Att G2 - 2021 Dunn County Benefit Booklet.pdf

800.272.2443 | www.m3ins.com

Employee Benefits

Enrollment Guide

TABLE OF CONTENTS

Carrier Contacts 1

Medical Plan 2-3

Health Savings Account (HSA) 4

Flexible Spending Accounts (FSA) 5

Dental Plan 6

Voluntary Income Continuation Insurance (ICI) 7

Basic Life and AD&D Insurance 7

Voluntary Critical Illness Insurance 8

Voluntary Accident Insurance 9

457(b)/Roth IRA, Holidays, Vacation, Sick Leave 10

Required Federal Notices 11

HIPAA Notice of Special Enrollment Rights 12

HIPAA Notice of Privacy Rights 13-17

Women’s Health and Cancer Rights Act Enrollment Notice 18

Medicare Part D: Creditable Coverage Notice 19-21

Medicare Part D: Non-Creditable Coverage Notice 22-24

New Health Insurance Marketplace Coverage Options 25-26

Premium Assistance Under Medicaid and the Children’s

Health Insurance Program (CHIP)

26-29

This document is an outline of the coverage proposed by the carrier(s), based on information provided by your employer.

It does not include all of the terms, coverage, exclusions, limitations and conditions of the actual contract language.

The policies and contracts themselves must be read for those details. Policy forms for your reference will be made available upon request. The intent of this document is to provide you with general information regarding the status of and/or potential concerns related to, your current employee benefits environment. It does not necessarily fully address all of your specific issue. It should not be construed as, nor is it intended to provide, legal advice. Questions regarding specific issues should be addressed by your general counsel or an attorney who specializes in this practice area.

CARRIER CONTACTS

COVERAGE CARRIER CONTACT

Health Medica 1-800-883-2177 www.medica.com

FSA

Employee Benefits

Corporation

800-346-2126 www.ebcflex.com

Dental Anthem 1-866-589-0582 www.anthem.com

Employee Assistance Program FEI 1-800-782-1948 www.feinet.com

Life MN Life – Securian

Employee Trust Fund

866-295-8690 madisonbranch@securian.com

Accident The Standard 866-851-2429 www.standard.com

Critical Illness The Standard 866-851-2429 www.standard.com

Deferred Compensation ICMA-RC 800-669-7400 www.icmarc.org

401(a) ICMA-RC 800-669-7400 www.icmarc.org

Income Continuation The Hartford 800-960-0052 iciquestions@thehartford.com

OPEB / RHS ICMA-RC

800-669-7400 www.icmarc.org

Wisconsin Retirement System Employee Trust Fund 877-533-5020 etf.wi.gov

This document is an outline of the coverage proposed by the carrier(s), based on information provided by your employer. It does not include all of the terms, coverage, exclusions, limitations and conditions of the actual contract language. The policies and contracts themselves must be read for those details. Policy forms for your reference will be made available upon request. The intent of this document is to provide you with general information regarding the status of and/or potential concerns related to, your current employee benefits environment. It does not necessarily fully address all of your specific issue. It should not be construed as, nor is it intended to provide, legal advice. Questions regarding specific issues should be addressed by your general counsel or an attorney who specializes in this practice area.

MEDICAL PLANS

MEDICAL PLANS ELIGIBILITY

You get the most from your benefits when you take the time to learn about your options and make decisions that are best for you and your family. Dunn County provides eligible employees the choice of 2 medical plans administered by Medica.

The High Deductible Health Plan (Option #2) offers the lowest premiums, but you’ll have a higher deductible and will pay more before the plan starts to cover some of your costs. This plan also has access to a Health Savings Account (HSA) that can be used to save pretax dollars to pay for health care expenses.

You have the freedom to receive care from any licensed provider.

However, you generally pay less when you receive care from doctors, hospitals and other health care facilities that participate in your network. Find a participating health care provider in your area by going to: www.medica.com.

o All full-time employees o All part-time employees o All former employees – o 1st of the month following 30 days

AND THEIR:

o Spouses o Biological children, stepchildren, legally adopted children

(effective from the date place for adoption), and foster children up to age 26.

Monthly Incentive Payment � Full-time employees with a family who waive the County’s family health insurance plan and provide proof of family coverage from another source will receive a monthly incentive amount of

$75.

� Full-time employees with a family electing to take the County’s single health insurance coverage

OR single employees electing to completely waive medical coverage through the County will receive a monthly incentive amount of $50. Proof of other coverage is required to be eligible for this payment.

TERMS TO KNOW

DEDUCTIBLE

The amount you pay out of your pocket each year before the plan begins sharing costs for most services. Payments to in-network and out-of-network providers count toward your annual deductible and annual out-of-pocket maximum.

COPAY

The dollar amount you must pay for certain covered services. Payments count toward your annual out-of-pocket maximum but not toward your deductible.

OUT-OF-POCKET MAXIMUM (OOPM)

The most you’ll have to pay out of your pocket in a calendar year for covered services.

COINSURANCE

The cost share between you and the plan after you meet the calendar year deductible. In other words, after you meet your deductible, you share any remaining covered expenses with the plan. The plan covers the percentage of the expense shown.

IN-NETWORK COINSURANCE

PLAN PAYS 80%

YOU PAY 20%

MEDICAL PLAN HIGHLIGHTS

Medica

OPTION 1: PPO $3,000 HSA

Mayo or Passport Network – Embedded

OPTION 2: PPO $5,000 HSA

Mayo or Passport Network – Embedded

In-Network Out-of-Network In-Network Out-of-Network

DEDUCTIBLE

Single

Family

$3,000

$6,000

$12,000

$5,000

$10,000

$10,000

$20,000

COINSURANCE 80% 60% 80% 50%

OOPM

$24,000

$7,000

$14,000

$15,000

$30,000

IN-NETWORK COVERAGE IN-NETWORK COVERAGE

PREVENTIVE CARE Select Services Are FREE Select Services Are FREE

PHYSICIAN SERVICES

Deductible & Coinsurance

Deductible & Coinsurance

Deductible & Coinsurance

Deductible & Coinsurance

Deductible & Coinsurance

Convenient Care Clinic Primary Care

Specialty Care

Urgent Care

HOSPITAL SERVICES

Inpatient / Outpatient Deductible & Coinsurance Deductible & Coinsurance

EMERGENCY CARE Deductible & Coinsurance Deductible & Coinsurance

PRESCRIPTION DRUG

Out-of-Pocket Maximum

Applies Towards Medical

Applies Towards Medical

Retail 30 Day Supply

Generic

Preferred Brand

Non-Preferred Brand

Specialty Mail Order 90 Day Supply

Deductible & Coinsurance Deductible & Coinsurance

Refer to the Summary Plan Descriptions (SPDs) or Summary of Benefits Coverage (SBCs) for detailed medical plan coverage information.

MONTHLY RATES

OPTION 1

Mayo

Option 1

Passport

OPTION 2

Mayo

Option 2

Passport

Employee $78.58 $127.68 $44.48 $106.74

Family $158.96 $264.92 $96.02 $144.02

Public Safety Employee $78.58 $78.58 $44.48 $71.16

Public Safety Family $158.96 $211.93 $96.02 $192.04

HEALTH SAVINGS ACCOUNT

A Health Savings Account (HSA) allows you to pay for your health and dependent care expenses tax free.

For all health care-related accounts, eligibility is determined in part by which medical plan you choose.

HDHP COPAY PLAN

Health Savings Account

Limited Flexible Spending Account

HEALTH SAVINGS ACCOUNT (HSA)

Dunn County offers two medical plans that feature an HSA – the High Deductible Health Plans. An HSA is the only investment tool available where the money you save goes in tax-free, earns interest tax free and can be spent on qualified health care expenses tax-free.

If you are enrolled in the High Deductible Health Plan option, you may open an HSA account with the bank or institution of your choice.

HOW THE HSA WORKS

MONEY GOES IN

Pretax contributions* from you, up to a total of:

o $3,600 for individual coverage o $7,200 if you enroll your spouse and/or dependent child(ren).

o An extra $1,000 if you are age 55 or older

MONEY GOES OUT

You pay the full cost of non-preventive care, including non-preventive prescription drugs, until you meet the deductible. You receive discounted rates in-network.

When you have an eligible health care expense, **you decide whether to use your HSA if you’ve accumulated enough money to cover it or pay with other resources. Either way, those dollars count toward the medical plans’ deductible and out-of-pocket maximum. Any amount you spend on qualified medical expenses is also tax-free.

HAVE MONEY LEFT?

IT ROLLS OVER!

Any money left in your account is yours to pay for health care in the future.

There’s no deadline and no limit on how large your account can grow. If you leave

Dunn County, you can take it with you.

* If you’re enrolling during the year, you may not be eligible to make a full-year contribution to your HSA. Talk to your tax advisor before signing up for pretax deductions. See IRS Publication 969 for more information.

** The HSA can be used to reimburse you for qualified medical, dental, and vision expenses. See IRS Publication 502 for more information.

HSA ELIGIBILITY

o You must be enrolled in a HDHP o You cannot have any other

“impermissible coverage” which includes a spouse’s non-HDHP plan or FSA coverage o You or your spouse cannot be currently enrolled in Medicare o You cannot be claimed as a dependent on another person’s tax return

FLEXIBLE SPENDING ACCOUNTS (FSA)

With an FSA, you can set aside tax-free money to pay for eligible medical and dependent care expenses. When you participate in an FSA, you decide how much you want to contribute each plan year (Jan. 1 through Dec.

31). The money you contribute is deducted from your pay before taxes are taken out. This lowers your taxable income, which means lower taxes for you! However, you must use the amounts in your account by year-end or lose the balance.

Dunn County offers two types of FSAs administered by Employee Benefits Corporation.

LIMITED HEALTH CARE FSA

The expenses that are reimbursed by this FSA are limited to dental and vision care expenses in the plan year only. You’re eligible if you’re enrolled in the High Deductible Health Plan Option; use the Limited Health Care

FSA along with a Health Savings Account (HSA) and maximize your tax savings!

LIMITED FSA CONTRIBUTION LIMITS

Dunn County follows the indexed contribution limits set for this type of account by the Internal Revenue

Service (IRS). The contribution limits for the Limited Health Care FSA work on an individual employee/financial representative basis. The individual maximum is $2,750. However, if you and your spouse are both eligible for the same employer’s FSA, you can each contribute separately to have your own $2,750 cap.

DEPENDENT CARE FSA

The Dependent Care FSA covers the eligible day care expenses for your tax-qualified dependent(s). This can include a tax-qualified dependent under the age of 13 or an elderly parent or spouse who is physically or mentally incapable of self-care and lives with the account owner.

Unmarried individuals and married couples who file a joint tax return can contribute up to a maximum of

$5,000 per year. Individuals who are married and file taxes separately can contribute up to a maximum of

$2,500. You can’t contribute more than you or your spouse earned in income for the year. If you’re enrolling during the year, you may not be eligible to make the maximum contribution to your FSAs. Talk to your tax advisor before signing up for pretax deductions. See IRS Publication 502 for more information.

DENTAL

Healthy teeth and gums are an important part of maintain your overall health. That’s why Dunn County offers two dental plans administered by Anthem – the Dentacare and Indemnity (FreeStanding) Plans.

Anthem Dentacare - DHMO Indemnity

(FreeStanding)

INDIVIDUAL ANNUAL MAXIMUM None $1,000

DEDUCTIBLE

Employee Only

$0

PREVENTATIVE SERVICES

Exams

Cleanings

Fluoride Treatments

X-Rays

Space Maintainers

Sealants

Emergency Treatment to Relieve Pain (Deductible Applies)

100%

100%

100%

100%

100%

100%

100%

100%

100%

BASIC RESTORATIVE SERVICES

Fillings

Endodontics – Simple / Complex

Periodontics – Simple / Complex

Extractions – Simple / Complex and other oral surgery (Deductible Applies)

100%/50%

MAJOR RESTORATIVE SERVICES

Crowns, Inlays, Onlays

Bridges and Dentures

Repairs and Adjustments to Bridges and Dentures

Implants

50%

50%

50%

ORTHODONTIC SERVICES

Coinsurance

Individual Lifetime Maximum

Dependents Eligible to Age

Full-Time Students Eligible to Age

100% after Lifetime Max

$695/treatment

No age limit

$800/member

MONTHLY RATES EMPLOYER COST EMPLOYEE COST DHMO EMPLOYEE COST PPO

Employee $50 $91.91 $63.87

Employee + Spouse $50 $91.91 $63.87

Employee + Child(ren) $50 $91.91 $63.87

Family $50 $91.91 $63.87

PROTECTION

VOLUNTARY INCOME CONTINUATION INSURANCE (ICI)

The Income Continuation Insurance (ICI) benefit is a voluntary “income replacement” benefit payable if you become disabled. This insurance is available to employees who participate in the Wisconsin Retirement

System (WRS).

ICI provides replacement income for short- and long-term disabilities. This benefit is offered through The

Hartford. Rates are based on your earnings and elimination period.

ICI benefits provide up to 75% of your average monthly earnings based on your previous calendar year earnings rounded to the next highest $1,000 and divided by 21. For newly hired employees, your estimated annual earnings are rounded to the next highest $1,000 and divided by 12.

Before the benefit starts, you must serve an elimination period. You may selection an elimination period up to

180 days. You must be completely off work during this time.

ICI benefits will not duplicate benefits available from other WRS programs, The Social Security Administration, workers’ compensation, unemployment compensation or certain other sources.

For more details, see the Income Continuation Insurance Booklet on the Dunn County website.

https://www.co.dunn.wi.us/ici

BASIC LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT (AD&D)

Life Insurance provides financial security for the people who depend on you. Your beneficiaries will receive a lump payment if you pass away while employed by Dunn County. As an eligible employee, you are covered for

Basic Life and AD&D insurance at no cost to you. This benefit is offered through Securian.

Dunn County offers a Group Term Life Insurance benefit plus accidental death and dismemberment insurance coverage to employees who participate in the Wisconsin Retirement System (WRS).

Basic Life Insurance Plan provides coverage equal to the earnings paid to you by Dunn County during the previous calendar year rounded to the next higher $1,000 (unit of coverage). Eligible employees may purchase up to three additional units of life insurance coverage provided they have the Basic Plan. In addition, eligible employees may purchase 1 or 2 units of spouse/dependent coverage. Rates are based on age and amount of coverage.

For more details, see the ETF Information Booklet on the Dunn County website.

https://www.co.dunn.wi.us/lifeinsurance

PROTECTION (continued)

VOLUNTARY CRITICAL ILLNESS INSURANCE

It takes a lot to beat a serious illness. Unfortunately, it can also cost a lot. When you or a family member suffers a serious illness like a stroke or heart attack, Critical Illness Insurance can help with expenses that medical insurance doesn't cover like deductibles or out of pocket costs, or services like experimental treatment. Critical

Illness supplements your medical and your disability income insurance. The lump sum benefit is paid when you need it most, upon diagnosis, so you can rest assured that you will have funds to offset upcoming out of pocket costs, and that you'll have the flexibility to elect treatments with less worry about the cost. Review your options and enroll today!

Coverage for… Coverage Amount…

You $5,000-$50,000 in increments of $5,000

Your Spouse $5,000-$30,000 in increments of $5,000, as long as it’s not more than your coverage amount

Your Child(ren) through age 25 Automatically covered at 25% of your coverage amount

Guarantee Issue Amount: $20,000 for yourself or $10,000 for your spouse

Benefit Amount

< 30 30-39 40-49 50-59 60-70

$5,000 $1.60 $2.60 $5.55 $11.45 $21.65

$10,000 $3.20 $5.20 $11.10 $22.90 $43.30

$15,000 $4.80 $7.80 $16.65 $34.35 $64.95

$20,000 $6.40 $10.40 $22.20 $45.80 $86.60

$25,000 $8.00 $13.00 $27.75 $57.25 $108.25

$30,000 $9.60 $15.60 $33.30 $68.70 $129.90

$35,000 $11.20 $18.20 $38.85 $80.15 $151.55

$40,000 $12.80 $20.80 $44.40 $91.60 $173.20

$45,000 $14.40 $23.40 $49.95 $103.05 $194.85

$50,000 $16.00 $26.00 $55.50 $114.50 $216.50

Note: Child cost is included with employee election

PROTECTION (continued)

VOLUNTARY ACCIDENT INSURANCE

Accidents happen every day. Did you know almost 39 Million emergency room visits a year are due to an injury? If you were injured from an accident, chances are you will have expenses that you were not anticipating

– will you be prepared? Accident Insurance can help you deal with those expenses. Benefit payments can help you with your medical deductibles and co-pays, and cover household expenses like groceries, mortgage payments and childcare, which can begin to pile up if you have to take some time off from work. You are guaranteed coverage, so please enroll today!

What Your Benefits Cover Amount Covered

Emergency Care Benefits $25-$600

Specific Injury Benefits $50-$7,500

Dislocations $100-$3,000

Fractures $75-$5,500

Surgical Benefits $150-1,000

Surgery Facility Benefit: $50

Hospital Benefits $50 per day-$500

Follow-Up Care $25-$500

Accidental Death and Dismemberment (AD&D)

Accidental Death Benefit

You: $25,000 Spouse: $12,500 Child: $6250

In the event of a covered accidental dismemberment or impairment, this policy would pay a percentage of the Accidental Death benefit.

In the event of an accidental death, this policy would pay the full Accidental Death benefit. In certain scenarios, it would also pay an additional percentage of the Accidental Death benefit.

In the event of an accidental death, accidental dismemberment or accidental impairment of public safety officer that occurs in the line of duty, an additional 100% of the accidental death or accidental dismemberment or impairment benefit amount will also be paid.

Line of Duty Benefit 100% of AD&D Benefit

Coverage Monthly Premiums – The Standard

Employee Only $7.39/mo.

Employee + Child(ren) $13.05/mo.

Employee + Spouse $10.67/mo.

Employee + Spouse + Child(ren) $19.93/mo.

457(b) /Roth IRA

Employees may defer earned compensation on a pre-tax basis (Traditional) or after tax ROTH basis to a maximum of $19,500 for 2020. An additional $6,500 for 2020 may be deferred as catch-up contributions by participants age

50 and over.

Dunn County’s 457(b) plan is administered by ICMA-RC. Dunn County’s ROTH IRA plan is administered by Ron

Gloe. To enroll, make changes or manage your account, please contact Human Resources at

Admin_HR@co.dunn.wi.us or 715-232-2429.

HOLIDAYS

Full-time employees are eligible for paid holidays. Our holiday schedule includes the following for 2021:

HOLIDAY OBSERVANCE DATE

New Year’s Day Friday, January 1st

Spring Holiday Friday, April 2nd

Memorial Day Monday, May 31th

Independence Day Monday, July 5th

Labor Day Monday, September 6th

Thanksgiving &

Day After Thanksgiving

Thursday, November 25th

Friday, November 26th

Christmas Eve Thursday, December 23rd

Christmas Day Friday, December 24th

Vacation

Dunn County provides employees with paid vacation time while meeting the operational needs of Dunn County.

Vacation eligibility shall be determined on the basis of the length of service. See the Dunn County Employee

Handbook for specific details.

Sick Leave

Dunn County provides employees with paid time to address their own personal health care needs or the health care needs of an immediate family member. See the Dunn County Employee Handbook for specific details.

REQUIRED FEDERAL NOTICES

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 eligibility for that other coverage (or if the employer stops contributing towards your or your dependents' other coverage). However, you must request enrollment within 30 days after your or your dependents' other coverage ends (or after the employer stops contributing toward the other coverage).

If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children's health insurance program is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your dependents' coverage ends under Medicaid or a state children's health insurance program.

If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from

Medicaid or through a state children's health insurance program with respect to coverage under this plan, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days after your or your dependents' determination of eligibility for such assistance.

To request special enrollment or obtain more information, contact Heather Murray, HR Director, hmurray@co.dunn.wi.us, 715-231-2429.

HIPAA NOTICE OF PRIVACY PRACTICES

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.

Effective Date of Notice:

October 1, 2020

Who will follow this notice:

This notice describes the health information practices of Medica and that of any third party that receives medical information from or for us to assist us in providing your medical and dental benefits.

Our pledge to you:

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you.

This notice is required by the Standards for Privacy of Individually Identifiable Health Information regulations (the “Rule”).

This notice will tell you about the ways in which we may use or disclose medical information about you. It also describes our obligations and your rights regarding the use and disclosure of medical information.

We are required by law to:

� make sure that medical information that identifies you is kept private;

� give you this notice of our legal duties and privacy practices with respect to medical information about you; and

� follow the terms of the notice that is currently in effect.

HOW THE PLAN MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION

The following categories describe different ways that we use and disclose medical information, as permitted by law. The

Plan, its business associates, and their agents/subcontractors, if any, will use or disclose medical information to carry out treatment, payment and health care operations or other purposes permitted or required by law.

In addition, the Plan may contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you. The Plan will disclose your medical information to Dunn County for purposes related to treatment, payment and health care operations. The plan sponsor has amended its plan documents to protect your medical information as required by the Rule.

Treatment means the provision, coordination, or management of health care by one or more health care providers, or a health care provider and a third party.

HIPAA NOTICE OF PRIVACY PRACTICES (continued)

Payment means activities undertaken by a health plan to determine coverage responsibilities and payment obligations for the provision of health care, or activities undertaken by a health care provider, or a health plan to obtain or provide reimbursement for health care.

For example, the Plan may disclose to your provider that you are eligible for benefits.

Health Care Operations means activities directly related to the provision of health care or the processing of health information. This includes internal quality oversight review, credentialing and health care provider evaluation, underwriting, insurance rating and other activities related to creation, renewal or replacement of a contract of health insurance or health benefits.

For example, the Plan may use medical information about you to project future benefit costs.

The Plan will disclose medical information about you when required by federal, state or local law.

The Plan may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

The Plan may disclose medial information if you are a member of the armed forces and this is required by military command authorities.

The Plan may disclose medical information about you for workers’ compensation or similar programs.

The Plan may disclose medical information about you for public health activities. These activities may include the following:

� to prevent or control disease, injury or disability;

� to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;

The Plan may disclose medical information to a health oversight agency for activities authorized by law.

The Plan may disclose medical information about you if you are involved in a lawsuit or a dispute and we are responding to a court or administrative order. Also, the Plan may disclose medical information about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute.

The Plan may disclose medical information about you if asked to do so by law enforcement official, such as in response to a court order, subpoena, warrant, summons or similar process;

The Plan may disclose medical information to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death or other duties as authorized by law. Also, disclosure to funeral directors, as necessary to carry out their duties, is permitted.

The Plan may not disclose psychotherapy notes (under most circumstances), may not disclose protected health information for marketing purposes, and may not make disclosures that constitute a sale of protected health information unless authorized by the individual. Other disclosures not mentioned in this notice also require authorization from the individual.

The Plan may not disclose protected health information that is genetic information under the Genetic Information

Nondiscrimination Act (“GINA”) for underwriting purposes.

YOUR RIGHTS

You have the following rights regarding medical information the Plan maintains about you:

You have the right to request an inspection and a copy of your medical information contained in a “designated record set,” for as long as the Plan maintains your medical information in the designated record set.

“Designated record set,” means a group of records maintained by or for a health plan that is enrollment, payment, claims adjudication and care or medical management record systems maintained by or for a health plan; or used in whole or in part by or for the health plan to make decisions about individuals. Information used for quality control or for health care operations and not used to make decisions about individuals is not in the designated record set.

The Plan has the right to charge a reasonable, cost-based fee for providing a copy of your medical information or summary or explanation of your medical information.

The Plan has the right to deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed.

If you feel the medical information the Plan has about you is incorrect or incomplete, you may ask the Plan to amend the information. You have a right to request an amendment for as long as the information is kept by the Plan.

To request an amendment, your request must be in writing and should be addressed to the following individual Heather

Murray. All requests for amendment of your medical information must include a reason to support the requested amendment.

The Plan may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, the Plan may deny your request if you ask to amend information that:

� is not part of the medical information kept by or for the Plan;

� was not created by the Plan, unless the person or entity that created the information is no longer available to make the amendment;

� is not part of the information which you would be permitted to inspect and copy.

You have the right to request an “accounting of disclosures,” where such disclosure was made for any purpose other than treatment, payment or health care operations. Additionally, no accounting of disclosures will be made for the following reasons:

� if the disclosure was made to the individual about his or her own medical information;

� if the disclosure was made pursuant to an authorization;

� if the disclosure was made to certain person involved in your care or payment for your care;

� if the disclosure was made prior to the compliance date of April 14, 2003.

To request an accounting of disclosures, address your request to the following individual: Heather Murray.

If you request more than one accounting in a 12-month period, the Plan can charge a reasonable, cost-based fee for each subsequent accounting, unless you withdraw or modify the request for a subsequent accounting to avoid or reduce the fee.

You have the right to request a restriction or limitation on the medical information the Plan uses or discloses about you for treatment, payment or health care operations. You have the right to request a limit on the medical information the

Plan discloses about you to someone who is involved in your care or payment for your care, such as friends or family members.

The Plan is not required to agree with your request.

You have the right to restrict certain disclosures of protected health information to a health plan where you pay out of pocket in full for the health care item or service.

To request restrictions, you must make your request in writing to the following individual: Heather Murray. The request must include (a) what information you want to limit, (b) whether you want to limit the Plan’s use, disclosure or both, and

(c) to whom you want the limits to apply.

You have the right to request to receive communications of your medical information from the Plan by alternative means or at alternative locations if you clearly state that the disclosure of all or part of the information could endanger you. The

Plan will accommodate all such reasonable requests.

You will be required to request confidential communications of your medical information in writing. The request should be addressed to the following individual: Heather Murray.

You have the right to a paper copy of this notice. You may ask the Plan to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To obtain a paper copy of this notice, contact the following individual: Heather Murray .

You have the right to be notified following a breach of unsecured protected health information.

If you believe your privacy rights have been violated, you may complain to the Plan. Any complaint must be in writing and addressed to the following individual: Heather Murray.

You may also file a complaint with the Secretary of Health and Human Services.

The Plan will not retaliate against you for filing a complaint. The Plan will only release the minimum amount of PHI necessary to complete the required task or request.

Other uses or disclosures of your medical information not covered by this notice or the laws that apply will be made only with your written authorization, subject to your right to revoke such authorization. You may revoke the authorization at any time, providing the revocation is done in writing. You understand that the Plan is unable to take back any disclosures already made with your permission.

WOMEN’S HEALTH AND CANCER RIGHTS ACT (WHCRA) ENROLLMENT NOTICE

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

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

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

� Prostheses; and

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

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. Please see your Summary of Benefits and Coverage (SBC) for deductible and coinsurance information.

If you would like more information on WHCRA benefits, call your Plan Administrator Heather Murray at 715-231-2429.

MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE OMB 0938-0990

FOR USE ON OR AFTER APRIL 1, 2011

MEDICARE PART D: CREDITABLE COVERAGE NOTICE

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Medica 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. MEDICA has determined that the prescription drug coverage offered by Dunn County is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

WHEN CAN YOU JOIN A MEDICARE DRUG PLAN?

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

December 7th.

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

CMS Form 10182-CC Updated April 1, 2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850

MEDICARE PART D: CREDITABLE COVERAGE NOTICE (continued)

WHAT HAPPENS TO YOUR CURRENT COVERAGE IF YOU DECIDE TO JOIN A MEDICARE DRUG PLAN?

If you decide to join a Medicare drug plan, your current MEIDCA coverage will not be affected.

If you do decide to join a Medicare drug plan and drop your current MEDICA coverage, be aware that you and your dependents will be able to get this coverage back.

WHEN WILL YOU PAY A HIGHER PREMIUM (PENALTY) TO JOIN A MEDICARE DRUG PLAN?

You should also know that if you drop or lose your current coverage with MEDICA 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: Heather Murray, HR Director

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 MEIDCA changes. You also may request a copy of this notice at any time.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland

21244-1850.

MEDICARE PART D: CREDITABLE COVERAGE NOTICE (continued)

FOR MORE INFORMATION ABOUT YOUR OPTIONS UNDER MEDICARE PRESCRIPTION DRUG COVERAGE...

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook.

You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:

• Visit www.medicare.gov

• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare &

You” handbook for their telephone number) for personalized help

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

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213

(TTY 1-800-325-0778).

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

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland

MODEL INDIVIDUAL NON-CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE OMB 0938-0990

MEDICARE PART D: NON-CREDITABLE COVERAGE NOTICE

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with MEDICA 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. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are three 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. MEDICA has determined that the prescription drug coverage offered by Dunn County is, on average for all plan participants, NOT expected to pay out as much as standard Medicare prescription drug coverage pays.

Therefore, your coverage is considered Non-Creditable Coverage. This is important because, most likely, you will get more help with your drug costs if you join a Medicare drug plan, than if you only have prescription drug coverage from the [Insert Name of Plan]. This also is important because it may mean that you may pay a higher premium (a penalty) if you do not join a Medicare drug plan when you first become eligible.

3. You can keep your current coverage from Dunn County. However, because your coverage is non-creditable, you have decisions to make about Medicare prescription drug coverage that may affect how much you pay for that coverage, depending on if and when you join a drug plan. When you make your decision, you should compare your current coverage, including what drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. Read this notice carefully - it explains your options.

WHEN CAN YOU JOIN A MEDICARE DRUG PLAN?

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

December .7th

CMS Form 10182-NC Updated April 1, 2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland

MEDICARE PART D: NON-CREDITABLE COVERAGE NOTICE (continued)

WHEN WILL YOU PAY A HIGHER PREMIUM (PENALTY) TO JOIN A MEDICARE DRUG PLAN?

Since the coverage under MEDICA is not creditable, depending on how long you go without creditable prescription drug coverage you may pay a penalty to join a Medicare drug plan. Starting with the end of the last month that you were first eligible to join a Medicare drug plan but didn’t join, if you go 63 continuous days or longer without prescription drug coverage that’s creditable, 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 (penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

WHAT HAPPENS TO YOUR CURRENT COVERAGE IF YOU DECIDE TO JOIN A MEDICARE DRUG PLAN?

If you decide to join a Medicare drug plan, your current MEDICA coverage will not be affected If you do decide to join a Medicare drug plan and drop your current MEDICA coverage, be aware that you and your dependents will not be able to get this coverage back.

MEDICARE PART D: NON-CREDITABLE COVERAGE NOTICE (continued)

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 Dunn County 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).

NEW HEALTH INSURANCE MARKETPLACE COVERAGE OPTIONS

GENERAL INFORMATION

When key parts of the health care law took effect, you were eligible for a new way to buy health insurance: the Health

Insurance Marketplace. To assist you as you look at options for you and your family, this notice provides some basic information about the new Marketplace and the employment based coverage offered to you.

WHAT IS THE HEALTH INSURANCE MARKETPLACE?

The Marketplace is designed to help you find private health insurance that meets your needs and fits your budget. The

Marketplace offers “one-stop shopping” to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Annual open enrollment for private health insurance coverage through the Marketplace runs during the months of November, December, January and February.

The specific timeline will be announced each year.

CAN I SAVE MONEY ON MY HEALTH INSURANCE PREMIUMS IN THE MARKETPLACE?

You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn’t meet certain standards. The savings on your premium that you are eligible for depends on your household income.

DOES THE HEALTH INSURANCE WE OFFER TO YOU AFFECT YOUR ELIGIBILITY FOR PREMIUM SAVINGS

THROUGH THE MARKETPLACE?

Yes. If we have offered you health coverage that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in our health plan. However, you may be eligible for a tax credit that lowers your monthly premium or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of self-only coverage under our health plan is more than 9.83% of your household income for the year, or if our health plan does not meet the "minimum value"1 standard set by the

Affordable Care Act, you may be eligible for a tax credit.

Note: If you purchase a health plan through the Marketplace instead of accepting our health plan coverage, then you may lose our contribution (if any) to your coverage under our health plan. Also, our contribution – as well as your employee contribution – is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis.

HOW CAN I GET MORE INFORMATION ABOUT THE MARKETPLACE?

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the marketplace and its cost. You can visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.

An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs.

NEW HEALTH INSURANCE MARKETPLACE COVERAGE OPTIONS (continued)

If you complete an application for coverage through the Marketplace, you will be asked for…