2015 employee benefits

Transcription

1 Full-Time Employees 2015 employee benefits YOUR GUIDE. YOUR ADVOCATE.

2 2 TABLE OF CONTENTS Benefits Overview Full-Time... 2 Benefit Plans Offered...2 Eligibility...2 Medical Benefits... 3 Health Savings Account (HSA)... 4 Dental Benefits... 5 Voluntary Vision Insurance... 5 Life and Accidental Death & Dismemberment Insurance... 6 Life Insurance...6 Accidental Death and Dismemberment (AD&D) Insurance...6 Long-Term Disability... 6 Employee Assistance Program... 6 Flexible Spending Account (FSA)... 6 Voluntary Life and AD&D Insurance... 7 Voluntary Short-Term Disability... 7 Voluntary Critical Illness Insurance... 7 Voluntary Accident Insurance... 7 Employee Contributions for Benefits... 8 Working Spouse Premium...8 BENEFITS OVERVIEW FULL-TIME Cogent Healthcare is proud to offer a comprehensive benefits package to eligible, full-time employees who work 30 hours per week and have completed 31 days of service. The complete benefits package is briefly summarized in this booklet. You share the costs of some benefits, and Cogent Healthcare provides other benefits at no cost to you. Benefit Plans Offered Medical Dental Voluntary Vision Life Insurance Accidental Death & Dismemberment (AD&D) Insurance Voluntary Life & AD&D Insurance Long-Term Disability Voluntary Short-Term Disability Employee Assistance Program Flexible Spending Accounts Voluntary Critical Illness Insurance Voluntary Accident Insurance Eligibility You and your dependents are eligible for Cogent Healthcare benefits on the first of the month following 31 days of employment. Eligible dependents are your spouse, domestic partner, children and stepchildren to age 26, and disabled dependents of any age. Elections made now will remain until the next open enrollment unless you or your family members experience a qualifying event. If you experience a qualifying event, please contact Gallagher Benefit Services within 31 days of the event to make any changes, otherwise, no changes can be made to your elections until the next open enrollment. Contact Information... 9 How To Enroll In Benefits... 9 Required Notices This document is an outline of the coverage proposed by the carrier(s), based on information provided by your company. 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 issues. 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.

3 3 MEDICAL BENEFITS Administered by Blue Cross and Blue Shield of Tennessee Comprehensive and preventive healthcare coverage is important in protecting you and your family from the financial risks of unexpected illness and injury. A little prevention usually goes a long way especially in healthcare. Routine exams and regular preventive care provide an inexpensive review of your health. Small problems can potentially develop into large expenses. By identifying the problems early, often they can be treated at little cost. Comprehensive healthcare also provides peace of mind. In case of an illness or injury, you and your family are covered with an excellent medical plan through Cogent Healthcare. Cogent Healthcare offers you the following two medical plans, a High Deductible Health Plan (HDHP) and a PPO plan. With these plans, you may select where you receive your medical services. If you use in-network providers, your costs will be less. To find an in-network physician or facility, you can go to and click on Find A Doctor. HDHP PPO In-Network Out-of-Network In-Network Out-of-Network Lifetime Benefit Maximum Unlimited Unlimited Annual Deductible $1,300 single / $2,600 family (Shared Family Deductible)* $2,600 single / $5,200 family (Shared Family Deductible)* $1,500 single / $3,000 family $3,000 single / $6,000 family Annual Out-of-Pocket Maximum $2,500 single / $5,000 family $7,500 single / $15,000 family (Shared Family Out-of-Pocket Maximum)* (Shared Family Out-of-Pocket Maximum)* $5,000 single / $10,000 family $15,000 single / $30,000 family Coinsurance 80% 60% 80% 60% DOCTOR S OFFICE Primary Care Office Visit 80% after deductible 60% after deductible $30 copay 60% after deductible Specialist Office Visit (including Urgent Care) Preventive Care (routine exams, x-rays/tests, immunizations, well baby care and mammograms) 80% after deductible 60% after deductible $50 copay 60% after deductible $0 copay 60% after deductible $0 copay 60% after deductible HOSPITAL SERVICES Emergency Room 80% after deductible 80% after deductible $250 copay $250 copay Inpatient Services 80% after deductible 60% after deductible 80% after deductible 60% after deductible Outpatient Surgery 80% after deductible 60% after deductible 80% after deductible 60% after deductible Routine Diagnostic Services (Outpatient) 100% after deductible 60% after deductible 100% after deductible 60% after deductible Advanced Radiological Imaging (Outpatient) 80% after deductible 60% after deductible 80% after deductible 60% after deductible Other Outpatient Services 80% after deductible 60% after deductible 80% after deductible 60% after deductible Ambulance Service 80% after deductible 80% after deductible 80% after deductible 80% after deductible Maternity Services 80% after deductible 60% after deductible 80% after deductible 60% after deductible Therapeutic Services 80% after deductible 60% after deductible 80% after deductible 60% after deductible MENTAL HEALTH SERVICES Inpatient Services 80% after deductible 60% after deductible 80% after deductible 60% after deductible Outpatient Services 80% after deductible 60% after deductible $30 copay 60% after deductible PRESCRIPTION DRUGS All Rx: 80% after deductible EXCEPT BCBST Preventive Care drugs Retail Generic Drug Retail Formulary Drug Retail Nonformulary Drug Mail Order (90-day supply) Nonpreventive: 80% after deductible Preventive: 3x copay $5 Preventive copay $25 Preventive copay $50 Preventive copay $8 copay $40 copay $60 copay N/A 2x copay N/A Specialty Drugs 80% after deductible 60% after deductible $20 / $70 / $100 $40 / $140 / $200 *Shared/Aggregate Family Deductible/ Out-of-Pocket Maximum Accumulation: On the HDHP, the entire family deductible must be met before coinsurance applies. Likewise, a family member will not be at 100% coverage until the full family out-of-pocket maximum is reached.

4 4 HEALTH SAVINGS ACCOUNT (HSA) Administered by HSA Bank The HDHP plan with HSA is a Qualified High Deductible Health Plan and per IRS guidelines, pre-tax dollars can be contributed into the HSA account to help pay for qualified medical expenses. Cogent Healthcare contributes the amounts listed below to help you pay for eligible healthcare expenses and meet your deductible. You may also contribute to your Health Savings Account on a pretax basis, up to $3,350 (for an individual) or $6,650 (for a family) per year, minus any employer funding that you receive. There is also a catch-up provision for those age 55+ to fund an additional $1,000 to your account. Any money not used in any calendar year will carry over to the next calendar year. Unused HSA dollars are always yours. Please keep in mind that HSA dollars must be used for qualifying medical expenses to avoid a 20% penalty. Employee Only $250/year Employee + Spouse $500/year Employee + Child(ren) $500/year Family $750/year

5 5 DENTAL BENEFITS Administered by Guardian Good oral care enhances overall physical health, appearance and mental wellbeing. Problems with the teeth and gums are common and easily treated health problems. Keep your teeth healthy and your smile bright with the Cogent Healthcare dental benefit plan. Participating Dentist Annual Deductible $25 per person / $75 family Annual Benefit Maximum Nonparticipating Dentist* $50 per person / $150 family $1,000 (does not include orthodontia) Preventive Dental Services (cleanings, exams, x-rays) Basic Dental Services (fillings, simple extractions and dental surgery, root canals, etc.) Major Dental Services (crowns, bridges, implants, dentures, repairs, etc.) Plan pays 100%, no deductible. Does not apply to annual maximum benefit. Plan pays 80% after deductible Plan pays 50% after deductible Orthodontia Services Plan pays 50% Lifetime Orthodontia Maximum $2,000 per person *When you receive services from a nonparticipating dentist, the percentages in the column indicate the portion of Guardian s Nonparticipating Dentist Fee that will be paid for those services. The nonparticipating dentist fee may be less than what your dentist charges and you are responsible for that difference. Maximum Rollover Annual Max Benefit: You must submit a claim for covered services and not exceed the $500 Threshold. The maximum Roll-over amount is $250 per year ($350 maximum for in-network only). The amounts rolled over from year to year may not accumulate to more than $1,000. Note: New entrants into the plan with only 3 months or less are not eligible for roll-over until the following year. Example: Someone enrolls October 2014, they won t be eligible for rollover until January 1, VOLUNTARY VISION INSURANCE Administered by VSP Regular eye examinations can not only determine your need for corrective eyewear, but also may detect general health problems in their earliest stages. Protection for the eyes should be a major concern to everyone. To find an innetwork provider, go to and click on Find A VSP Doctor. Choose VSP Choice when asked to select a Network. In-Network benefits are as follows: One eye exam covered in full each plan year after $20 copay. Prescription Glasses (Lenses and Frames) Covered in full up to $150 after $20 copay Lenses covered every 12 months and frames covered every 24 months. Contact Lens Up to $130 allowance for contacts and contact lens exam (fitting and evaluation)

6 6 LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE Insured by Unum Life Insurance Life insurance provides financial security for the people who depend on you. Your beneficiaries will receive a lump-sum payment in the event of your death while employed by Cogent Healthcare. The company provides basic life insurance of 1x salary to a maximum of $450,000 at no cost to you. Accidental Death and Dismemberment (AD&D) Insurance Accidental Death and Dismemberment (AD&D) insurance provides payment to you or your beneficiaries if you lose a limb or die in an accident. Cogent Healthcare provides AD&D coverage of 1x salary to a maximum of $450,000 at no cost to you. This coverage is in addition to your company-paid life insurance described above. LONG-TERM DISABILITY Insured by Unum Each full-time Cogent Healthcare employee is provided long-term disability insurance coverage. If you become disabled, this coverage pays 60% of your salary up to $10,000 per month. Benefits begin after 90 days of your disability and lasts until your disability ends or to Social Security Normal Retirement Age (SSNRA). This benefit can be reduced by Other Income Benefits. EMPLOYEE ASSISTANCE PROGRAM Administered by Unum Personal problems, planning for life events or simply managing daily life can affect your work, health and family. Unum is a no-cost, company-sponsored benefit that is available to you and your dependents to provide confidential support, resources and information to get through life s challenges. The following resources are available: Confidential counseling on personal issues Legal information, resources and consultation Financial information, resources and tools Online information, tools and services Unum can be reached at or go to user ID and password: lifebalance. FLEXIBLE SPENDING ACCOUNT (FSA) Administered by Igoe You can save money on your healthcare and/or dependent daycare expenses with an FSA. You set aside funds each pay period on a pretax basis and use them tax-free for qualified expenses. You pay no federal income or Social Security taxes on your contributions to an FSA (that s where the savings comes in). Your FSA contributions are deducted from your paycheck before taxes are withheld, so you save on income taxes and have more disposable income. Healthcare Contribution Limit $2,550 Dependent Care Contribution Limit $5,000

7 7 Not everyone s personal situation is the same; your family needs may be different from the needs of your coworkers. In recognition of these differences, Cogent Healthcare offers voluntary benefits, which you can purchase at group rates. VOLUNTARY LIFE AND AD&D INSURANCE Insured by Unum You may purchase additional life and AD&D insurance on yourself. If you purchase additional life insurance coverage for yourself, you may also purchase life insurance for your dependents also. You are guaranteed coverage without answering medical questions if you enroll when you are first eligible. Employee Life $10,000 increments to maximum of $500,000. Guarantee Issue (GI) is $250,000. Spouse 50% of the employee elected/approved amount up to $150,000. GI is $50,000. Children $10,000 Employee AD&D $10,000 increments to maximum of $500,000. VOLUNTARY SHORT-TERM DISABILITY Insured by Unum Cogent Healthcare offers a voluntary short-term disability insurance coverage to all full-time employees that you may purchase. If you become disabled, this coverage pays 60% of weekly salary up to $2,500 per week. Benefits begin after 7 days of disability or injury and last for 13 weeks. This benefit can be reduced by Other Income Benefits. VOLUNTARY CRITICAL ILLNESS INSURANCE Insured by Unum Critical Illness insurance can pay a lump sum benefit at the diagnosis of a critical illness. You can choose to purchase $15,000 of coverage, and you can use the money in any way you see fit. Covered conditions include heart attack, major organ failure, stroke, coma, permanent paralysis, cancer, occupational HIV, end-stage renal (kidney) failure, etc. One key advantage of this coverage is that you can use this coverage more than once. If you receive a full benefit payout for a covered illness, your coverage can be continued for the remaining covered conditions. The diagnosis of a new covered illness must occur at least 90 days after the most recent diagnosis and be medically unrelated. Each condition if payable once per lifetime. Please note that if you purchase this coverage, your dependent children (newborn until age 26 years) will automatically be covered at 25% of the employee benefit amount for no additional cost. Also, you may choose to purchase $10,000 of coverage on your spouse (age 17 through 65 years) for an additional cost. VOLUNTARY ACCIDENT INSURANCE Insured by Unum Accident insurance pays a lump sum benefit based on the type of injury (or covered incident) you sustain or the type of treatment you need. Examples of covered injuries include broken bones, burns, torn ligaments, cuts repaired by stitches, coma due to covered injury, eye injuries, ruptured discs and concussion. Some covered expenses include emergency room treatment, outpatient surgery, doctor office visit, hospitalization, occupational/physical/speech therapy, and/ or chiropractic visits. You choose the coverage that s right for you. Your accident insurance plan can provide benefits for covered accidents that occur on and off the job. Accident insurance is offered to all eligible employees who are actively at work. Please keep in mind that spouse and child coverage is also available. You decide if it s right for you and your family.

8 8 EMPLOYEE CONTRIBUTIONS FOR BENEFITS Benefit Plan Per Pay Period Benefit Plan Per Pay Period MEDICAL / RX HDHP DENTAL PLAN Employee $18.88 Employee + Spouse $79.28 Employee + Child(ren) $67.95 Family $ MEDICAL / RX PPO Employee $53.00 Employee + Spouse $ Employee + Child(ren) $ Family $ Employee $7.00 Employee + Spouse $14.00 Employee + Child(ren) $15.78 Family $26.50 VISION PLAN Employee $3.38 Employee + 1 $4.91 Family $8.80 Working Spouse Premium If you enroll a spouse who has medical coverage available through his or her employer, you will pay a premium of $50.00 per month in addition to your regular contribution amount (If your spouse is also employed by Cogent Healthcare and you have family coverage, you will only pay the regular contribution amount). If your spouse is employed and does not have access to other coverage, you will be required to provide proof from their employer that no other coverage is available.

9 9 CONTACT INFORMATION If you have specific questions about a Cogent Healthcare benefit plan, please contact Gallagher Benefit Services at or cogentbenefits@ajg.com, or the administrator listed below. Benefit Administrator Phone Website Medical/Pharmacy BCBSTN Dental Guardian Vision VSP Life and AD&D / Disability Unum EAP Unum FSA Igoe (k) Prudential Health Savings Account HSA Bank Voluntary Critical Illness Insurance & Voluntary Accident Insurance Unum Maryland Way, Suite 300 Brentwood, TN HOW TO ENROLL IN BENEFITS 1. Click on your internet icon and type in 2. Login: Registered users click on User Login (please note: If you have already registered for ipay, you do not need to register again. The access is the same login information). Your User ID is generally your FirstInitialLastname@COGENT (legal name on paycheck, i.e. JDoe@COGENT). If you don t remember your User ID there is a Forgot your User Id link on the log in page. If you have not registered there is a First Time Users Register Here link on the log in page. Enter your password If you don t remember your password there is a forgot your password link on the log in page. 3. Once you have accessed the Cogent Healthcare ADP Portal, under the Benefits dropdown choose Review/Change Benefits. The Open Enrollment screen will appear. 4. Update personal and dependent information. Then Proceed To Your Account. 5. Review/update EEO information. 6. Verify if you have a working spouse. 7. Please select Walk me through this process and click Start. 8. Make your benefit elections. 9. When completed, Submit to Administrator and print a confirmation statement as of January 1, 2015.

10 10 REQUIRED NOTICES Michelle s Law Michelle s Law requires group health plans to provide continued coverage for a dependent child covered under the plan if the child loses eligibility under Cogent Healthcare because of the loss of student status resulting from a medically necessary leave of absence from a post-secondary educational institution. If your child is covered under Cogent Healthcare Medical Plan, but will lose eligibility because of a loss of student status caused by a medically necessary leave of absence, your child may be able to continue coverage under our plan for up to one year during the medically necessary leave of absence. This coverage continuation may be available if on the day before the medically necessary leave of absence begins your child is covered under Cogent Healthcare medical plan and was enrolled as a student at a post-secondary educational institution. A medically necessary leave of absence means a leave of absence from a postsecondary educational institution (or change in enrollment status in that institution) that: (1) begins while the child is suffering from a serious illness or injury, (2) is medically necessary, and (3) causes the child to lose student status as defined under our plan. The coverage continuation is available for up to one year after the first day of the medically necessary leave of absence and is the same coverage your child would have had if your child had continued to be a covered student and not needed to take a medical leave of absence. Coverage continuation may end before the end of one year if your child would otherwise lose eligibility under the plan for example, by reaching age 26. If your child is eligible for this coverage continuation and loses coverage under the plan at the end of the continuation period, COBRA continuation may be available at the end of the Michelle s Law coverage continuation period. If you have any questions concerning this notice or your child s right to continued coverage under Michelle s law, please contact your Human Resources Department. Newborn s and Mother s Health Protection Act 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 insurers may not, under Federal law, require that a provider obtain authorization from the plan or the insurer for prescribing a length of stay not more than 48 hours (or 96 hours). Protecting Your Health Information Privacy Rights Cogent Healthcare is committed to the privacy of your health information. The administrators of the Cogent Healthcare use strict privacy standards to protect your health information from unauthorized use or disclosure. The Plan s policies protecting your privacy rights and your rights under the law are described in the Plan s Notice of Privacy Practices. You may receive a copy upon request of the Notice of Privacy Practices by contacting your Human Resources Department. Women s Health & Cancer Rights Act 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 states 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 physician 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 the plan. If you would like more information on WHCRA benefits, call your Human Resources Department

11 11 Important Notice from Cogent Healthcare, Inc. About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Cogent Healthcare, Inc. 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. Cogent Healthcare, Inc. has determined that the prescription drug coverage offered by the Cogent Healthcare, Inc. medical plans are, 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. 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 Cogent Healthcare, Inc. coverage will be affected. If you do decide to join a Medicare drug plan and drop your current Cogent Healthcare, Inc. 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 Cogent Healthcare, Inc. and don t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice or Your Current Prescription Drug Coverage Contact the person listed below for further information call Gallagher Benefit Services at 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 Cogent Healthcare, Inc. 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 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 Q Q Call MEDICARE ( ). TTY users should call 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 or call them at (TTY ). 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). Date: 01/01/2015 Name of Entity/Sender: Cheryl Slack Contact Position/Office: Chief Human Resource and Physician Services Officer Address: Cogent Healthcare, Inc Maryland Way, Suite 300 Brentwood, TN Phone Number:

12 12 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 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 877.KIDS.NOW or 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 or call EBSA (3272). If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of July 31, You should contact your State for further information on eligibility. ALABAMA Medicaid Website: Phone: ALASKA Medicaid Website: Phone (Outside of Anchorage): Phone (Anchorage): ARIZONA CHIP Website: Phone (Outside of Maricopa County): Phone (Maricopa County): COLORADO Medicaid Medicaid Website: Medicaid Phone (In state): Medicaid Phone (Out of state): FLORIDA Medicaid Website: Phone: GEORGIA Medicaid Website: - Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: IDAHO Medicaid Medicaid Website: PremiumAssistance/tabid/1510/Default.aspx Medicaid Phone: INDIANA Medicaid Website: Phone: IOWA Medicaid Website: Phone: KANSAS Medicaid Website: Phone: KENTUCKY Medicaid Website: Phone: LOUISIANA Medicaid Website: Phone: MAINE Medicaid Website: Phone: TTY MASSACHUSETTS Medicaid and CHIP Website: Phone: MINNESOTA Medicaid Website: Click on Health Care, then Medical Assistance Phone: MISSOURI Medicaid Website: Phone: MONTANA Medicaid Website: Phone: NEBRASKA Medicaid Website: Phone:

13 13 NEVADA Medicaid Medicaid Website: Medicaid Phone: NEW HAMPSHIRE Medicaid Website: Phone: NEW JERSEY Medicaid and CHIP Medicaid Website: medicaid/ Medicaid Phone: CHIP Website: CHIP Phone: NEW YORK Medicaid Website: Phone: NORTH CAROLINA Medicaid Website: Phone: NORTH DAKOTA Medicaid Website: Phone: OKLAHOMA Medicaid and CHIP Website: Phone: OREGON Medicaid Website: Phone: PENNSYLVANIA Medicaid Website: Phone: RHODE ISLAND Medicaid Website: Phone: SOUTH CAROLINA Medicaid Website: Phone: SOUTH DAKOTA Medicaid Website: Phone: TEXAS Medicaid Website: Phone: UTAH Medicaid and CHIP Website: Phone: VERMONT Medicaid Website: Phone: VIRGINIA Medicaid and CHIP Medicaid Website: Medicaid Phone: CHIP Website: CHIP Phone: WASHINGTON Medicaid Website: Phone: , ext WEST VIRGINIA Medicaid Website: Phone: , HMS Third Party Liability WISCONSIN Medicaid Website: Phone: WYOMING Medicaid Website: Phone: To see if any more States have added a premium assistance program since July 31, 2014, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor Employee Benefits Security Administration EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services , Menu Option 4, Ext OMB Control Number (expires 10/31/16)

14 14 NOTES

15 15 NOTES

16 This benefit summary prepared by 15GBS23379B