Providence Engineering - 2023 Benefits Guide
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<strong>2023</strong> BENEFITS<br />
ENROLLMENT GUIDE
Mark your calendar for<br />
OPEN ENROLLMENT!<br />
October 28th - November 8th<br />
October<br />
28<br />
REMEMBER: Open Enrollment must be completed by the deadline or<br />
you may not be able to enroll yourself and/or your eligible dependents until our<br />
next open enrollment, or a qualifying event occurs.
CONTENTS<br />
4-5 <strong>Benefits</strong> Overview<br />
6-10 Medical Insurance<br />
11-12 Health Savings Account<br />
13-14 Flexible Spending Accounts<br />
15-16 Dental Insurance<br />
17 Vision Insurance<br />
18 Disability Insurance<br />
19-22<br />
Basic & Voluntary Life and Accidental Death &<br />
Dismemberment Insurance<br />
23 Accident Insurance<br />
24 Cancer Insurance<br />
25-27 Critical Illness Insurance<br />
28 Pet Insurance<br />
29 Open Enrollment Instructions<br />
30 Important Contacts<br />
31-40 Compliance Notices<br />
41 Glossary
BENEFITS OVERVIEW<br />
ENROLLMENT<br />
You can enroll in benefits or change your elections at the following times:<br />
• 30 days prior to your initial eligibility date (as a newly hired employee)<br />
• During the annual benefits open enrollment period<br />
• Within 30 days of experiencing a qualifying life event<br />
BENEFIT OPTIONS<br />
We offer a comprehensive benefits package consisting of:<br />
• Medical Insurance<br />
• Health Savings Account<br />
• Flexible Spending Accounts<br />
• Dental Insurance<br />
• Vision Insurance<br />
• Group Life and AD&D Insurance<br />
• Voluntary Life and AD&D Insurance<br />
• Long-Term Disability Insurance<br />
• Short-Term Disability Insurance<br />
• Voluntary Accident Insurance<br />
• Voluntary Cancer Insurance<br />
• Voluntary Critical Illness Insurance<br />
• Voluntary Pet Insurance<br />
4
BENEFITS OVERVIEW<br />
ELIGIBILITY<br />
Full-time employees working at least 30 hours per week are eligible for<br />
benefits on the first of the month following date of hire. Many of the plans<br />
offer coverage for eligible dependents, including:<br />
• Your legal spouse<br />
• Your children to age 26, regardless of student, marital, or tax-dependent<br />
status (including stepchild, legally adopted child, a child placed with you<br />
for adoption, or a child for whom you are the legal guardian)<br />
• Your dependent children over age 26 who are physically or mentally<br />
unable to care for themselves<br />
CHANGING BENEFITS AFTER OPEN ENROLLMENT<br />
You may pay your portion of your select coverages, and fund the Health<br />
Savings Account and Flexible Spending Accounts, on a pre-tax basis. Due to<br />
IRS regulations, once you have made your elections for the plan year, you<br />
cannot change your benefits until the next annual open enrollment period.<br />
The only exception is if you experience a qualifying event these election<br />
changes must be consistent with the life event.<br />
To request a benefits change, notify Human Resources within 30 days of the<br />
qualifying life event. Change requests submitted after 30 days cannot be<br />
accepted. You may need to provide proof of the life event.<br />
Qualifying life events include, but are not limited to:<br />
• Marriage, divorce, or legal separation<br />
• Birth or adoption of an eligible child<br />
• Death of your spouse or covered child<br />
• Change in your spouse’s work status that affects his or her benefits<br />
• Change in your child’s eligibility for benefits<br />
• Qualified Medical Child Support Order<br />
5
MEDICAL INSURANCE<br />
CARRIER:: Blue Cross Blue Shield of Louisiana<br />
Please refer to the official plan documents for additional information on coverage and exclusions.<br />
Click Link for Video: HDHP PPO Copay<br />
COVERED BENEFITS<br />
Blue Saver<br />
Premier Blue<br />
Individual Family Individual Family<br />
In-Network Deductible $2,000 $4,000 $1,200 $3,000<br />
Annual Out-of-Pocket Maximum $4,400 $8,800 $4,500 $8,000<br />
Lifetime Maximum Unlimited Unlimited<br />
Primary Services Deductible + 20% $30 Copay<br />
Specialist Physician Office Visit Deductible + 20% $50 Copay<br />
Preventive Care Services Covered at 100% Covered at 100%<br />
Urgent Care Center Deductible + 20% $100 Copay<br />
Hospital Services<br />
Emergency Room Deductible + 20% $150 Copay<br />
Outpatient Facility Deductible + 20% Deductible + 20%<br />
MRI, CT, MRA, and PET Deductible + 20% Deductible + 20%<br />
Severe Mental/Nervous<br />
Inpatient Deductible + 20% Deductible + 20%<br />
Outpatient Deductible + 20% $30 Copay<br />
Prescription Drug <strong>Benefits</strong><br />
Deductible Embedded with Medical $0<br />
Tier I (Generic) Deductible + 0% $7 Copay<br />
Tier II (Preferred Brand) Deductible + 20% $35 Copay<br />
Tier III (Non-Preferred Brand) N/A $100 Copay<br />
Tier IV (Specialty) N/A 20% up to $250/per Rx<br />
Pharmacy Tier Review: Bcbsla.com/covered drugs<br />
6
WHICH MEDICAL INSURANCE PLAN IS<br />
RIGHT FOR YOU?<br />
Choosing the right medical plan is an important decision. Take the<br />
time to learn about your options to ensure you select the right plan<br />
for you and your family.<br />
THINGS TO CONSIDER<br />
1. Do you prefer to pay more for medical insurance out of your<br />
paycheck, but less when you need care?<br />
2. Or, do you prefer to pay less out of your paycheck, but more<br />
when you need care?<br />
3. What planned medical services do you expect to need in the<br />
upcoming year?<br />
4. Are you able to budget for your deductible by setting aside<br />
pre-tax dollars from your paycheck in an HSA or FSA?<br />
5. Do you or any of your covered family members take<br />
prescription medications on a regular basis?<br />
Here is a short video summarizing the differences in the plans<br />
available:<br />
HDHP VS PPO<br />
Below is an example of how each plan would pay if you<br />
were to have a large claim:<br />
HDHP VS Premier Blue<br />
Cost Example<br />
Example: Claims Totaling $10,000<br />
Plan<br />
Annual Premium<br />
Cost<br />
Deductible Copay 80% Coinsurance<br />
HSA Company<br />
Contribution<br />
Total Annual<br />
Cost<br />
Premier Blue 759.60 $1,200 $50 $3,250 - 5,259.60<br />
Blue Saver 450.96 $2,000 - $2,400 $600 4,250.96<br />
Assumptions: Employee Only Coverage & Claim is In-Network<br />
7
<strong>2023</strong> Medical Insurance Premiums<br />
MEDICAL RATES<br />
COVERAGE LEVEL<br />
Blue Saver<br />
Employee<br />
Semi-Monthly Deduction<br />
Premier Blue<br />
Employee<br />
Semi-Monthly Deduction<br />
Employee Only $18.79 $31.65<br />
Employee & Spouse $173.45 $369.66<br />
Employee & Child(ren) $147.44 $314.99<br />
Employee & Family $329.72 $543.81<br />
<strong>Providence</strong>, on average, contributes $360.92 semi-monthly towards the Premier Blue plan and<br />
$400.54 semi-monthly towards the BlueSaver Plan<br />
8
TELEMEDICINE / VIRTUAL VISITS<br />
When it comes to healthcare, access<br />
is important. You want care that is<br />
convenient, high-quality and<br />
low-cost. But depending on your<br />
condition, going to your personal<br />
physician or an urgent care clinic<br />
might not be your best option. We<br />
are proud to offer telemedicine /<br />
virtual visits.<br />
TREATED THROUGH TELEMEDICINE<br />
Allergies<br />
Cold & Flu Symptoms<br />
Cough<br />
Ear Infection<br />
Pink Eye<br />
Prescription Refills<br />
Respiratory Infection<br />
Sinus Problems / Nasal Congestion<br />
Urinary Tract Infection<br />
And more!<br />
NOT TREATED THROUGH TELEMEDICINE<br />
Sprains, broken bones or injuries requiring bandaging<br />
Anything that needs a hands-on exam<br />
Anything that needs a lab test or X-ray<br />
Chronic conditions<br />
HOW TO REGISTER<br />
● Step 1: Visit www.BlueCareLA.com or download the BlueCare mobile app on your Apple or<br />
Android device.<br />
● Step 2: Create a member account.<br />
● Step 3: Log into that account each time you use BlueCare online or with the app.<br />
9
MEDICAL INSURANCE<br />
CARRIER:: Blue Cross Blue Shield of Louisiana<br />
BCBS Digital ID Card<br />
If you do need to see a doctor in person, you now have the option to present a digital ID<br />
card. You can access your ID card from your mobile device and online through the member<br />
portal. You’ll need to have an online account to access your digital ID card. If you don’t have<br />
an online account, register today at www.bcbsla.com/login.<br />
●<br />
●<br />
From the BCBSLA mobile app, first make sure you have the latest update of the app.<br />
Once you log in, click My ID Card to see the ID cards available to you.<br />
From the Blue Cross member portal, log into your online account at bcbsla.com. You’ll<br />
see My ID Card with a drop down menu of the ID cards available for viewing. You can<br />
also save these as PDF files.<br />
Sample<br />
10
HEALTH SAVINGS ACCOUNT<br />
CARRIER: HealthEquity<br />
If you enroll in the high-deductible health (HDHP) plan, you may be eligible to fund a<br />
Health Savings Account (HSA). An HSA is a personal health care savings account you<br />
can use to pay out-of-pocket health care expenses with pre-tax dollars. Your<br />
contributions are tax free and the money remains in the account for you to spend on<br />
eligible expenses no matter where you work or how long it stays in the account.<br />
WHO IS ELIGIBLE?<br />
You are eligible to open and fund an HSA if:<br />
● You are enrolled in the High-Deductible Health Plan<br />
● You are not covered by a non-HSA plan, health care FSA, or health reimbursement arrangement<br />
● You are not eligible to be claimed as a dependent on someone else’s tax return<br />
● You are not enrolled in Medicare<br />
● You have not received Veterans Administration <strong>Benefits</strong> in the last three months<br />
HSA EMPLOYER CONTRIBUTIONS<br />
● <strong>Providence</strong> will help you save by contributing $50 per<br />
month.<br />
● Contributions to a health savings account (including the<br />
employee contributions) cannot exceed the annual IRS<br />
contribution maximums.<br />
● Employees age 55+ by 12/31/2022 may contribute<br />
additional funds to their HSA (up to $1,000 in <strong>2023</strong>).<br />
● You must open your HSA through Healthequity to<br />
receive contributions.<br />
PROVIDENCE<br />
CONTRIBUTES $50 TO YOUR<br />
HSA EACH MONTH<br />
$3,850<br />
INDIVIDUAL<br />
$7,750<br />
ALL OTHER<br />
TIERS<br />
$1,000<br />
AGE 55+<br />
CATCH-UP<br />
CONTRIBUTION<br />
11
HEALTH SAVINGS ACCOUNT<br />
CARRIER: HealthEquity<br />
MAXIMIZE YOUR TAX SAVINGS<br />
• Contributions to an HSA are tax-free and can be made through payroll deductions on a pre-tax<br />
basis.<br />
• The money in your HSA (including interest and investment earnings) grows tax-free.<br />
• As long as you use the funds to pay for qualified medical expenses, the money is spent tax-free.<br />
YOU INDIVIDUALLY OWN YOUR HSA<br />
• You own and administer your HSA.<br />
• You determine how much you will contribute to your account and when to use the money to pay<br />
for eligible health care expenses.<br />
• You can change your contributions at any time during the plan year without a qualifying event.<br />
• Like a bank account, you must have a balance in order to pay for eligible health care expenses.<br />
• Keep all receipts for tax documentation.<br />
• An HSA allows you to save and “rollover” money from year to year.<br />
• The money in the account is always yours, even if you change health plans or jobs.<br />
• There are no vesting requirements or forfeiture provisions.<br />
ACCESSING YOUR HSA FUNDS<br />
Debit Card: Draws directly from your HSA and can be used to pay for eligible expenses at your<br />
doctor’s office, pharmacy, or other locations where you purchase health related items or services.<br />
USE YOUR HSA TO PAY QUALIFIED MEDICAL EXPENSES<br />
• You can use your HSA money to pay for eligible expenses now or in the future.<br />
• Funds in your HSA can be used for your expenses and those of your spouse and eligible<br />
dependents, even if they are not covered by the HDHP Plan.<br />
• Eligible expenses include deductibles, doctor’s office visits, dental expenses, eye exams,<br />
prescription expenses and LASIK eye surgery.<br />
• A complete list of eligible expenses can be found at www.irs.gov<br />
• You can also visit this link for for further information from Healthequity: HSA Resource Center<br />
12
FLEXIBLE SPENDING ACCOUNTS<br />
CARRIER: iSolved Benefit Services<br />
<strong>Providence</strong> offers two Flexible Spending Account (FSA) options – the Health Care FSA and the<br />
Dependent Care FSA – that allow you to pay for eligible health care and dependent care expenses with<br />
pre-tax dollars.<br />
Log into your account at www.isolvedbenefitservices.com to view your account balance(s), calculate<br />
tax savings, view eligible expenses, download forms, view transaction history, and more.<br />
HEALTH CARE FSA<br />
• Set aside pre-tax money from your paycheck to pay for eligible out-of-pocket expenses, such<br />
as deductibles, copays, and other health-related expenses, that are not paid by the medical,<br />
dental, or vision plans.<br />
• Over-the-counter (OTC) medications are eligible for reimbursement without a prescription.<br />
DEPENDENT CARE FSA<br />
• Set aside pre-tax money from your paycheck for daycare expenses when you and your spouse<br />
work or attend school full time.<br />
• Eligible dependents are children under age 13, or a child over 13, spouse, or elderly parent<br />
residing in your house who is physically or mentally unable to care for himself or herself.<br />
• Examples of eligible expenses are daycare facility fees, before and after-school care, and<br />
in-home babysitting fees (income must be reported by your care provider).<br />
Refer to the official Summary Plan Document for a list of eligible expenses to maximize the Value of your Flexible<br />
Spending Account.<br />
HEALTH CARE FSA<br />
$3,050 $5,000<br />
DEPENDENT CARE FSA<br />
$2,500<br />
married filing jointly or<br />
single / head of household<br />
married filing separately<br />
13
FLEXIBLE SPENDING ACCOUNTS<br />
CARRIER: iSolved Benefit Services<br />
HOW DOES AN FSA WORK?<br />
You decide how much to contribute to each FSA on a plan year basis up to the maximum allowable<br />
amounts. Your annual election will be divided by the number of pay periods and deducted evenly on<br />
a pre-tax basis from each paycheck throughout the year.<br />
You will receive a debit card from iSolved Benefit Services, which can be used to pay for eligible health<br />
care expenses at the point of service. If you do not use your debit card or if you have dependent care<br />
expenses to be reimbursed, submit a claim form and a bill or itemized receipt from the provider to<br />
iSolved Benefit Services. Keep all receipts in case iSolved Benefit Services requires you to verify the<br />
eligibility of a purchase. To find further information, you can visit the Isolved FSA resource center at:<br />
Isolved FSA Resource Center<br />
THINGS TO CONSIDER<br />
• Both the healthcare and dependent care FSA dollars are use it or lose it, so be careful to estimate<br />
your eligible medical expenses.<br />
• You cannot take income tax deductions for expenses you pay with your FSA(s)<br />
• You cannot stop or change your FSA contribution(s) during the plan year unless you experience a<br />
qualifying life event.<br />
SPECIAL HEALTH CARE FSA ACCOUNT FEATURES<br />
ROLLOVER<br />
You have the ability to<br />
roll over up to $610<br />
from one plan year to<br />
the next.<br />
14
DENTAL INSURANCE<br />
CARRIER: Sun Life<br />
●<br />
●<br />
●<br />
●<br />
You will pay less out of pocket when you choose an in-network provider.<br />
Locate an in-network provider at www.sunlife.com/us<br />
Be sure to ask for a pre-treatment estimate.<br />
Out-of-network providers can balance bill ( bill you for the difference between<br />
the provider’s charge and the allowed amount).<br />
DENTAL<br />
ELECTION<br />
SEMI-MONTHLY<br />
PAYROLL DEDUCTION<br />
Employee Only $0.00<br />
Employee & Spouse $29.88<br />
Employee & Child(ren) $37.50<br />
Employee & Family $67.67<br />
COVERED BENEFITS<br />
Deductible (per calendar year) Waived for Preventive<br />
Annual Plan Benefit Maximum<br />
Type I - Preventive Care Oral exams, cleanings, X-rays, fluoride treatment(1 in any<br />
6 month period)<br />
Bite-Wing x-Rays (1 in any 12 month period)<br />
Intraoral x-Rays (1 in any 60 month period)<br />
Type II - Basic Services Periodontal & endodontic services, oral surgery, fillings,<br />
simple extractions<br />
Periodontal Maintenance (1 in any 6 consecutive months)<br />
Type III - Major Services Inlays, onlays, crown restoration<br />
Bridges & dentures (10 year replacement limit)<br />
Dental Implants (10 year replacement limit)<br />
PLAN PAYS<br />
$50 per person, $150 per family<br />
$5,000 per covered member<br />
100%<br />
80%<br />
50%<br />
Orthodontia Services (Dependent Children to age 26) 50%<br />
Lifetime Orthodontia Plan Max (Dependent Children to age 26) $1,500<br />
15
Dental Insurance Card<br />
14
VISION INSURANCE<br />
CARRIER: Sun Life<br />
● You will pay less out of pocket when you choose an in-network provider.<br />
● Locate an in-network provider at www.vsp.com .<br />
● You must submit a claim form for out-of-network expenses.<br />
● LASIK surgery discounts available.<br />
VISION<br />
ELECTION<br />
SEMI-MONTHLY<br />
PAYROLL DEDUCTION<br />
Employee Only $3.81<br />
Employee & Spouse $7.67<br />
Employee & Child(ren) $8.13<br />
Employee & Family $12.86<br />
COVERED BENEFITS<br />
IN-NETWORK<br />
Eye Exam (every 12 months)<br />
$10 copay<br />
Standard Plastic Lenses (every 12 months)<br />
Standard Progressive<br />
Premium Progressive<br />
Custom Progressive<br />
$25 copay<br />
$25 copay<br />
$95-$105 copay<br />
$150-$175 copay<br />
Frames (every 24 months)<br />
$130 allowance + 20% off balance<br />
$70 allowance at Costco®<br />
Contact Lenses in lieu of standard plastic lenses<br />
(every 12 months)<br />
Up to $60 / 15% savings on your contact lens exam<br />
(fitting and evaluation)<br />
$130 allowance<br />
17
DISABILITY INSURANCE<br />
CARRIER: SunLife<br />
LONG-TERM DISABILITY INSURANCE<br />
Long-Term Disability (LTD) Insurance is automatically provided to all benefitseligible<br />
employees at no cost. LTD Insurance is designed to help you meet your<br />
financial needs during longer disability periods. Benefit may be offset due to other<br />
benefits such as paid sick leave or workers’ compensation.<br />
• Benefit: 60% of base monthly salary up to $10,000 per month<br />
• Elimination Period: 180 days<br />
• Benefit Duration: Until Social Security Normal Retirement Age<br />
• Pre-Existing Condition Waiting Period: 3 month/12 month<br />
VOLUNTARY SHORT-TERM DISABILITY INSURANCE<br />
Short-Term Disability (STD) Insurance is designed to help you meet your financial<br />
needs if you become unable to work due to a non-work related illness or injury.<br />
This is a voluntary plan; employees are responsible for 100% of the cost.<br />
Premiums are calculated as a percentage of your annual base salary. Benefit may<br />
be offset due to other benefits such as paid sick leave or workers’ compensation.<br />
• Benefit: 60% of base weekly salary up to $1,500 per week<br />
• Elimination Period: 7 days, benefit starts on 8th day<br />
• Benefit Duration: Up to 25 weeks<br />
• Pre-Existing Condition Waiting Period: 3 month/12 month<br />
• Portability: included<br />
STD Semi-Monthly Rate per $10 of Weekly Benefit: $0.208<br />
Step 1:<br />
$______________ ÷ 52 (weeks) = $____________<br />
Annual Salary<br />
Weekly Salary<br />
Step 2:<br />
$_____________ X 60% = $_________________<br />
Weekly Salary<br />
Weekly Benefit<br />
Step 3: $_______________________ = (Weekly Benefit X .208) ÷ 10<br />
Semi-Monthly Deduction<br />
*NOTE: You will see your exact Payroll Deduction when you log into Employee Navigator.<br />
1. Annual Salary ÷ 52 = Weekly Salary<br />
2. Weekly Salary * 60% = Weekly Benefit<br />
3. Semi-Monthly Deduction = (Weekly Benefit * .208) ÷ 10<br />
18
GROUP LIFE INSURANCE<br />
CARRIER: Sun Life<br />
LIFE and ACCIDENTAL DEATH & DISMEMBERMENT (AD&D)<br />
<strong>Providence</strong> provides $50,000 Employer Paid Life and Accidental benefits to all<br />
full-time employees through Sun Life.<br />
The company also offers Basic Life and AD&D for your spouse in the amount of<br />
$10,000 and children over 6 months in the amount of $5,000. If elected, the<br />
premium is $1.03 a paycheck.<br />
● Employee Coverage reduces to 67% at age 70 and 50% at age 75<br />
● Child eligibility – For the voluntary life insurance, child eligibility includes<br />
children up to their 26 th birthday regardless of full time student status. A<br />
reduced benefit of $500 is payable for a child from 14 days - 6 months.<br />
VOLUNTARY LIFE INSURANCE<br />
CARRIER: Sun Life<br />
WHAT IS VOLUNTARY LIFE INSURANCE?<br />
Voluntary Life insurance is offered through an employer<br />
but is paid by employees.<br />
WHY PURCHASE VOLUNTARY LIFE<br />
INSURANCE?<br />
● This type of life insurance has limited<br />
underwriting required. This allows for people<br />
with health conditions or lifestyles that might<br />
otherwise disqualify them to qualify for life<br />
insurance.<br />
● The group rates are lower than what you could purchase on your own.<br />
● You may purchase a policy for your spouse and children IF you elect coverage for yourself.<br />
REMINDER<br />
Review your beneficiary designations<br />
19
VOLUNTARY LIFE INSURANCE<br />
CARRIER: Sun Life<br />
Category<br />
Employee Coverage<br />
Benefit Amount<br />
Benefit Increments<br />
Benefit Maximum<br />
Guaranteed Issue Coverage<br />
Spouse Coverage<br />
Benefit Amount<br />
Benefit Increments<br />
Benefit Maximum<br />
Guaranteed Issue Coverage<br />
Age Reduction Schedule<br />
Age 70<br />
Age 75<br />
Dependent Child Coverage<br />
*Unmarried dependent children from 14 days to<br />
age 21 or to age 24 if full-time student<br />
*Children ages 14 days - 6 months are eligible for<br />
a reduced benefit<br />
Up to 5x Annual Salary<br />
$10,000<br />
$500,000<br />
$100,000<br />
Benefit<br />
Up to 50% Employee Amount<br />
$5,000<br />
$100,000<br />
$25,000<br />
To 67% at Age 70<br />
To 50% at Age 75<br />
$10,000<br />
$500<br />
Notes:<br />
- Rates are age-banded; cost increases with age<br />
- Employee must be enrolled in Supplemental Life Coverage for dependents to enroll in coverage<br />
- Supplemental Life Coverage is portable upon Retirement<br />
- Spouse termination age - 70<br />
- After your initial enrollment, Evidence of Insurability (EOI) is required for additional coverage<br />
Amounts elected over the guaranteed issue amount will require Evidence of Insurability (medical<br />
questions). To complete the evidence of insurability online: https://www.sunlife-usa.net/eoi<br />
REMINDER<br />
Review your beneficiary designations<br />
20
EMPLOYEE VOLUNTARY LIFE INSURANCE<br />
RATES<br />
CARRIER: Sun Life<br />
REMINDER<br />
Review your beneficiary designations<br />
*NOTE: You will see your exact Payroll Deduction when you log into Employee Navigator.<br />
21
DEPENDENT VOLUNTARY LIFE<br />
INSURANCE RATES<br />
CARRIER: Sun Life<br />
*NOTE: You will see your exact Payroll Deduction when you log into Employee Navigator.<br />
22
VOLUNTARY ACCIDENT INSURANCE<br />
CARRIER: Sun Life<br />
Accident Insurance supplements your existing medical insurance in case you have an accident;<br />
medical insurance alone may not be enough to cover your expenses. This plan pays a cash benefit<br />
during the term of your coverage following a covered accident and could help cover:<br />
● Out-of-pocket expenses such as copays and deductibles<br />
● Transportation<br />
● Lodging costs<br />
● Emergency room expenses<br />
Accidental Death $25,000<br />
Accidental Death Common Carrier $100,000<br />
Catastrophic Loss: Both arms or both hands, both legs or both feet, one hand and one foot or<br />
one are and one leg, or irrecoverable loss of sight of both eyes<br />
$15,000<br />
One hand, one foot, one leg, one arm $7,500<br />
Two or more fingers or toes $1,500<br />
One finger or one toe $750<br />
Dislocations Open Closed<br />
Hip $4,000 $2,000<br />
Knee, ankle, or bones of the foot $2,000 $1,000<br />
Shoulder $1,000 $500<br />
Fractures Open Closed<br />
Hip or thigh $4,000 $2,000<br />
Leg $2,000 $1,000<br />
Rib, Finger, Toe or Coccyx $350 $175<br />
Coma $10,000<br />
Concussion $100<br />
Diagnostic Exam: Arteriogram, Angiogram, CT, CAT, EKG, EEG, or MRI (1 time per benefit year) $200<br />
Diagnostic Exam X-ray (1 time per covered accident) $40<br />
Accident Emergency Treatment, nonemergency room (once per covered accident) $50<br />
Physician's Follow-up Treatment office visit (per visit, up to 6 times per covered accident) $25<br />
Physical Therapy (per visit up to 10 visits per covered accident) $40<br />
Hospital Admission (Once per benefit year) $1,000<br />
Ambulance Ground/Air $200/$1,500<br />
Wellness Screening Benefit (Once per benefit year) $50<br />
ACCIDENT<br />
SEMI-MONTHLY<br />
RATES<br />
PAYROLL DEDUCTIONS<br />
Employee Only $4.63<br />
Employee & Spouse $8.00<br />
Employee & Child(ren) $9.05<br />
Employee & Family $12.42<br />
23
VOLUNTARY CANCER INSURANCE<br />
CARRIER: Sun Life<br />
Cancer Insurance supplements your existing medical insurance in<br />
case you are diagnosed with cancer; medical insurance alone may<br />
not be enough to cover your expenses. This plan pays a cash<br />
benefit during the term of your coverage following a positive<br />
diagnosis of certain cancers.<br />
WHY PURCHASE CANCER INSURANCE?<br />
You and your loved ones can rest a little easier knowing you have<br />
protection inplace to help avoid depleting your bank accounts or<br />
taking on additional debt to cover day-to-day living expenses.<br />
These reimbursements will free up additional monies for:<br />
● Help cover medical plan deductibles, co-pays and other out-of-pocket costs<br />
● Help cover everyday living expenses such as groceries, rent and mortgage payments<br />
● Hire extra help for around the house, such as in-home caregivers<br />
● Pay for travel to treatment facilities away from home as well as family visits<br />
Category<br />
First Occurrence<br />
Pays the amount shown when the insured person is diagnosed for the first time as having internal<br />
cancer. This benefit is only payable once per lifetime.<br />
Benefit<br />
$5,000<br />
Continuous Hospital Confinement (Daily up to 90 days)<br />
$400 daily<br />
Radiation and Chemotherapy<br />
• Injected Cytoxic Medications (weekly)<br />
$1,000<br />
• Pump Dispensed Cytotoxic Medications (first prescription & refill)<br />
$1,000<br />
• Oral Cytotoxic Medications (per prescription)<br />
$500<br />
• Cytotoxic Medications Administered by any other method (weekly)<br />
$1,000<br />
• External Radiation Therapy (weekly)<br />
$600<br />
• Insertion of Interstitial or Intracavitary administration of radioisotopes or Radium (weekly) $750<br />
• Oral or I.V. Radiation (weekly)<br />
$600<br />
Post-hospital Doctor Visits (per visit) $50<br />
Home Health Care (per visit) within 7 days of hospital release and max 30 days per hospital<br />
$50<br />
confinement. Max 90 days per benefit year<br />
Extended Care Facility (paid daily) Max 90 days per benefit year $200<br />
Hospice (paid per day) Max 100 days lifetime $100<br />
CANCER<br />
SEMI-MONTHLY<br />
RATES<br />
PAYROLL DEDUCTIONS<br />
Employee Only $12.48<br />
Employee & Spouse $20.79<br />
Employee & Child(ren) $14.25<br />
Employee & Family $22.56<br />
24
VOLUNTARY CRITICAL ILLNESS INSURANCE<br />
CARRIER: Sun Life<br />
Critical Illness Insurance supplements your existing medical<br />
insurance in case you are diagnosed with a covered condition,<br />
like a heart attack or stroke; medical insurance alone may not<br />
be enough to cover your expenses. The plan pays a cash benefit<br />
during the term of your coverage following a covered diagnosis.<br />
Critical illness insurance may not cover all types of cancer, but it does cover heart and vascular<br />
conditions, cancer-related conditions, and major organ failure.<br />
● Employee Benefit Amount: $5,000 - $30,000 of coverage, in increments of $5,000.<br />
● Employee Benefit Reduction Schedule: 50% at age 70.<br />
●<br />
●<br />
●<br />
●<br />
Spouse Benefit Amount: If you elect coverage for yourself, you can choose $2,500 - $15,000 of coverage,<br />
in increments of $2,500. NOT TO EXCEED 50% OF THE EMPLOYEE COVERAGE AMOUNT.<br />
Spouse Benefit Reduction Schedule: Benefit may be reduced when the employee benefit amount is<br />
reduced.<br />
Child(ren) Benefit Amount: If you elect coverage for yourself, you can choose $2,500 - $5,000 of<br />
coverage. NOT TO EXCEED 50% OF THE EMPLOYEE COVERAGE AMOUNT. Available to Dependent<br />
Child(ren) from birth to age 26.<br />
Child(ren) Benefit Reduction Schedule: Benefit may be reduced when the employee benefit amount is<br />
reduced.<br />
COVERED CONDITIONS - The plan pays 100% of the benefit amount unless stated otherwise.<br />
*Please refer to the official carrier plan summary for all details, limitations, and exclusions.<br />
Core Conditions:<br />
Heart Attack, End-Stage Kidney Disease, Occupational HIV/Hepatitis B, C, or D, Major Organ Failure, Stroke, Coronary<br />
Artery Bypass Graft, Angioplasty.<br />
Other Conditions:<br />
Complete Blindness, Complete Loss of Hearing, Loss of Speech, Benign Brain Tumor, Coma, Severe Burns, Advanced<br />
ALS/Lou Gehrig’s Disease, Advanced Parkinson’s Disease (Pays 25%), Advanced Alzheimer’s Disease (Pays 25%),<br />
Paralysi.<br />
Wellness Screening Benefit:<br />
Payable to any covered person on your plan one time each year, once you provide proof of an eligible health<br />
screening.<br />
Employee: $50<br />
Spouse: $50<br />
Child: $50<br />
25
EMPLOYEE VOLUNTARY CRITICAL ILLNESS<br />
INSURANCE RATES<br />
CARRIER: Sun Life<br />
EMPLOYEE<br />
COVERAGE<br />
AMOUNT<br />
Critical Illness Non Tobacco Semi Monthly Rates<br />
DEPENDENT VOLUNTARY CRITICAL ILLNESS<br />
INSURANCE RATES<br />
CARRIER: Sun Life<br />
SPOUSE<br />
COVERAGE<br />
AMOUNT<br />
Critical Illness Non Tobacco Semi Monthly Rates<br />
PET INSURANCE<br />
CARRIER: Best Pets<br />
Pet Insurance reimburses you for vet bills when your<br />
pet is sick or injured, to help take the financial worry<br />
out of vet visits.<br />
• Fast claims processing and payment<br />
• Optional direct deposit and direct vet pay options<br />
• Use any veterinarian in the U.S., including<br />
specialty and emergency clinics<br />
• Optional coverage for routine care<br />
• Access to a 24/7 pet helpline<br />
HOW IT WORKS<br />
1. Choose a Plan: It only takes 5 minutes. Simple, no medical records to enroll, instant approval, and 30-day<br />
money back guarantee.<br />
2. Get Treatment: When your pet becomes ill or injured, you have the option to take them to any licensed<br />
veterinarian of your choice.<br />
3. File a Claim: You pay their vet bill and then submit a claim. There is no need to send medical records<br />
unless Pets Best requests them.<br />
4. Get Reimbursed: Most claims are processed within 5 business days for quick reimbursement. Get<br />
reimbursed 70%-90% of the actual vet bill after an annual deductible.<br />
Pets Best has setup a custom enrollment path for <strong>Providence</strong> employees. If you wish to enroll in Pet Insurance,<br />
you can enroll by visiting www.petsbest.com/providence or you can call 888-984-8700.<br />
You must reference the referral code: PROVIDENCE in order to be eligible to receive the discounted premium.<br />
28
OPEN ENROLLMENT INSTRUCTIONS<br />
During the Employee <strong>Benefits</strong> Enrollment process, representatives from Human Resources and<br />
BXS+Cadence Insurance will be available to answer any questions regarding the benefits package<br />
<strong>Providence</strong> <strong>Engineering</strong> offers to eligible employees.<br />
STEP 1: Go to the following link to<br />
create an account as an employee:<br />
https://www.employeenavigator.com/ben<br />
efits/Account/Register<br />
Note: It is recommended you use an email<br />
address for your user name.<br />
STEP 2: You will be asked for personal<br />
identifying data as well as the following<br />
Company Identifier: PROVENGENV<br />
STEP 3: Write down the username and password you created for future reference.<br />
STEP 4: You are now ready to make your benefit elections! Please select the “Start Enrollment”<br />
button. The system will guide you through the process. Be sure to select ‘Save & Continue’ on every<br />
screen. Note: IF you are covering a spouse and /or child, please have their full name, DOB, and SSN<br />
available.<br />
STEP 5: Choose the “Click to Sign” button to complete your enrollment.<br />
Once you have created your account, use the following link anytime to finish or view your benefit<br />
elections: https://employeenavigator.com/benefits/Account/Login<br />
REMEMBER: Open Enrollment must be completed by the deadline or<br />
you may not be able to enroll yourself and/or your eligible dependents until our<br />
next open enrollment, or a qualifying event occurs.<br />
This summary of benefits is not intended to be a complete description of the terms of <strong>Providence</strong> <strong>Engineering</strong>, LLC’s insurance benefit plans. Please<br />
refer to the plan document(s) for a complete description. Each plan is governed in all respects by the terms of its legal plan document, rather than by<br />
this or any other summary of the insurance benefits provided by the plan. In the event of any conflict between a summary of the plan and the official<br />
document, the official document will prevail. Although <strong>Providence</strong> <strong>Engineering</strong>, LLC maintains its benefit plans on an ongoing basis, <strong>Providence</strong><br />
<strong>Engineering</strong>, LLC reserves the right to terminate or amend each plan, in its entirety or in any part at any time.<br />
29
IMPORTANT CONTACTS<br />
BENEFIT CARRIER PHONE WEBSITE<br />
Medical Insurance<br />
Telemedicine<br />
Blue Cross Blue Shield<br />
of Louisiana<br />
Blue Cross Blue Shield<br />
of Louisiana<br />
800-599-3583 www.bcbsla.com<br />
855-269-3554 www.BlueCareLA.com<br />
Health Savings Account HealthEquity 877-987-8123 www.healthequity.com<br />
Flexible Spending<br />
Account<br />
iSolved Benefit<br />
Services<br />
866-370-3040 www.isolvedbenefitservices.com<br />
Dental Insurance Sun Life 800-442-7742 www.sunlife.com/us<br />
Vision Insurance Sun Life (VSP) 800-786-5433 www.vsp.com<br />
Disability Insurance Sun Life 800-786-5433 www.sunlife.com/us<br />
Group Life Insurance Sun Life 800-786-5433 www.sunlife.com/us<br />
Accident / Cancer /<br />
Critical Illness Insurance<br />
Sun Life 800-786-5433 www.sunlife.com/us<br />
Pet Insurance Pets Best 88-984-8700<br />
www.petsbest.com/providence<br />
Use referral code: PROVIDENCE<br />
<strong>Providence</strong> <strong>Engineering</strong><br />
and Environmental<br />
Group, LLC<br />
Robin Liggett or Liz<br />
Fischer<br />
225-766-7400 humanresources@providenceeng.com<br />
Enrollment Website Employee Navigator n/a www.employeenavigator.com<br />
YOUR CADENCE INSURANCE ACCOUNT REPRESENTATIVE:<br />
(formerly BXS Insurance)<br />
Ashley Fernandes<br />
225-621-0037<br />
ashley.fernandes@cadenceinsurance.com<br />
30
COMPLIANCE<br />
DISCLOSURES<br />
PLEASE NOTE: The attached disclosures must be or should be provided to you<br />
at open enrollment. However, your employer/plan sponsor will likely have<br />
additional disclosure obligations throughout the calendar/plan year. Those<br />
disclosures are not included in this booklet. While Cadence Insurance<br />
(formerly BXS Insurance) may assist your employer in providing the required<br />
disclosures, it is ultimately your employer's responsibility to provide them to<br />
you. Please contact your employer if you have questions or need additional<br />
information.
COMPLIANCE DISCLOSURES<br />
SPECIAL ENROLLMENT RIGHTS<br />
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<br />
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<br />
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<br />
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,<br />
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<br />
adoption.<br />
To request special enrollment or obtain more information, contact: Robin Liggett, <strong>Providence</strong> <strong>Engineering</strong>, 1201 Main Street, Baton Rouge, LA 70802, P:<br />
225-766-7400, E: robinliggett@providenceeng.com<br />
NEWBORNS’ ACT DISCLOSURE<br />
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<br />
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<br />
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<br />
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<br />
prescribing a length of stay not in excess of 48 hours (or 96 hours).<br />
Under the law, if your plan provides benefits for obstetrical services, your benefits will include coverage for postpartum services. Coverage will include benefits of<br />
inpatient care and home visit(s), which shall be in accordance with the medical criteria, outlined in the most current version of or an official update to the “<strong>Guide</strong>lines<br />
for Perinatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists or the “Standards for<br />
Obstetric-Gynecologic Services” prepared by the American College of Obstetricians and Gynecologists. Coverage for obstetrical services as an inpatient in a general<br />
Hospital or obstetrical services by a Physician shall provide such benefits with durational limits, deductibles, coinsurance factors and copayments that are no less<br />
favorable than for physical illness generally.<br />
PATIENT PROTECTION NOTICE<br />
BCBSLA generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who<br />
is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers,<br />
contact your plan administrator listed below.<br />
For children, you may designate a pediatrician as the primary care provider.<br />
You do not need prior authorization from BCBSLA or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological<br />
care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with<br />
certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of<br />
participating health care professionals who specialize in obstetrics or gynecology, contact BCBSLA.<br />
PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)<br />
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<br />
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<br />
these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit<br />
www.healthcare.gov.<br />
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<br />
assistance is available.<br />
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,<br />
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<br />
that might help you pay the premiums for an employer-sponsored plan.<br />
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<br />
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<br />
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<br />
call 1-866-444-EBSA (3272).<br />
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<br />
January 31, 2022. Contact your State for more information on eligibility –<br />
32
COMPLIANCE DISCLOSURES<br />
PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) Continued<br />
ALABAMA – MEDICAID<br />
Website: http://myalhipp.com/<br />
Phone: 1-855-692-5447<br />
ALASKA - MEDICAID<br />
The AK Health Insurance Premium Payment Program<br />
Website: http://myakhipp.com/<br />
Phone: 1-866-251-4861<br />
Email: CustomerService@MyAKHIPP.com<br />
Medicaid Eligibility: http://dhss.alaska.gov/dpa/<br />
Pages/medicaid/ default.aspx<br />
ARKANSAS - MEDICAID<br />
Website: http://myarhipp.com/<br />
Phone: 1-855-MyARHIPP (855-692-7447)<br />
CALIFORNIA - MEDICAID<br />
Website: Health Insurance Premium Payment (HIPP)<br />
Program http://dhcs.ca.gov/hipp<br />
Phone: 916-445-8322<br />
Fax: 916-440-5676<br />
Email: hipp@dhcs.ca.gov<br />
COLORADO – HEALTH FIRST COLORADO<br />
(COLORADO’S MEDICAID PROGRAM) & CHILD<br />
HEALTH PLAN PLUS (CHP+)<br />
Health First Colorado Website: https://www.heal<br />
thfirstcolorado.com/<br />
Health First Colorado Member Contact Center:<br />
1-800-221-3943/ State Relay 711<br />
CHP+: https://www.colorado.gov/pacific/hcpf/<br />
child-health-plan-plus<br />
CHP+ Customer Service: 1-800-359-1991/ State Relay<br />
711 Health Insurance Buy-In Program<br />
(HIBI): https://www.colorado.gov/pacific/hcpf/<br />
health- insurance-buy-program<br />
HIBI Customer Service: 1-855-692-6442<br />
FLORIDA - MEDICAID<br />
Website: https://www.flmedicaidtplrecovery.com/<br />
flmedicaidtplrecovery. com/hipp/index.html<br />
Phone: 1-877-357-3268<br />
GEORGIA - MEDICAID<br />
A HIPP Website: https://medicaid.georgia.gov/<br />
health-insurance-premium-payment-program-hipp<br />
Phone: 678-564-1162, Press 1 GA CHIPRA Website:<br />
https://medicaid.georgia.gov/programs/third-party-li<br />
ability/childrens-health-insurance-program-reauthoriz<br />
ation- act-2009-chipra<br />
Phone: (678) 564-1162, Press 2<br />
INDIANA – MEDICAID<br />
Healthy Indiana Plan for low-income adults 19-64<br />
Website: http://www.in.gov/fssa/hip/<br />
Phone: 1-877-438-4479<br />
All other Medicaid<br />
Website: https://www.in.gov/medicaid/<br />
Phone 1-800-457-4584<br />
IOWA – MEDICAID AND CHIP (HAWKI)<br />
Medicaid Website: https://dhs.iowa.gov/ime/<br />
members<br />
Medicaid Phone: 1-800-338-8366<br />
Hawki Website: http://dhs.iowa.gov/Hawki<br />
Hawki Phone: 1-800-257-8563<br />
HIPP Website: https://dhs.iowa.gov/ime/members<br />
/medicaid-a-to-z/hipp<br />
HIPP Phone: 1-888-346-9562<br />
KANSAS - MEDICAID<br />
Website: https://www.kancare.ks.gov/<br />
Phone: 1-800-792-4884<br />
KENTUCKY – MEDICAID<br />
Kentucky Integrated Health Insurance Premium<br />
Payment Program (KI-HIPP) Website: https:// chfs<br />
.ky.gov/agencies/dms/member/Pages/kihipp.aspx<br />
Phone: 1-855-459-6328<br />
Email: KIHIPP.PROGRAM@ky.gov<br />
KCHIP Website: https://kidshealth.ky.gov/Pages<br />
/index.aspx<br />
Phone: 1-877-524-4718<br />
Kentucky Medicaid Website: https://chfs.ky.gov<br />
LOUISIANA - MEDICAID<br />
Website: www.medicaid.la.gov or<br />
www.ldh.la.gov/lahipp<br />
Phone: 1-888-342-6207 (Medicaid hotline) or<br />
1-855-618-5488 (LaHIPP)<br />
MAINE - MEDICAID<br />
Enrollment Website: https://www.maine.gov/dhhs<br />
/ofi/applications-forms<br />
Phone: 1-800-442-6003<br />
TTY: Maine relay 711<br />
Private Health Insurance Premium Webpage: https:<br />
//www.maine.gov/dhhs/ofi/applications-forms<br />
Phone: 1-800-977-6740.<br />
TTY: Maine relay 711<br />
MASSACHUSETTS – MEDICAID AND CHIP<br />
Website: https://www.mass.gov/masshealth/pa<br />
Phone: 1-800-862-4840<br />
MINNESOTA - MEDICAID<br />
Website: https://mn.gov/dhs/people-we-serve/<br />
children-and-families/health-care/health-care-pro<br />
grams/programs-and-services/other-insurance.jsp<br />
Phone: 1-800-657-3739<br />
MISSOURI - MEDICAID<br />
Website: http://www.dss.mo.gov/mhd/ participan<br />
ts/pages/hipp.htm<br />
Phone: 573-751-2005<br />
MONTANA - MEDICAID<br />
Website: http://dphhs.mt.gov/MontanaHealthcare<br />
Programs/HIPP<br />
Phone: 1-800-694-3084<br />
NEBRASKA- MEDICAID<br />
Website: http://www.ACCESSNebraska.ne.gov<br />
Phone: 1-855-632-7633<br />
Lincoln: 402-473-7000<br />
Omaha: 402-595-1178<br />
NEVADA - MEDICAID<br />
Medicaid Website: http://dhcfp.nv.gov<br />
Medicaid Phone: 1-800-992-0900<br />
NEW HAMPSHIRE - MEDICAID<br />
Website: https://www.dhhs.nh.gov/oii/hipp.htm<br />
Phone: 603-271-5218<br />
Toll free number for the HIPP program:<br />
1-800-852-3345, ext 5218<br />
NEW JERSEY – MEDICAID AND CHIP<br />
Medicaid Website: http://www.state.nj.us/human<br />
services/dmahs/clients/medicaid/<br />
Medicaid Phone: 609-631-2392<br />
CHIP Website: http://www.njfamilycare.org/index<br />
.html<br />
CHIP Phone: 1-800-701-0710<br />
NEW YORK - MEDICAID<br />
Website: https://www.health.ny.gov/health_care<br />
/medicaid/<br />
Phone: 1-800-541-2831<br />
NORTH CAROLINA - MEDICAID<br />
Website: https://medicaid.ncdhhs.gov/<br />
Phone: 919-855-4100<br />
NORTH DAKOTA - MEDICAID<br />
Website: http://www.nd.gov/dhs/services/medi<br />
calserv /medicaid/<br />
Phone: 1-844-854-4825<br />
OKLAHOMA – MEDICAID AND CHIP<br />
Website: http://www.insureoklahoma.org<br />
Phone: 1-888-365-3742<br />
OREGON - MEDICAID<br />
Website: http://healthcare.oregon.gov/Pages/<br />
index.aspx<br />
http://www.oregonhealthcare.gov/index-es.html<br />
Phone: 1-800-699-9075<br />
PENNSYLVANIA - MEDICAID<br />
Website: https://www.dhs.pa.gov/Services/Assist<br />
ance/Pages/HIPP-Program.aspx<br />
Phone: 1-800-692-7462<br />
RHODE ISLAND – MEDICAID AND CHIP<br />
Website: http://www.eohhs.ri.gov/<br />
Phone: 1-855-697-4347, or 401-462-0311 (Direct<br />
RIte Share Line)<br />
SOUTH CAROLINA – MEDICAID<br />
Website: https://www.scdhhs.gov<br />
Phone: 1-888-549-0820<br />
SOUTH DAKOTA - MEDICAID<br />
Website: http://dss.sd.gov<br />
Phone: 1-888-828-0059<br />
TEXAS - MEDICAID<br />
Website: http://gethipptexas.com/<br />
Phone: 1-800-440-0493<br />
UTAH – MEDICAID AND CHIP<br />
Medicaid Website: https://medicaid.utah.gov/<br />
CHIP Website: http://health.utah.gov/chip<br />
Phone: 1-877-543-7669<br />
VERMONT - MEDICAID<br />
Website: http://www.greenmountaincare.org/<br />
Phone: 1-800-250-8427<br />
VIRGINIA – MEDICAID AND CHIP<br />
Website: https://www.coverva.org/en/famis -select<br />
https://www.coverva.org/en/hipp<br />
Medicaid Phone: 1-800-432-5924<br />
CHIP Phone: 1-800-432-5924<br />
WASHINGTON - MEDICAID<br />
Website: https://www.hca.wa.gov/<br />
Phone: 1-800-562-3022<br />
WEST VIRGINIA - MEDICAID<br />
Website: https://dhhr.wv.gov/bms/<br />
http://mywvhipp.com/<br />
Medicaid Phone: 304-558-1700<br />
CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-699-<br />
8447)<br />
WISCONSIN – MEDICAID AND CHIP<br />
Website: https://www.dhs.wisconsin.gov/badger<br />
careplus/p-10095.htm<br />
Phone: 1-800-362-3002<br />
WYOMING - MEDICAID<br />
Website: https://health.wyo.gov/healthcarefin/<br />
medicaid/programs-and-eligibility/<br />
Phone: 1-800-251-1269<br />
33
COMPLIANCE DISCLOSURES<br />
PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) Continued<br />
To see if any other states have added a premium assistance program since Jan. 31, 2022, or for more information on special enrollment rights contact:<br />
U.S. Department of Labor<br />
U.S. Department of Health and Human Services<br />
Employee <strong>Benefits</strong> Security Administration<br />
Centers for Medicare and Medicaid Services<br />
dol.gov/agencies/ebsa<br />
www.cms.hhs.gov<br />
(866) 444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext 61565<br />
Paperwork Reduction Act Statement<br />
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection<br />
displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of<br />
information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of<br />
information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to<br />
penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.<br />
The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged<br />
to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S.<br />
Department of Labor, Employee <strong>Benefits</strong> Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room<br />
N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.<br />
OMB Control Number 1210-0137 (expires 1/31/<strong>2023</strong>)<br />
THE WOMEN’S HEALTH AND CANCER RIGHTS<br />
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<br />
individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:<br />
All stages of reconstruction of the breast on which the mastectomy was performed;<br />
• Surgery and reconstruction of the other breast to produce a symmetrical appearance;<br />
• Prostheses; and<br />
• Treatment of physical complications of the mastectomy, including lymphedema.<br />
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. Therefore,<br />
the following deductibles and coinsurance apply: [insert deductibles and coinsurance applicable to these benefits]. If you would like more information on WHCRA<br />
benefits, call your plan administrator: Robin Liggett, <strong>Providence</strong> <strong>Engineering</strong>, 1201 Main Street, Baton Rouge, LA, 70802, P: 225-766-7400, E:<br />
robinliggett@providenceeng.com.<br />
WOMEN’S HEALTH AND CANCER RIGHTS ENROLLMENT NOTICE<br />
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<br />
reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema?<br />
Call your plan administrator at: 225-766-7400 or more information.<br />
34
COMPLIANCE DISCLOSURES<br />
HIPAA PRIVACY NOTICE<br />
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY OBTAIN ACCESS TO THIS INFORMATION.<br />
PLEASE REVIEW IT CAREFULLY.<br />
Name of Health Plan: <strong>Providence</strong> <strong>Engineering</strong><br />
Why is the Plan providing me with this Privacy Notice?<br />
This Notice is being provided to you in accordance with the requirements of the Standards for Privacy of Individually Identifiable Health Information of the Health<br />
Insurance Portability and Accountability Act (the “HIPAA Privacy Rules”). The HIPAA Privacy rules are federal laws that seek to ensure the privacy and confidentiality of<br />
your health information. The HIPAA Privacy Rules require the Plan to take certain actions to protect the privacy of your health information. This Notice has been<br />
prepared to advise you of the uses and disclosures of your Protected Health Information (as defined below) that may be made by the Plan and to advise you of your<br />
rights and the Plan’s legal duties relating to the privacy of your Protected Health Information.<br />
What is Protected Health Information?<br />
Protected Health Information generally is individually identifiable health information, including demographic information, collected from you or created or received by a<br />
health care provider, health care clearinghouse, a health plan or your employer on behalf of a group health plan that relates to:<br />
(1) your past, present or future physical or mental health or condition;<br />
(2) the provision of health care to you; or<br />
(3) the past, present or future payment for the provision of health care to you.<br />
For example, the information included in an explanation of benefits (“EOB”) from the Plan is Protected Health Information. In addition, Protected Health Information<br />
includes genetic information which includes information about your genetic tests or the genetic tests of your family members or the manifestation of a disease in one of<br />
your family members. For example, the fact that your spouse is diagnosed with Type II diabetes is genetic information.<br />
Will the Plan have access to my Protected Health Information?<br />
Yes. As an individual enrolled in the Plan, you should be aware that the Plan may have access to your Protected Health Information from time to time. The Plan may<br />
receive your Protected Health Information in a variety of ways. An example of how the Plan may receive this information is when your healthcare provider, such as your<br />
doctor or your hospital, submits bills for services rendered to you to be paid by the Plan.<br />
When may the Plan use or disclose my Protected Health Information?<br />
The law permits the Plan to use or disclose Protected Health Information to carry out “treatment,” “payment” and other “health care operations”. When the Plan<br />
makes uses or disclosures of your Protected Health Information for treatment, payment or health care operations purposes, the Plan is not required to notify you or<br />
obtain your Authorization (discussed further below).<br />
Treatment: Treatment means the provision, coordination, or management of healthcare and related services by health care providers, including the coordination or<br />
management of health care by a health care provider with a third party (such as an insurer of the Plan), consultation between providers with respect to a patient, and<br />
the referral of a patient for health care from one provider to another. The Plan itself does not engage directly in “treatment” under the HIPAA Privacy Rules. However,<br />
the Plan may interact with a health care provider in treatment transactions.<br />
Payment: Payment means activities undertaken by the Plan to determine eligibility for benefits or fulfill its responsibility for coverage and provision of benefits under<br />
the Plan. Examples of when the Plan might use or disclose Protected Health Information for payment purposes include disclosures to facilitate the payment of claims<br />
made on the Plan by health care providers, the Plan’s activities to obtain or provide reimbursement for the provision of health care, or the Plan’s activities in obtaining<br />
premiums. When the Plan discloses information for payment purposes, the Plan will attempt only to disclose that Protected Health Information which is minimally<br />
necessary to ensure proper and timely payment of claims.<br />
Health Care Operations: The term “health care operations” means those other functions and activities that the Plan performs in connection with providing health care<br />
benefits. Examples of what constitute health care operations during which the Plan might use or disclose your Protected Health Information include activities relating to<br />
creation, renewal or replacement of a contract of health insurance or health benefits, business planning and development relating to the Plan, and compliance with the<br />
HIPAA Privacy Rules. Another example would include the Plan’s use or disclosure of Protected Health Information to better manage its operations, such as when the<br />
Plan discloses information with a vendor or consultant (commonly referred to as a “Business Associate”) to ensure proper accounting and record-keeping relating to the<br />
Plan’s provision of health care benefits. Under contractual agreements with the Plan, Business Associates can receive, create, maintain, use, and disclose your Protected<br />
Health Information, without your consent, but only to assist the Plan with its payment, operations, and other limited purposes.<br />
May the Plan use or disclose my Protected Health Information for other purposes?<br />
Yes. For uses or disclosures of Protected Health Information that are not made for treatment, payment, or health care operations purposes and for which no exception<br />
regarding Authorization applies, the law requires the Plan to obtain your Authorization. An Authorization is your approval for the Plan’s disclosure of your Protected<br />
Health Information to a particular person or entity for a particular purpose. For example, in general and subject to specific conditions, the Plan will not use or disclose<br />
your psychiatric notes. You may revoke an Authorization at any time, but a revocation is not effective if the Plan has already reasonably relied on your Authorization to<br />
make a particular use or disclosure. Examples of when an Authorization would be required include when the uses or disclosures are made to your employer for<br />
disability, fitness for duty or drug testing purposes. Additionally, if you request that the Plan use or disclose your Protected Health Information, the Plan may require<br />
that you sign an Authorization that permits the Plan to honor your request.<br />
When might the Plan make a use or disclosure of my Protected Health Information without my Authorization?<br />
As discussed above, the Plan is not required to obtain your Authorization to use or disclose your Protected Health Information for treatment, payment or health care<br />
operations purposes. Additionally, there are some limited exceptions in which the law allows the Plan to use or disclose your Protected Health Information for purposes<br />
other than treatment, payment, or health care operations without your Authorization. Most of these uses or disclosures are<br />
35
COMPLIANCE DISCLOSURES<br />
HIPAA PRIVACY NOTICE Continued<br />
the types of uses or disclosures of Protected Health Information that may be made without your Authorization and without giving you the opportunity to object include<br />
those made: to avert communicable or spreading diseases; for public health activities; for federal intelligence, counter-intelligence and national security purposes; to<br />
properly assist law enforcement to carry out their duties; when a judge or administrative tribunal orders the release of such Protected Health Information; for cadaveric<br />
organ, eye and tissue donations (where appropriate); to help apprehend criminals; to assist armed forces personnel and operations; for military service, veterans affairs<br />
separation/discharge matters; for coroner/medical examiner purposes; for health oversight purposes (such as when the government requests certain information from<br />
the Plan to determine its compliance with applicable laws); to assist victims of abuse, neglect or domestic violence; to address work-related illness/workplace injuries<br />
and for workers’ compensation purposes; to carry out clinical research that involves treatment where the proper body has determined the importance for doing so; for<br />
FDA-related purposes; for certain health and safety purposes; for funeral/funeral director purposes; to help determine veterans eligibility status; to protect Presidential<br />
and other high-ranking officials; and for reporting to correctional institutions/law enforcement officials acting in a custodian capacity.<br />
There are also several types of uses or disclosures of Protected Health Information that the Plan may make without your Authorization as long as, whenever possible,<br />
you are given an opportunity to agree or object before the Plan makes the use or disclosure. These exceptions are very limited and generally involve the release of a<br />
limited amount of Protected Health Information to aid your family members, close personal friends, or disaster relief personnel in locating you in the event of an<br />
emergency or in case of your incapacity.<br />
Will the Plan disclose my Protected Health Information to my employer?<br />
The Plan has the right to disclose your Protected Health Information to the Plan Sponsor, which is usually your employer, subject to certain limitations. The Plan may<br />
generally disclose to the Plan Sponsor information regarding whether you are enrolled in the Plan and “summary health information,” which means information that<br />
summarizes the claims history and experiences of the individuals enrolled in the plan without specifically identifying you or other plan participants. The Plan may<br />
disclose this information without your Authorization, and the Plan Sponsor may only use the information for its activities relating to its sponsorship of the Plan. For<br />
example, the Plan Sponsor may use this information to seek bids from health insurers or to analyze its health plan expenses. If the Plan Sponsor needs more than<br />
“summary health information” or enrollment information to carry out its responsibilities, then documents that govern the Plan will determine the extent to which<br />
Protected Health Information may be used or disclosed, except that in no case may the Plan Sponsor use or disclose your Protected Health Information for<br />
employment-related decisions or for any other purposes other than as permitted by the Plan documents or by law. Additionally, Plan Sponsors that receive Protected<br />
Health Information from the Plan must make certain certifications to the Plan regarding the uses and disclosures of the information and must ensure that any agents or<br />
subcontractors of the Plan Sponsor agree to the same restrictions and conditions that apply to the Plan Sponsor.<br />
Will the Plan use or disclose my Protected Health Information for marketing, fundraising or other similar purposes?<br />
While the Plan does not anticipate using or disclosing your Protected Health Information for marketing, fundraising or other similar purposes, under the HIPAA Privacy<br />
Rules, the Plan may only make such uses or disclosures with your Authorization, unless the Plan communicates with you face-to-face or provides you with some<br />
promotional gift of nominal value, in which case your Authorization would not be required.<br />
Is the Plan Subject to Other Restrictions Regarding the Use and Disclosure of my Protected Health Information?<br />
The Plan will not:<br />
(1) use your genetic information for underwriting purposes, which includes determining whether you are eligible for benefits; or<br />
(2) directly or indirectly receive payment in exchange for your Protected Health Information unless the Plan obtains a valid authorization from you.<br />
Do I have the right to request additional restrictions on the uses or disclosures of my Protected Health Information?<br />
Yes. You have the right to request additional restrictions relating to the Plan’s use or disclosure of your Protected Health Information beyond those otherwise required<br />
under the HIPAA Privacy Rules. You also have the right to limit disclosures to family members or friends who are involved in your care or payment for your care. For<br />
example, you could ask that the Plan not use or disclose information about a surgery that you had. Although the Plan is not legally required to grant these requests, it is<br />
your right to make such a request. If the Plan agrees to the restriction, it can stop complying with the restriction after providing notice to you. For additional<br />
information or to obtain the proper form for making such a request, please contact the Plan’s Privacy Officer.<br />
May I request that certain communications of my Protected Health Information be made to me at alternate locations?<br />
Yes. The Plan may communicate your Protected Health Information to you in a variety of ways, including by mail or telephone. If you believe that the Plan’s<br />
communications to you by the usual means will endanger you or your health care and you would like the Plan to make its communications that involve Protected Health<br />
Information to you at an alternate location, you may contact the Plan’s Privacy Officer to obtain the appropriate request form. The Plan will only accommodate<br />
reasonable requests and may require information as to how payment, if any, will be handled.<br />
Do I have the right to obtain access to my Protected Health Information?<br />
Generally yes. You have the right to request and obtain access to your Protected Health Information maintained by the Plan unless an exception applies. The Plan may<br />
deny you access to your Protected Health Information if the information is not required to be accessible under the HIPAA Privacy Rules or other applicable law. For<br />
example, you do not have a right to access information compiled by the Plan in anticipation of or for use in a civil, criminal or administrative proceeding.<br />
If the information you request is maintained electronically, and you request an electronic copy, the Plan will provide a copy in the electronic form and format you<br />
request, provided the information may be readily produced in that manner. If not, the Plan will work with you to come to an agreement on form and format. If you and<br />
the Plan cannot agree on an electronic form and format, the Plan will provide you with a paper copy.<br />
The Plan may charge you a reasonable, cost-based fee for copying (including the cost of supplies and labor) any Protected Health Information required to be copied to<br />
adequately respond to your access request, as well as any postage costs and costs associated with preparing an explanation or summary of the Protected Health<br />
Information necessary to adequately respond to your access request (unless otherwise precluded by applicable State or other law). If you would like to request access<br />
to your Protected Health Information, please notify the Plan’s Privacy Officer so that you can complete the appropriate forms.<br />
36
COMPLIANCE DISCLOSURES<br />
HIPAA PRIVACY NOTICE Continued<br />
Do I have the right to request an amendment to my Protected Health Information?<br />
Yes. You have the right to request that the Plan amend your Protected Health Information. The Plan reserves the right to deny or partially deny requests for<br />
amendments that are not required to be granted under the HIPAA Privacy Rules. For example, the Plan may deny a request for amendment when the Protected<br />
Health Information at issue is accurate and complete. If you would like to request an amendment of your Protected Health Information, please notify the Plan’s<br />
Privacy Officer so that you can complete the appropriate forms.<br />
Do I have the right to an accounting of disclosures of my Protected Health Information made by the Plan?<br />
Yes. You have the right to request and obtain a proper accounting of disclosures the Plan has made of your Protected Health Information. The Plan is not required<br />
to account for all uses and disclosures of Protected Health Information that the Plan makes. For example, the Plan is not required to provide an accounting for<br />
disclosures made for treatment, payment, or health care operations purposes or for disclosures made with your Authorization. Additionally, the Plan reserves the<br />
right to limit its accountings to disclosures made after the compliance date of the HIPAA Privacy Rules.<br />
The Plan will provide you with your first accounting at no charge to you. If you request any additional accountings within a 12-month period, the Plan may charge<br />
you a reasonable, cost-based fee. At the time that you request a subsequent accounting, the Plan will provide you with information regarding the fees, and you<br />
will have the opportunity to withdraw or modify your request if you wish to do so. If you would like to request an accounting of your Protected Health<br />
Information, please notify the Plan’s Privacy Officer so that you can complete the appropriate forms.<br />
Do I have the right to receive notice if the privacy or security of my Protected Health Information is compromised?<br />
Yes. In certain circumstances, you have the right to receive notice from the Plan if the privacy or security of your Protected Health Information is compromised.<br />
The notice will describe what occurred, the date of the occurrence (or if later, the date on which the Plan learned of the occurrence), the type of information<br />
involved, actions you should take to protect your information, and actions the Plan is taking to mitigate the harm and reduce the likelihood of recurrence.<br />
If I have an objection to the way my Protected Health Information is being handled, may I file a complaint?<br />
Yes. The Plan has procedures in place for receiving and resolving complaints. If you believe that the Plan has violated your privacy rights or has acted inconsistently<br />
with its obligations under the HIPAA Privacy Rules, you may file a complaint by contacting the Plan’s Privacy Officer. You may send a letter outlining your complaint<br />
to the Privacy Officer or you may call the Privacy Officer and request a complaint form. The Plan requests that you attempt to resolve your complaint with the Plan<br />
via these complaint procedures since the Plan is in the best position to respond to your complaint. However, if you believe the Plan has violated your privacy<br />
rights, you may also file a complaint with the Office of Civil Rights (“OCR”) at the United States Department of Health and Human Services (“HHS”). You may<br />
contact the HHS OCR at: Medical Privacy, Complaint Division, Office of Civil Rights, United States Department of Health and Human Services, 200 Independence<br />
Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201, Voice Hotline Number (800) 368-1019, Internet Address www.hhs.gov/ocr.<br />
It is against the policies and procedures of the Plan to retaliate against any person who has filed a privacy complaint, either with us or with HHS OCR. Should you<br />
believe that you are being retaliated against in any way upon your filing a complaint with us or the HHS OCR, please immediately contact the Plan’s Privacy Officer,<br />
so that the Plan may properly address the issue.<br />
May the Plan amend this Notice?<br />
Yes. The Plan is required to abide by the Notice that is currently in effect; however, the Plan reserves the right to change the terms of this Notice at any time and<br />
to make the new Notice effective for all Protected Health Information maintained by the Plan. If this Notice is amended, you will be provided with a copy of the<br />
new Notice through regular mail, electronic mail, posting at work site, posting on Intranet sites, or by some other reliable method intended to reach all Plan<br />
participants.<br />
May I obtain a paper copy of this Notice?<br />
Yes. If you received this Notice via the Internet or electronic mail, you have the right to request and receive a paper copy of this Notice. If you would like to receive<br />
a paper copy of this Notice, please contact the Plan’s Privacy Officer.<br />
What if I have additional questions that are not answered in this Notice?<br />
If you have any questions, concern or issues relating to the privacy of your Protected Health Information that is not covered in this Notice, please contact the<br />
Plan’s Privacy Officer.<br />
How do I contact the Plan’s Privacy Officer?<br />
You may contact the Plan’s Privacy Officer by calling Robin Liggett at 225-766-7400 or writing to:<br />
<strong>Providence</strong> <strong>Engineering</strong><br />
1201 Main Street<br />
Baton Rouge, LA 70802<br />
What is the effective date of this Notice?<br />
This Privacy Notice is effective as of January 1, <strong>2023</strong><br />
37
COMPLIANCE DISCLOSURES<br />
MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE FOR USE ON OR AFTER APRIL 1, 2011 OMB 0938-0990<br />
IMPORTANT NOTICE FROM <strong>Providence</strong> <strong>Engineering</strong> ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND MEDICARE<br />
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage and about your options<br />
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<br />
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<br />
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.<br />
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:<br />
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<br />
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<br />
coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.<br />
2. <strong>Providence</strong> <strong>Engineering</strong> has determined that the prescription drug coverage offered by the BCBSLA is, on average for all plan participants, expected to pay out as<br />
much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable<br />
Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.<br />
When Can You Join A Medicare Drug Plan?<br />
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 th to December 7 th .<br />
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<br />
Period (SEP) to join a Medicare drug plan.<br />
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?<br />
If you decide to join a Medicare drug plan, your coverage may be affected.<br />
If you do decide to join a Medicare drug plan and drop your current coverage, be aware that you and your dependents may not be able to get this coverage back.<br />
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?<br />
You should also know that if you drop or lose your current coverage with <strong>Providence</strong> <strong>Engineering</strong> and don’t join a Medicare drug plan within 63 continuous days after<br />
your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.<br />
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<br />
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<br />
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<br />
prescription drug coverage. In addition, you may have to wait until the following October to join.<br />
For More Information About This Notice Or Your Current Prescription Drug Coverage…<br />
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<br />
plan, and if this coverage through BCBSLA changes. You also may request a copy of this notice at any time.<br />
For More Information About Your Options Under Medicare Prescription Drug Coverage…<br />
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<br />
mail every year from Medicare. You may also be contacted directly by Medicare drug plans.<br />
For more information about Medicare prescription drug coverage:<br />
• Visit www.medicare.gov<br />
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number)<br />
for personalized help<br />
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.<br />
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<br />
Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).<br />
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<br />
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).<br />
Date: January 1, <strong>2023</strong><br />
Name of Sender: <strong>Providence</strong> <strong>Engineering</strong><br />
Contact: Robin Liggett<br />
Address: 1201 Main Street, Baton Rouge 70802<br />
Phone number: 225-766-7400<br />
Email address: robinliggett@providenceeng.com<br />
38
COMPLIANCE DISCLOSURES<br />
Model General Notice of COBRA Continuation Coverage Rights<br />
(For use by single-employer group health plans)<br />
** Continuation Coverage Rights Under COBRA**<br />
Introduction<br />
You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA<br />
continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available<br />
to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other<br />
coverage options that may cost less than COBRA continuation coverage.<br />
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation<br />
coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights<br />
and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.<br />
You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health<br />
Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs.<br />
Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan<br />
generally doesn’t accept late enrollees.<br />
What is COBRA continuation coverage?<br />
COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific<br />
qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.”<br />
You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan,<br />
qualified beneficiaries who elect COBRA continuation coverage may pay or COBRA continuation coverage.<br />
If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:<br />
●<br />
●<br />
Your hours of employment are reduced, or<br />
Your employment ends for any reason other than your gross misconduct.<br />
If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:<br />
●<br />
●<br />
●<br />
●<br />
●<br />
Your spouse dies;<br />
Your spouse’s hours of employment are reduced;<br />
Your spouse’s employment ends for any reason other than his or her gross misconduct;<br />
Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or<br />
You become divorced or legally separated from your spouse.<br />
Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:<br />
The parent-employee dies;<br />
●<br />
●<br />
●<br />
●<br />
●<br />
The parent-employee’s hours of employment are reduced;<br />
The parent-employee’s employment ends for any reason other than his or her gross misconduct;<br />
The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);<br />
The parents become divorced or legally separated; or<br />
The child stops being eligible for coverage under the Plan as a “dependent child.”<br />
When is COBRA continuation coverage available?<br />
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The<br />
employer must notify the Plan Administrator of the following qualifying events:<br />
●<br />
●<br />
●<br />
The end of employment or reduction of hours of employment;<br />
Death of the employee;<br />
The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).<br />
For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child),<br />
you must notify the Plan Administrator within 60 days [or enter longer period permitted under the terms of the Plan] after the qualifying event occurs. You must<br />
provide this notice to: Robin Liggett, <strong>Providence</strong> <strong>Engineering</strong> at 1201 Main Street, Baton Rouge, LA 70802 or you may call 225-766-7400.<br />
How is COBRA continuation coverage provided?<br />
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries.<br />
Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf<br />
of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.<br />
39
COMPLIANCE DISCLOSURES<br />
Model General Notice of COBRA Continuation Coverage Rights Continued<br />
COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work.<br />
Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.<br />
There are also ways in which this 18-month period of COBRA continuation coverage can be extended:<br />
Disability extension of 18-month period of COBRA continuation coverage<br />
If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and<br />
your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to<br />
have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation<br />
coverage.<br />
Second qualifying event extension of 18-month period of continuation coverage<br />
If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up<br />
to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This<br />
extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled<br />
to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent<br />
child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first<br />
qualifying event not occurred.<br />
Are there other coverage options besides COBRA Continuation Coverage?<br />
Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace,<br />
Medicare, Medicaid, Children’s Health Insurance Program (CHIP), or other group health plan coverage options (such as a spouse’s plan) through what is called a “special<br />
enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.<br />
Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?<br />
In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have<br />
an 8-month special enrollment period [1] to sign up for Medicare Part A or B, beginning on the earlier of<br />
●<br />
●<br />
The month after your employment ends; or<br />
The month after group health plan coverage based on current employment ends.<br />
If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in<br />
coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage<br />
ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage<br />
may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.<br />
If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay<br />
second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.<br />
For more information visit https://www.medicare.gov/medicare-and-you.<br />
[1]<br />
https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b/part-a-part-b-sign-up-periods.<br />
If you have questions<br />
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information<br />
about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws<br />
affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee <strong>Benefits</strong> Security Administration (EBSA) in your<br />
area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information<br />
about the Marketplace, visit www.HealthCare.gov.<br />
Keep your Plan informed of address changes<br />
To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of<br />
any notices you send to the Plan Administrator.<br />
Plan contact information<br />
Robin Liggett, <strong>Providence</strong> <strong>Engineering</strong>, 1201 Main Street, Baton Rouge, LA, 70802, P: 225-766-7400, E: robinliggett@providenceeng.com.<br />
40
GLOSSARY<br />
Coinsurance: Your share of the cost of a covered health care service, calculated as a percent (for example, 20%)<br />
of the allowed amount for the service, typically after you meet your deductible. For instance, if your plan’s<br />
allowed amount for an office visit is $100 and you’ve met your deductible (but haven’t yet met your<br />
out-of-pocket maximum), your coinsurance payment of 20% would be $20. Your plan sponsor or employer<br />
would pay the rest of the allowed amount.<br />
Copay: The fixed amount, as determined by your insurance plan, you pay for health care services received.<br />
Deductible: The amount you owe for medical services before your medical insurance or plan sponsor<br />
(employer) begins to pay its portion. For example, if your deductible is $3,000, your plan does not pay anything<br />
until you’ve met your $3,000 deductible for covered health care services. This deductible may not apply to all<br />
services, including preventive care. Preventive care is 100% covered by the plan.<br />
Employee Contribution: The weekly amount you pay for your insurance coverage.<br />
Explanation of <strong>Benefits</strong> (EOB) / Personal Health Statement (PHS): A statement sent by your insurance carrier<br />
that explains which procedures and services were provided, how much they cost, what portion of the claim was<br />
paid by the plan, and what portion is your liability, in addition to how you can appeal the insurer’s decision.<br />
These statements are also posted on the carrier’s website for your review.<br />
Flexible Spending Accounts (FSA): An option that allows participants to set aside pre-tax dollars to pay for<br />
certain qualified expenses during a specific time period (usually a 12-month period).<br />
Health Care Cost Transparency: Also known as Market Transparency or Medical Transparency. Health care<br />
provider costs can vary widely, even within the same geographic area. To make it easier for you to get the most<br />
cost-effective health care products and services, online cost transparency tools, which are typically available<br />
through health insurance carriers, allow you to search an extensive national database to compare costs for<br />
everything from prescription drugs and office visits to MRIs and major surgeries.<br />
Health Savings Account (HSA): A personal health care bank account funded by you or your employer’s tax-free<br />
dollars to pay for qualified Medical expenses. You must be enrolled in a HDHP to open an HSA. Funds<br />
contributed to an HSA roll over from year to year and the account is portable, meaning if you change jobs, your<br />
account goes with you.<br />
High Deductible Health Plan (HDHP): Plan option that provides choice, flexibility and control when it comes to<br />
spending money on health care. Preventive care is covered at 100% with in-network providers, there are no<br />
copays, and all qualified employee-paid Medical expenses count toward your deductible and your out-of-pocket<br />
maximum.<br />
In-Network: In-network providers are doctors, hospitals and other providers that contract with your insurance<br />
company to provide health care services at discounted rates.<br />
Out-of-Network: Out-of-network providers are doctors, hospitals and other providers that are not contracted<br />
with your insurance company. If you choose an out-of-network doctor, services will not be provided at a<br />
discounted rate and your cost sharing (deductibles and coinsurance) will increase.<br />
Out-of-Pocket Maximum: The maximum amount of money you will pay for medical services during the plan<br />
year. The out-of-pocket maximum is the sum of your deductible and coinsurance payments.<br />
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Prepared by:<br />
Prepared for:<br />
PROVIDENCE ENGINEERING AND<br />
ENVIRONMENTAL GROUP, LLC