Exhibit C - Employee Guide.pdf

2023 - 2024

EMPLOYEE BENEFITS GUIDE

Questions 3

Open Enrollment 4

Eligibility 5

Medical Coverage 6

Additional Medical Benefits 7

Heath Saving Account (HSA) 8

Flexible Saving Account (FSA) 9

Dental Coverage 10

Vision Coverage 11

Cost for Coverage 12

Allstate Coverage 13

Employee Assistance Program (EAP) 14

Terms to Know 15

Where to Go Guide 16

Annual Notices 17

YOUR BENEFITS PACKAGE

Please review this guide to learn about the benefit options available to you by Northwestern Community Services

Board. When you make well-informed decisions, you can help reduce your out-of-pocket health care costs, and help control the rising costs of health care premiums.

This Benefit Summary does not provide all of the details about all of the benefit programs. Additional information is available by request from the Human Resources

Department.

This brochure summarizes the coverage that is available during the 2023-2024 plan year. If you have any questions, please contact Human Resources.

Benefit Contact Telephone Website

Medical and Pharmacy Cigna 866-494-2111 www.myCigna.com

Dental Cigna 800-244-6224 www.myCigna.com

Vision Cigna 800-244-6224 www.myCigna.com

Health Savings Accounts

(HSA)

Flores 800-532-3327 www.flores247.com

Flexible Spending Accounts (FSA) Flores 800-532-3327 www.flores247.com

Virginia Retirement

System (VRS) VRS 888-827-3847 www.varetire.org

Employee Assistance

Program (EAP) Cigna 877-622-4327 www.myCigna.com

QUESTIONS?

http://www.mycigna.com/ http://www.mycigna.com/ http://www.mycigna.com/ http://www.flores247.com/ http://www.flores247.com/ http://www.varetire.org/ http://www.mycigna.com/

OPEN ENROLLMENT

Each year we have an annual Open Enrollment period for benefit plans. During Open Enrollment you may make changes to your benefit program (change plans, add or delete eligible dependents, etc).

Open enrollment is in May with all changes taking effect on July 1, 2023 through June 30, 2024. In order to receive the benefits you want for the new fiscal year, you must complete all appropriate forms. All forms must be emailed to benefits@nwcsb.com.

If your open enrollment forms are not received by the close of business on

May 19, 2023, you will be enrolled in all benefits comparable to your 2023 – 2024 elections, with the exception of the Flexible Spending Account which you will forfeit.

Late enrollment forms will not be accepted.

If you have questions or need assistance, please do not hesitate to contact us:

benefits@nwcsb.com or hrteams@nwcsb.com

REMEMBER!

All Open Enrollment

Forms Must Be

Submitted to benefits@nwcsb.com by Close of Business on May 19, 2023.

ELIGIBILITY

Employees working on average 30 hours or more per week are eligible for Northwestern Community Services

Board benefits.

New employees are eligible for benefits on the first of the month following date of hire.

You may enroll your eligible dependents in the same plans you choose for yourself. Eligible dependents include your legal spouse and your children up to age 26.

WHEN TO ENROLL

You can enroll for coverage within 30 days of your hire date, qualifying event, or during the annual open enrollment period. If you do not enroll for coverage within 30 days of your eligibility date, you will not be able to elect coverages during the Plan Year unless you have a qualified change in family status.

MAKING CHANGES

The choices you make when you are first eligible remain in effect for the plan year which ends on June 30, 2023. Once you enroll for coverage, you must wait until the next open enrollment period to change your benefits and add or remove coverage for dependents, unless you have a qualified change in family status as defined by the IRS.

The following are a few examples:

◼ Marriage, divorce, legal separation, or annulment

◼ Birth or adoption of a child

◼ Loss of other health coverage

◼ Change in health coverage due to your spouse’s annual Open Enrollment period

◼ Change in eligibility for you or a dependent for Medicaid or Medicare

◼ Change in your or your spouse’s work status that affects your benefits or an eligible dependent’s benefits

Under IRS code:

You or your dependent must request enrollment within 30 days after losing eligibility for coverage or after a marriage, birth, adoption, or placement for foster care.

You or your dependent must request enrollment within 60 days of the loss of coverage under a State CHIP or Medicaid program or the determination of eligibility for premium assistance under those programs.

Plan Details

In Network Coverage $1,500 Deductible $3,000 Deductible HSA

Deductible (Single/Family) $1,500/$3,000 $3,000/$6,000

Out of Pocket Max (Single/Family) $6,000/$12,000 $6,550/$13,100

Coinsurance 30% 30%

Physician Office Visit $30 copay Deductible then 30%

Specialist Office Visit $50 copay Deductible then 30%

Preventive Care 100% covered 100% covered

Urgent Care $50 copay Deductible then 30%

Emergency Room Deductible then 30% Deductible then 30%

Labs & X Rays Labs (lab facility) 100% covered, X-Rays Deductible then 30% Deductible then 30%

Diagnostic Services (MRI, PET, etc.) Deductible then 30% Deductible then 30%

Outpatient Hospital Services Deductible then 30% Deductible then 30%

Inpatient Hospital Services Deductible then 30% Deductible then 30%

Prescription Drugs

Retail Copay (30 day supply)

Tier 1/Tier 2/Tier3/Tier 4 $10/$40/$60/20% Deductible then 30%

Mail Order Copay (90 day supply)

Tier 1/Tier 2/Tier 3/Tier 4 $25/$100/$150/20% Deductible then 30%

Out of Network Coverage

Deductible (Single/Family) $3,000/$6,000 $6,000/$12,000

Coinsurance 50% 50%

Out of Pocket Max (Single/Family) $12,000/$24,000 $13,100/$26,200

This is a summary of benefits for informational purposes only. Please refer to the Carrier Certificate of Coverage for complete terms of coverage and eligibility.

MEDICAL COVERAGE

As a foundation for your good health, Northwestern Community Services Board provides a selection of medical plans offering quality, flexibility and value. Choose the plan that best meets your needs.

Visit www.myCigna.com or download the myCigna app for additional features such as view benefits, check deductible and out of pocket max balances, find providers, manage claims, manage prescriptions, view health programs, and much more!

www.unifedtrust.com

ADDITIONAL CIGNA BENEFITS

myCigna Online and Mobile App Using www.myCigna.com or the myCigna mobile app you can find in network providers, review coverage, manage and track claims, view print and fax ID card, see cost estimates for medical procedures and prescription drugs, compare quality of care information for doctors and hospitals, compare cost for 30 and

90 day medications and see any lower cost drug alternatives available, find retail pharmacy's that offer a 90 day supply of your prescription, access a variety of health and wellness tools, along with much more.

24/7/365 Cigna Support 866-494-2111 Cigna’s member services is available around the clock to help you with any questions or needs.

Health Information Line 866-494-2111 Know before you go. Speak with a clinician who can help you understand and make informed decisions about health issues you are experiencing, at no extra cost.

Care Management Programs www.myCigna.com

Personal services to help you with your personal health needs. A Cigna case manager can work closely with you and your doctor to check on your progress. You can get help with conditions and illnesses such as cancer, renal disease, neonatal care, and pain management.

My Health Assistant www.myCigna.com

Programs to help you control stress, lose weight or eat better, enjoy exercise, quit tobacco, manage your diabetes, COPD, asthma, and other conditions.

Virtual Visits – MDLIVE Connect with a board-certified doctor via video chat or phone from your home, office, or on the go. You can get the care you need along with most prescriptions for many minor conditions. Minor conditions such as allergies, asthma, bronchitis, colds and flu, ear infections, headaches, insect bites, joint aches and pains, nausea and vomiting, pink eye, poison ivy, rashes, respiratory infections, sinus infections and sore throats.

Download the MDLIVE mobile app or register online or by phone www.MDLIVEforCigna.com 888-726-3171 http://www.mycigna.com/ http://www.mycigna.com/ http://www.mdliveforcigna.com/

What are the advantages of participating?

◼ Pre-tax savings – never pay the federal government taxes on your HSA funds as long as you spend the money on eligible IRS 213(d) health care (medical, dental, vision) expenses

◼ Unused funds carry over from year to year and can build over time

◼ Complete control over how and when funds are used

◼ Balances over a certain amount may have investment opportunities

◼ Funds remaining in your account after you reach the age of 65 can be used for non-medical expenses with ordinary taxes paid, similar to a 401(k)

◼ HSAs are portable; if you leave the company, you can take the account and all funds in it with you

HEALTH SAVINGS ACCOUNT (HSA)

When you elect to enroll in the HDHP medical plan, you are eligible to open a Health Savings Account (HSA). An

HSA allows you to save money on a tax-free basis to use for your out-of-pocket health care expenses. You are the owner of this account, and unlike a traditional Flexible Spending Account, your funds can roll over from year-to-year and build over time. If you are new to the HDHP medical plan, this account will be set up for you after you complete the Flores HSA paperwork. You have the opportunity to have pre-tax dollars deducted from your paycheck and deposited into this account, or you can make post-tax deposits as you wish.

For the 2023 plan year, an individual can contribute up to

$3,850 or $7,750 for a family.

Ages 55+ may contribute an additional $1,000 catch-up.

What are the advantages of participating?

◼ Pre-tax savings – never pay the federal government taxes on your HSA funds as long as you spend the money on eligible

IRS 213(d) health care (medical, dental, vision) expenses

◼ Unused funds carry over from year to year and can build over time

◼ Complete control over how and when funds are used

◼ Balances over a certain amount may have investment opportunities

Access your HSA account information 24/7 www.flores247.com or call 800-532-3327 http://www.flores247.com/

FLEXIBLE SPENDING ACCOUNTS (FSA)

HEALTH FSA and DEPENDENT CARE FSA

Flexible Spending Accounts (FSAs) allow you to pay for eligible health care and dependent care expenses with pre-tax dollars. The money you contribute to the FSAs is payroll-deducted pre-tax, saving you income and Social Security taxes.

Each year you participate in the FSAs, you must elect the amount you want to contribute to each account. Your contributions will be deducted from your paychecks in equal installments throughout the year and deposited into your account(s). Both accounts function independently. When you incur expenses, you can access the funds in your account to pay for eligible health care or dependent care expenses.

Accessing Your FSA Funds

When enrolling in an FSA, Flores, will issue you a debit card to pay for your expenses.

Eligible expenses for the Health Care FSA include medical, dental, and vision expenses not covered under your health care plans, e.g. office visit copays, drug copays, expenses subject to your deductible, orthodontia, eyeglasses, etc.

Eligible expenses for the Dependent Care FSA are those that allow you and your spouse (if you are married) to pay for care for dependents while you work. These services generally include day care, most day camps, and caregivers for disabled dependents.

Rules to Keep in Mind

FSAs offer big tax advantages, but are subject to IRS regulations:

◼ The IRS has a “use it or lose it” rule: $570 from the current plan year for your Health Care FSA will roll over to the following plan year however any funds remaining over the $570 roll over will be forfeited.

◼ Once you enroll in the FSAs, you cannot change your contribution amount during the year unless you experience a qualified status change, such as marriage, or birth of a child.

◼ You cannot transfer funds from one FSA to another.

For the 2023 Plan Year you may contribute up to $3,050 to the Health Care FSA and

$5,000 to the Dependent Care

FSA.

FSA Reminders

◼ “Use-it-or-lose-it” unused Health Care amounts over the $570 roll over amount will be forfeited, so estimate your contribution wisely

◼ Save your receipts - No matter how you access your FSA funds, be sure to keep your receipts to validate your reimbursements

◼ Eligible expenses must be incurred only during the plan year you are enrolled

◼ You must re-enroll each year if you wish to continue funding the account

Access your FSA account information 24/7 www.flores247.com or call 800-532-3327 http://www.flores247.com/

Visit Your Dentist Regularly

Regular preventive visits to your dentist can help protect your health. According to the Centers for Disease

Control and Prevention, there may be associations between oral infections and diabetes, heart disease, stroke, and preterm, low-weight births. Research is underway to further examine these connections.

View dental benefits online or search for providers

Visit www.myCigna.com

DENTAL COVERAGE

In and Out of Network

Annual Deductible

Individual

Family

$50

$150

Annual Maximum Paid by Plan Per Member $1,000

Diagnostic and Preventive Services

X-rays, Cleanings, Exams 100%

Basic and Restorative Services

Fillings, Extractions, Root Canals 80%

Major Services

Dentures, Crowns, Bridges, Implants 50%

Orthodontia (Age 18 and Under) 50%

Orthodontia Lifetime Max $1,000

Strong teeth and gums are an important part of good health. Dental Insurance helps you pay for most necessary dental services and supplies, including diagnosis and preventive care, basic and restorative services and major services.

http://www.lfg.com/

VISION CARE

The vision plan includes benefits for eye exams, eyeglasses, and contact lenses. Visit an in-network provider to take advantage of higher benefits coverage.

Plan Benefit In-Network You Pay Frequency

Exam $10 copay Once every 12 months

Lenses Single Vision

Lined Bifocal

Lined Trifocal

Lenticular

$25 copay Once every 12 months

Frames Up to $150 allowance Once every 24 months

Contacts (in lieu of glasses) Up to $150 allowance Once every 12 months

A qualified vision care professional can help treat and manage:

▪ Cataracts

▪ Corneal diseases

▪ Diabetic retinopathy

▪ Eye infections

▪ Glaucoma

▪ Macular degeneration

Did you know?

Taking care of your vision can also mean early detection for symptoms of:

▪ Diabetes

▪ Hypertension

▪ High cholesterol

▪ Tumors

▪ Thyroid disorders

▪ Neurological disorders

Visit www.myCigna.com to view benefits and find a provider.

COST FOR YOUR 2023 HEALTH COVERAGE

Premiums listed are per month

MEDICAL

Per Month

Employee Only Employee

Children

Employee

Spouse Family

$1,500

Deductible Plan $165.67 $341.94 $838.30 $1,340.63

$3,000 HSA

Deductible Plan $50.00 $198.02 $609.39 $1,024.72

DENTAL

Per Month

Employee Only Employee

Children

Employee

Spouse Family

$41.72 $103.05 $80.79 $149.53

VISION

Per Month

Employee Only Employee

Children

Employee

Spouse Family

$7.09 $14.33 $14.19 $22.87

NOTES

ALLSTATE COVERAGE

ACCIDENT INSURANCE

Today, active lifestyles in or out of the home may result in bumps, bruises and sometimes breaks. Getting the right treatment can be vital to recovery, but it can also be expensive. And if an accident keeps you away from work during recovery, the financial worries can grow quickly. Allstate coverage can help pick up where other insurance leaves off and provide cash to help cover the expenses. Allstate coverage pays you cash benefits that correspond with hospital and intensive care confinement. The plan also includes coverage for a variety of occurrences, such as: dismemberment; dislocation or fracture; ambulance services; physical therapy and more. The cash benefits can be used to help pay for deductibles, treatment, rent and more.

CRITICAL ILLNESS INSURANCE

No one is ever really prepared for a life-altering critical illness diagnosis. The whirlwind of appointments, tests, treatments and medications can add to your stress levels. Critical Illness coverage helps provide financial support if you are diagnosed with a covered critical illness. With the expense of treatment often high, seeking the treatment you need could seem like a financial burden. When a diagnosis occurs, you need to be focused on getting better and taking control of your health, not stressing over financial worries.

With Allstate you choose benefits to protect yourself and any family members if diagnosed with a critical illness. Then, if diagnosed with a covered critical illness, you will receive a cash benefit based on the percentage payable for the condition.

HOSPITAL INDEMNITY INSURANCE

Life is unpredictable. Without any warning, an illness or injury can lead to a hospital confinement and medical procedures and/or visits, which may mean costly out-of-pocket expenses. Expenses associated with a hospital stay can be financially difficult if money is tight and you are not prepared. But having the right coverage in place before you experience a sickness or injury can help eliminate your financial concerns and provide support at a time when it is needed most. Hospital Indemnity insurance pays a cash benefit for hospital confinements, this benefit is payable directly to you. It is increasingly important to not only protect your finances if faced with an unexpected illness, but also to empower yourself to seek the necessary treatment.

GROUP WHOLE LIFE INSURANCE

With Group Whole Life Insurance you can provide your family with financial peace of mind for the future and the journey to get there. Not only do you get protection for your lifetime, but you also have the ability to build cash value as you go. With Group Whole Life Insurance you get simplified and straightforward coverage. You decide how much coverage and who to cover. You get guaranteed rates for the life of the policy and a guaranteed death benefit to be paid to your beneficiaries. As the policy builds cash value, you can achieve your financial goals or borrow against it should you need to.

counselor in your area. Video-based sessions arealso available to fit your busy schedule.

Le ga l assistance: 30-minute consultation withan attorney, face-to-face or by phone.*

Financial: 30-minute telephone consultation with a qualified specialist on topics such as debt counseling or planning for retirement.

· Parenting: Resources and referrals for childcare providers, before and after school programs,camps, adoption organizations, child development,prenatal care and more.

Eldercare: Resources and referrals for home health agencies, assisted living facilities, social and recreational programs and long-distance caregiving.

Pet care: Resources and referrals for petsitting, obedience training, veterinarians and pet stores.

Identity theft: 60-minute consultation with a fraud resolution specialist.

H O W C A N W E

H E L P Y O U T O DA Y ?

The C i g n a Employee Assistance Program ( E A P ) has you covered.

As an employee of Northwestern Community Services Board you have access to the valuable Cigna Employee

Assistance Program (EAP) at no cost to you.

EAP personal advocates will work with you and your household family members to help you resolve issues you may be facing, connect you with the right mental health professionals, direct you to a variety of helpful resources in your community andmore.

Take advantage of a wide range of services offered at no cost to you

· 3 face-to-face counseling sessions witha

We’re here to listen. Contact us any day, anytime.

Contact us any day, anytime.

Call 877-622-4327 or visit myCigna.com.

Employer ID: NCSB

(for initial registration)

*Assistance with employment-related legal issues is not available through this program.

Some work/life services offered under the Cigna Employee Assistance Program may be provided by a Cigna contracted third-party vendor.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Behavioral Health, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. All pictures are used for illustrative purposes only.

838614 f 04/19 © 2019 Cigna. Some content provided under license.

TTY/TDD users call 711

TERMS TO KNOW

Copay – A fixed amount you pay for covered health care services, typically paid at time of visit.

Deductible - Amount an employee pays out of pocket prior to the insurance company paying a percentage of the provider charges.

Coinsurance - The amount of payment split between the employee and the insurance company.

Example: Insurance company pays 70% and employee pays 30% of the charges after the deductible is met.

Out of Pocket Maximum - The maximum an employee is responsible for paying out of pocket in any one calendar year prior to the insurance company paying the entire eligible amount for the remaining of the calendar year.

In-Network Providers - Doctors, Hospitals and other healthcare providers who have an agreement/contract with insurance companies agreeing to charge a discounted amount for services they render.

Pre-Authorization - Certain procedures or hospitalizations may require that the provider receive authorization. The provider is typically the one to go through this process with the insurance company and obtain pre-authorization.

Pre-Determination - If you are having a major procedure done, your doctor or dentist can submit a pre-determination to the insurance company so you can know in advance of treatment how much of the bill you will be responsible for.

Explanation of Benefits (EOB) - The EOB is mailed to the employee after a claim is received and processed by the insurance company. The EOB will describe how the claim was processed and outline what portion of the charges are applied to the deductible, what portion the employee is responsible for, and explain if there is a denial or error processing the claim.

Appeal - If your health insurance company doesn’t pay for a specific health care provider or service, you have the right to appeal the decision and have it reviewed by an independent third party.

WHERE TO GO GUIDE

The cost for care and time you wait can vary greatly depending on where you go. Below is a simple guide to choosing the right place to go for health care

Conditions Treated* Your Cost & Time

Emergency Room

For the immediate treatment of critical injuries or illness. If a situation seems life-threatening, call 911 or go to the nearest emergency room.

Open 24/7.

· Sudden numbness, weakness

· Uncontrolled bleeding

· Seizure or loss of consciousness

· Shortness of breath

· Chest pain

· Head injury/major trauma

· Blurry or loss of vision

· Severe cuts or burns

· Overdose

· Costs are highest

· No appointment needed

· Wait times may be long, averaging over 4 hours

Urgent Care Center

For conditions that are not life threatening. Staffed by nurses and doctors and usually have extended hours.

· Minor cuts, sprains, burns, rashes

· Fever and flu symptoms

· Headaches

· Chronic lower back pain

· Joint pain

· Minor respiratory symptoms

· Urinary tract infections

· Costs are lower than an ER visit

· No appointment needed

· Wait times vary

Doctor’s Office

The best place to receive routine or preventive care, track medications, or get a referral to see a specialist.

· General health issues

· Preventive services

· Routine checkups

· Immunizations and screenings

· May include coinsurance and/or deductible

· Appointment usually needed

· May have little wait time

Virtual Medicine

Virtual visits with a doctor anytime 24/7/365 via computer with webcam capability or smartphone mobile app.

· Cold and flu symptoms such as a cough, fever and headaches

· Allergies

· Sinus infections

· Family health questions

· Cost is lower than office visit

· No appointment needed

· Immediate, private, and secure visits

*List is not all inclusive. To find a specific health care facility or doctor, go to your medical carrier’s website or call the number on your ID card. The listing of a health care professional or facility in the online directory does not guarantee that the services rendered by that professional or facility are covered under your specific medical plan. Check your official plan document for information about the services covered under your plan benefits. The information provided here is for informational purposes only. During a medical emergency, you should always visit the nearest hospital or call 911 for assistance.

C o st

T im e

GREATER

LOWER

Annual Notices

For purposes of this notice, the Plan Administrator is:

Melissa Shaffer-Reyes, 540-636-4250

Medicare Part D Creditable Coverage Notice

Important Notice from Northwestern Community Services Board

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 offered by the

Cigna Medical through Northwestern Community Services Board 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. Northwestern Community Services Board has determined that the prescription drug coverage offered by the Cigna Medical 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 through 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, your current coverage through Northwestern Community Services Board will not be affected. You can keep this coverage if you elect Part D, and this plan will coordinate with Part D coverage.

If you decide to join a Medicare drug plan and drop your current group health coverage through Northwestern Community Services Board, be aware that you and your dependents will be able to get this coverage back. If you are able to get this coverage back, reentry into the plan is subject to the underlying terms of the Plan.

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 group health coverage through Northwestern Community Services Board 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 Plan Administrator listed below for further information. NOTE: You’ll get this notice each year or if the creditable coverage status of this plan through Northwestern Community Services Board changes. You 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).

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/ http://www.socialsecurity.gov/

Notice of Privacy Practices 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.

Your Rights

You have the right to:

• Get a copy of your health and claims records

• Correct your health and claims records

• Request confidential communication

• Ask us to limit the information we share

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

• Get a copy of this privacy notice

• Choose someone to act for you

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

Your Choices

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

• Answer coverage questions from your family and friends

• Provide disaster relief

• Market our services and sell your information

Our Uses and Disclosures

We may use and share your information as we:

• Help manage the health care treatment you receive

• Run our organization

• Pay for your health services

• Administer your health plan

• Help with public health and safety issues

• Do research

• Comply with the law

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

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

• Respond to lawsuits and legal actions

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

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 th is.

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

Request confidential communications

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

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

Ask us to limit what we use or share

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

• We are not required to agree to your request, and we may say “no” if it would affect your care.

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 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 wil l 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 on page 1.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200

Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

Your Choices

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

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

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

• Share information in a disaster relief situation

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

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

• Marketing purposes

• Sale of your information

Our Uses and Disclosures

How do we typically use or share your health information?

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

Help manage the health care treatment you receive

We can use your health information and share it with professionals who are treating you.

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

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.

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.

How else can we use or share your health information?

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

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

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

Do research

We can use or share your information for health research.

Comply with the law

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

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

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

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

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

We can use or share health information about you:

• For workers’ compensation claims

• For law enforcement purposes or with a law enforcement official

• With health oversight agencies for activities authorized by law

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

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

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

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

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

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

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

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, and we will mail a copy to you.

WHCRA Enrollment/Annual Notice

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. If you would like more information on WHCRA benefits, call your plan administrator as identified at the end of these notices.

Annual Notice

Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema?

Newborns’ Act Disclosure

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

Special Enrollment Notice

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

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

Finally, if you or an eligible dependent has coverage under a state Medicaid or child health insurance program and that coverage is terminated due to a loss of eligibility, or if you or an eligible dependent become eligible for state premium assistance under one of these programs, you may be able to enroll yourself and your eligible family members in the Plan. However, you must request enrollment no later than 60 days after the date the state Medicaid or child health insurance program coverage is terminated or the date you or an eligible dependent is determined to be eligible for state premium assistance.

For purposes of these notices, the plan administrator is:

Melissa Shaffer-Reyes 540-636-4250 http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

Your Rights and Protections Against Surprise Medical Bills

When youget emergencycare or are treatedbyan out-of-networkproviderat an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments,coinsuranceand/ordeductible.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called

“balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider.

Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You’re protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choosea providerorfacility in your plan’snetwork.

When balance billing isn’t allowed, you also have these protections:

• You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.

• Generally, your health plan must:

o Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).

o Cover emergency services by out-of-network providers.

o Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.

o Count any amount you pay for emergencyservices or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you’ve been wrongly billed, contact the No Surprises Helpdesk, operated by the U.S. Department of Health and Human

Services, at 1.800.985.3059.

Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.

https://www.healthcare.gov/glossary/out-of-pocket-costs/ https://www.healthcare.gov/glossary/co-payment/ https://www.healthcare.gov/glossary/co-insurance/ https://www.healthcare.gov/glossary/deductible/ http://www.cms.gov/nosurprises/consumers

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 January 31, 2023. 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)

Website:

Health Insurance Premium Payment (HIPP) Program http://dhcs.ca.gov/hipp

Phone: 916-445-8322

Fax: 916-440-5676

Email: 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: https://medicaid.georgia.gov/health-…