

VISION BENEFITS 16

LIFE INSURANCE AND VOLUNTARY LIFE BENEFITS 17-18

OTHER BENEFITS 19-20

IMPORTANT CONTACTS 21

DISCLAIMER 22

IMPORTANT NOTICES APPENDIX

Welcome Welcome to the City of Holly Hill Benefits Guide for the 2026 plan year. Inside you will find all the information you need to evaluate benefits for you and your dependents.

Please review the information carefully and contact Human Resources with any questions.

Florida Health Care Plans (FHCP), City of Holly Hill’s health insurance carrier, is based locally in Central Florida and has been servicing this community since 1974. FHCP is also an affiliate of Florida Blue.

FHCP’s Mission: To provide our members with health care and related services through dedicated employees and service partners who manage both the quality and cost of health care..

For 2026, There are no changes to any of the in-force benefit carrier partners.

These fiscally responsible decisions were made with you in mind!

If you have questions, please contact:

Human Resources Manager:

Jeaneen Witt, 386-248-9440, Jwitt@hollyhillfl.org

Benefits Eligibility City of Holly Hill employees regularly scheduled to work at least 30 hours per week are benefits eligible.

Your Eligible Dependents Include

• Your spouse

• Your children, stepchildren, children of your domestic partner, or children in your guardianship up to age 26

• Adult children, stepchildren, or children in your guardianship of any age who are deemed disabled

• Grandchild, only if the employee’s dependent child (parent of grandchild) is under age 18

Verifying Your Dependents

City of Holly Hill may require eligibility verification of your enrolled dependents by providing appropriate documentation at the time you enroll. This documentation would include legal documents such as a marriage license, birth certificates, and the top portion of your most recent federal tax return.

If this documentation is not provided upon request, your dependent will not be eligible to be enrolled in our benefit plans.

New Hires/Newly Eligible

New hires or newly benefits-eligible employees are eligible for coverage starting on the first day of the month following 30 days of employment.

Enrollment must be made within the first 31 days of the hire or eligibility date.

Changing Your Benefits Outside Of Open Enrollment

The benefits you elect during the 2026 benefits plan year will remain in effect through December 31, 2026 . By law, you can only make changes to your coverage during the year if you experience a qualifying life event, and notify Human Resources within 30 days.

Qualifying Life Events

A qualifying event is a personal event that may require you to either add or remove coverage for yourself and/or your dependents. These events include:

• Marriage, divorce, or legal separation

• Birth or adoption of a dependent child

• Death of a dependent spouse or child

• Gain or loss of coverage for you or your eligible dependents

• Reaching age 26 for dependent children

Important Deadline For Qualifying Event Changes

You must make any coverage change within 31 days of the qualifying event. Report this change to Jeaneen Witt, Human Resources Manager, jwitt@hollyhillfl.org, with as much information as you have, within the 31 day deadline.

You may be asked to include documentation to substantiate your qualifying event. If you miss the deadline, or do not provide the supporting documentation, changes will not be approved.

Definitions

• Accidental Death and Dismemberment (AD&D):

Insurance that is a rider to a life insurance policy that covers the accidental death or dismemberment of the insured.

Out-of- Pocket

Maximum

Coinsurance

Deductible

Copay

• Dismemberment: Typically, the AD&D policy pay a percentage for the loss of a limb, partial or permanent paralysis, or the loss of use of specific body parts, such as the loss of sight, hearing or speech.

• Heath Savings Account (HSA): A type of savings account that lets you set aside money on a pre-tax basis to pay for qualified medical expenses. By using untaxed dollars in an HSA to pay for deductibles, copayments, coinsurance, and some other expenses, you may be able to lower your out-of-pocket health care costs. HSA funds may not be used to pay premiums.

• In-network: Doctors, clinics, hospitals and other providers with whom the health plan has an agreement to care for its members. Health plans cover a greater share of the cost for in-network health providers than for providers who are out-of-network.

• Coinsurance: Your share of the costs of a covered health care service, calculated as a percent of the allowed amount for that service, usually paid after the deductible has been satisfied.

• Copay: A fixed amount you pay for a covered health care service, usually when you receive the service.

• Deductible: The amount you owe for covered health care services before your health insurance begins to pay.

Definitions

• Life insurance: A contract between an insurer and a policyholder in which the insurer guarantees payment of a death benefit to named beneficiaries upon the death of the insured.

• Out-of-network: Treatment received from doctors, clinics, hospitals and other providers who are not in network. A health plan may cover these costs, but covered employees will pay more out-of-pocket to use out-of-network providers than for in-network providers.

• Out-of-Pocket Maximum (OOPM): The most you pay during a policy period. When you’ve reached your OOPM, the Plan will pay 100% of covered health care services for the remainder of the plan year. OOPM includes: deductible, coinsurance, and copays.

• Point-of-service plan (POS): A plan that provides coverage through a network of participating health care providers, as well as coverage outside of the network. POS enrollees receive more generous benefits for services within the network and for specialist care authorized by their primary care physicians. Benefits are less generous for care received outside the network and for self-referrals.

• Premium: The amount that must be paid for a health insurance plan by covered employees, by their employer, or shared by both. A covered employee's share of the annual premium is generally paid periodically, and deducted from his or her paycheck.

• Primary Care Physician (PCP): A physician who is usually the first health professional to examine a patient and who recommends secondary care physicians, medical or surgical specialists with expertise in the patient's specific health problem, if further treatment is needed.

FULL-TIME EMPLOYEE (30 hours/week+) — DENTAL Cost

Employee $17.71

Employee/Spouse $36.44

Employee/Child(ren) $40.81

Family $63.88

FULL-TIME EMPLOYEE (30 hours/week+) — VISION Cost

Employee $2.43

Employee/Spouse $4.62

Employee/Child(ren) $4.86

Family $7.13

FULL-TIME EMPLOYEE (30 hours/week+) — FHCP T95 HDHP HSA Cost

Employee $0.00

Employee/Spouse $227.60

Employee/Child(ren) $227.60

Family $352.61

Employee Per-Paycheck* Rates

*Rates based on 24 deductions per year

Medical Benefits Schedule - FHCP

Plan Name T95

Name of Network HDHP POS(HSA)

Calendar Year Deductible

Individual Family

$1,700 $3,400

Annual Out-of-Pocket Maximum Includes deductible, copays, coinsurance)

Individual Family

$3,400 $6,800

Coinsurance (Coins) (Amount paid after deductible is met)

You pay….. 20%

Physician Services

Office Visit Specialist Chiropractic Care

Deductible + Coinsurance Deductible + Coinsurance Deductible + Coinsurance

Adult and Child Wellness Exams 100% Covered

Hospital Services

Inpatient Hospital Per Admission Outpatient Surgery Emergency Room Urgent Care

Deductible + Coinsurance Deductible + Coinsurance Deductible + Coinsurance Deductible + Coinsurance

Prescription Drugs

Retail (1 month supply) Preferred Generic Non Preferred Generic Preferred Brand Non-Preferred Brand Preferred Specialty Non-Preferred Specialty

Mail Order (3 month Supply)

FHCP | Walgreens (*After Deductible) $3* Copay | $15* Copay $10* Copay | $15* Copay $30* Copay | $35* Copay $55* Copay | $60* Copay

15% Coinsurance* | N/A 25% Coinsurance* | N/A

$6* | $27* | $87* | $162*

Non-Network

Calendar Year Deductible (Individual/Family) Out of Pocket Max (Individual/Family) Coinsurance

$2,800 / $5,600 $6,000 / $12,000

40%

FHCP Resources

FHCP Fitness Program

Wellness Initiative – Earning the City’s 2026 HSA Deposit The City of Holly Hill is committed to health and wellness and continues to adopt plans to encourage healthy behaviors. The 2026 Wellness Initiative offers a funding incentive for achieving certain health targets. The City will deposit the amount of $1,400.00 via the January 15, 2026 paycheck into employee's Heath Savings Account if the employee has completed a physical examination and the Florida Health Care Plan's on-line health assessment during the timeframe of January 1, 2026 through December 11, 2026 . No contribution may be obtained without completion of these initial two requirements.

To be eligible to receive the up to $500 additional contribution from City, employee must participate and earn a total of up to 5 points, bringing the City's maximum contribution to $1,900. Wellness Initiative forms must be completed & submitted by December 11, 2026 for the 2027 plan year.

*Special Exception: Employees who obtained their physicals in November or December 2025, may have until January 31st, 2027 to complete and submit wellness forms. Payment of incentive would then occur on February 11, 2027.

Health Savings Account (HSA) A Health Savings Account combines high deductible health insurance with a tax-favored savings account.

Money in the savings account can help pay the costs of qualified medical expenses not covered by medical insurance for you and your dependents. Money left in the savings account earns interest and is yours to keep.

• Employee-Owned Account

• Pre-tax contributions

• Pay for any qualified medical expenses. (See IRS Publication 502 for a list of qualified medical expenses).

To be HSA-eligible for a month, an individual must:

• Be covered by an HDHP on the first day of the month;

• Not be covered by other health coverage that is not an HDHP (with certain exceptions);

• Not be enrolled in Medicare; and

• Not be eligible to be claimed as a dependent on another person’s tax return.

Why might an HSA be the right choice for you?

¨ It saves you money. For individuals with few regular health expenses, paying a traditional health plan premium can feel like throwing money out the window. HDHPs come with much lower premiums than traditional health plans, meaning less money is deducted from your paychecks. Plus, HSAs are basically “cash” accounts, so you may be able to negotiate pricing on many medical services.

¨ It’s portable. Even if you change jobs, you get to keep your HSA.

¨ It’s a tax saver. Contributions to your HSA are made with pre-tax dollars. Since your taxable income is decreased by your contributions, you pay less in taxes.

¨ It allows for an improved retirement account. Funds roll over at the end of each year and accumulate tax-free, as does the interest on the account. Also, once you reach the age of 55, you are allowed to make additional “catch-up” contributions to your HSA until age 65.

¨ It puts money in your pocket. You never lose unused HSA funds. They always roll over to the next year.

Maximum annual contribution for 2026:

Employee only coverage: $4,400 Family coverage: $8,750 Age 55 or older – additional election of $1,000

City of Holly Hill will contribute a maximum of $1,900.00 for the plan year to an HSA account for each employee who enrolls in the High Deductible Health Plan if the employee completes all requirements as established in the Wellness Initiative Plan. A prorated contribution will be granted to newly hired employees.

Dental Benefits - Principal Below is your Principal dental plan, which gives you freedom to use in-network or out-of-network dentists. Since network providers offer reduced contracted rates, you save money by using network providers for all your dental needs.

All benefits received from out-of-network dentists are subject to “reasonable and customary” fees. Any amount that exceeds the dental carrier’s “reasonable and customary” amounts is the patient’s responsibility. You can access the dental provider’s network and find a dentist near you by clicking here: https://www.principal.com/find-dentist.

Dental Services In-Network Out-of-Network

Calendar Year Maximum Benefit $5,000

Calendar Year Deductible Individual/Family $50/$150 $50/$150

PREVENTIVE PROCEDURES: Deductible Waived

Routine Exams & Cleaning (prophylaxis) Fluoride Treatments– Under age 14 Bitewing X-rays Full Mouth X-rays Sealants– Under age 14

Plan pays 100% Plan pays 100%

BASIC PROCEDURES: Deductible Applies

Fillings Endodontics (Root Canals) Periodontal Surgery Periodontal Scaling & Root Planing Simple & Complex Surgery

Plan pays 80% Plan pays 80%*

MAJOR PROCEDURES: Deductible Applies

Crowns Bridges & Dentures Implant Services

Plan pays 50% Plan pays 50%*

ORTHODONTIC PROCEDURES Deductible Waived

Lifetime maximum—$1,000 (All Insureds– Adult & Child(ren)) Plan pays 50% Plan pays 50%*

See carrier benefit summaries for additional plan information.

*Percent of reasonable & customary charges (We process claims using prevailing fees at the 90th percentile.)

**Enrolled dependents are covered until the end of the calendar year during which the dependent reaches age 26.

https://www.principal.com/find-dentist https://www.principal.com/find-dentist https://www.principal.com/find-dentist https://www.principal.com/find-dentist https://www.principal.com/find-dentist https://www.principal.com/find-dentist https://www.principal.com/find-dentist https://www.principal.com/find-dentist https://www.principal.com/find-dentist

Vision Benefits - Eyemed City of Holly Hill offers a vision plan through Eyemed. This plan covers eye exams, prescription lenses and frames, or contact lenses for you and your dependents when you receive services from in-network or out-of-network providers. As you can see from the table below, staying in-network cuts costs down and gives you more of a benefit.

To find a participating provider log on to www.eyemed.com and choose the SELECT Network.

Vision Services In-Network Out-of-Network

Eye Exams Frequency

$10 Copay Once every 12 months

Reimbursed up to $35 Once every 12 months

BASIC LENSES

Frequency Single vision Bifocal vision Trifocal vision

Once every 12 months $25 Copay $25 Copay $25 Copay

Once every 12 months Reimbursed up to $35 Reimbursed up to $49 Reimbursed up to $74

FRAMES

Frequency* Benefit

Once every 24 months $100 Allowance + 20% off balance

Once every 12 months Reimbursed up to $50

CONTACTS

Frequency* Elective Medically Necessary

Once every 12 months $115 Allowance + 15% off balance

Covered in Full

Once every 12 months Reimbursed up to $92

Reimbursed up to $210

*Contacts and eyeglasses cannot be purchased in the same year **Enrolled dependents are covered until the end of the calendar year during which the dependent reaches age 26.

http://www.eyemed.com/

Life, Accidental Death and Dismemberment

City of Holly Hill- Provided Benefit (at no cost to you):

Life and Accidental Death And Dismemberment (AD&D) Insurance:

Life insurance protects your family or other beneficiaries in the event of your death. The death benefit helps replace the income you would have provided and can help meet important financial needs. The City of Holly Hill provides basic life insurance to our employees through USAble at no cost.

Employees can purchase Basic Dependent Life at a rate of $1.68 for your spouse and/or child(ren). This rate provides spouse coverage of $5,000 and child(ren) coverage from birth to 6 months of $1,000; from 6 months of age to age 26 of $2,500.

Employees have an opportunity to purchase additional Voluntary Life Insurance with USAble for you alone, you and your spouse, and/or your dependents at a group rate (located on the next page). It includes the features of waiver of premium, accelerated life benefit, portability as described in the USAble summary of coverage.

City of Holly Hill- Summary of Voluntary Life Insurance

If you chose to enroll in the additional voluntary life insurance, you may insure you alone or you and your spouse . A summary of this coverage is listed in the table below, if you should have questions on this policy see your USAble Certificate of Benefits or visit www.usable.com. Please note, all voluntary insurance is portable.

Summary of Insurance

Guarantee Issue (under age 70) Minimum Benefit Amount Maximum Benefit Amount Increments of…

Spouse Coverage (under age 70) Spouse Guarantee Issue Minimum Benefit Amount Maximum Benefit Amount Increments of…

Dependent Coverage Child Guarantee Issue (6 months - 26 years) Maximum Benefit Amount Increments of…

$120,000 $10,000 $500,000 or 5x salary (whichever is less) $10,000

$30,000 $5,000 100% of employee amount or $250,000 (whichever is less) $5,000

$10,000 ($1,000 for children birth - 6 months) $10,000 $2,000

Life, Accidental Death and Dismemberment

Additional Information:

• Age reduction:

50% of original amount at age 75

• Age-bracketed premiums:

Premiums increase on plan anniversary after you enter next 5 year age group

• Evidence of Insurability (EOI) Form Is required for employees who do not enroll during their initial eligibility period. For those who enrolled in the 2024 plan year, one increment of coverage up to Guarantee Issue will be available for the 2026 plan year annual enrollment without EOI.

• Accelerated Benefit Option:

Allows you to apply for up to 75% of your insurance (not to exceed $500,000) if diagnosed with a terminal health condition.

Age of you or your spouse (spouse premium based off your spouse’s own age)

Your cost for each $1,000 of voluntary life...

Employee Spouse <25 $0.072 $0.042

25-29 $0.082 $0.051 30-34 $0.102 $0.068 35-39 $0.146 $0.076 40-44 $0.208 $0.085 45-49 $0.330 $0.127 50-54 $0.524 $0.195 55-59 $0.806 $0.365 60-64 $1.258 $0.560 65-69 $2.184 $1.077 70-74 $3.896 $1.077 75+ $7.634 $1.077

Employee/Spouse Life & AD&D Monthly Cost:*

If your coverage level is...

Your cost for each $1,000 of supplemental life is...

Child Life $0.225

Child AD&D $0.026

Dependent Children Monthly Cost:**

*AD&D coverage is available for $0.023 per $1,000 for you and/or your spouse. Note: The amount of AD&D must be in an equal amount as the voluntary life.

**You can elect in increments of $2,000 up to $10,000 of coverage. Note: If electing AD&D, increments must be equal to child voluntary life increments.

Important: Rates and cost per paycheck is calculated in Plansource during the enrollment process.

How to figure your voluntary life cost per paycheck:

• Indicate your elected benefit amount (EBA)

• Divide EBA by $1,000

• Find age rate from cost table

• Multiply answer of Step 2 by answer of Step 3

• Multiply answer of Step 4 by 12 then divide by

24 to calculate your cost per paycheck

Other Benefits Travel Assistance Program

Congratulations! You and your dependents now have access to the Travel Assistance Program provided by USAble . This program offers you a broad range of valuable travel and medical support services 24 hours a day, 365 days a year. With one simple phone call to our response center, you will be connected to a global network of providers to assist you when you travel 100 miles or more from home. The program vendor is AXA Travel Assistance as provided through USABle Life.

Travel Assistance

• Lost Documents and Luggage assistance

• Emergency cash/bail assistance

• Telephone interpretation

• General travel information

Medical Assistance

• Medical and dental referrals

• Medical evacuation or repatriation

• Hospital admission and critical care monitoring

• Dispatch of prescription medications

If you have any questions about the services or require assistance, please contact us at: 1 (866) 384.2786 OR +1 (630) 616.4536 (collect) OR medassist-usa@axa-assistance.us

The Dignity Planner

FUNERAL PLANNING MADE PERSONAL The Dignity Planner allows you to create a personalized funeral plan for yourself or a loved one. We all have unique passions and personal stories, and whether you’re planning a memorial for yourself or for a loved one, The Dignity Planner allows you to create a plan simply by answering a few questions. Dignity will take care of the rest of the details for yourself or a loved one. We all have unique passions and personal stories, and whether you’re planning a memorial for yourself or for a loved one, The Dignity Planner allows you to create a plan simply by answering a few questions. Dignity will take care of the rest of the details.

VISIT WWW.USABLELIFE.COM/DIGNITYPLANNER TO LEARN MORE.

Important Contacts

Benefit Carrier Phone # Web

Medical Florida Healthcare Plans 1-877-615-4022 www.fhcp.com

Dental Principal 1-800-986-3343 www.principal.com

Vision Eyemed 1-866-299-1358 (Pre-Enrollment) 1-866-939-3633 www.eyemed.com

Life USAble 1-(800) 370-5856 www.usable.com

Disclaimer

The information provided by Brown & Brown, Inc. and/or its affiliates (“Company”) in this Guidebook is advisory.

Separate plan documents explain each benefit in more detail, and the various benefits are controlled by the language of the plan documents. Benefits may be modified, added, or terminated at any time, at the Company's discretion, or by the insurance company. This information is provided for general information purposes only and should not be considered legal, tax, accounting or other professional advice or opinion on any specific facts or circumstances.

Readers are urged to consult their legal counsel, tax or other professional advisor concerning any legal, tax or related questions that may arise. Any tax information contained in this communication (including any attachments) is not intended to be used, and cannot be used, for purposes of (i) avoiding penalties imposed under the U. S. Internal Revenue Code or (ii) promoting, marketing or recommending to another person any tax-related matter. The Company assumes no liability whatsoever in connection with the use of such information or documents.

City of Holly Hill 1065 S.Ridgewood Ave.

Holly Hill, FL 32117

(386) 248-9420 www.hollyhillfl.org

This Benefit Guide provides a brief description of plan benefits. For more information on plan benefits, exclusions, and limitations, please refer to the Plan documents or contact the carrier/administrator directly. If any conflict arises between this Guide and any plan provisions, the terms of the actual plan document or other applicable documents will govern in all cases. Benefits are subject to modification at any time.