1 OPEN ENROLLMENT OPEN ENROLLMENT NOVEMBER 1 - NOVEMBER 30, 2016

OPEN ENROLLMENT NOVEMBER 1 - NOVEMBER 30, 2016 1 OPEN ENROLLMENT Please retain this document for your future reference. Open Enrollment Period fo...
0 downloads 0 Views 3MB Size
OPEN ENROLLMENT NOVEMBER 1 - NOVEMBER 30, 2016

1

OPEN ENROLLMENT

Please retain this document for your future reference.

Open Enrollment Period for Fringe Benefits Open enrollment begins November 1 and runs through November 30, 2016. All changes will go into effect on January 1, 2017. If you want to enroll or continue to participate in the Flexible Spending Account programs, you must register within this period. Employees can enroll, change coverage, or drop coverage in our medical and dental plans during this time without having to satisfy a qualifying event. If you are already enrolled in medical or dental coverage and do not need to make changes, no further action is required. 2

OPEN ENROLLMENT

3

OPEN ENROLLMENT

For more information, contact Glynn Griffing & Associates at 601-982-0331 or visit glynn.info.

Flexible Spending Accounts Our open enrollment period affects our Flexible Spending Accounts (FSAs). The following information will educate you on the benefits and tax savings associated with these programs.

Note: Current FSA participants MUST complete new enrollment forms for 2017.

FSA signup forms are included with this brochure. They may also be found at your facility and on the HR Portal.

4

OPEN ENROLLMENT

5

OPEN ENROLLMENT

Put money away conservatively. You’ll lose it if you don’t use it, but don’t let that scare you! Contribute what you know you will spend, and you’ll save!

Flexible Spending Accounts FAQs What is a Section 125 Plan?

What is a Flexible Spending Account?

A Section 125 Plan, often called a Cafeteria Plan, refers to the IRS code that allows you to pay for medical premiums, deductibles, out-of-pocket expenses, co-pays, non-covered medical expenses, and dependent care expenses on a pre-tax basis. You still pay for these expenses, but you see a savings because you pay for them on a pre-tax basis.

Cafeteria Plans have the option of adding Flexible Spending Accounts (FSAs). FSAs enable you to set aside money on a pre-tax basis to pay for any unreimbursed medical and dependent care expenses.

Does Ergon have a Cafeteria Plan?

What are my FSA Options? There are two types of FSAs.

Ergon has had a Cafeteria Plan in the form of a “premium only plan” since the late 1990s. In other words, the money for medical coverage that comes out of your checks is part of a Cafeteria Plan. You still pay for the coverage by paying the premium, but on a pre-tax basis. At the end of the year, your taxable salary is reduced by what comes out of your paycheck.

6

Health FSA: This type of account is designed to cover such items as medical plan deductibles, co-payments, and uninsured medical care expenses, such as dental and vision care. The Affordable Care Act limits the maximum contribution to a medical Flexible Spending Account to $2,600 for 2017.

OPEN ENROLLMENT

Dependent Care FSA: This type of account is designed to cover items such as child day care because they enable you to work. There is a $5,000 annual limit on Dependent Care FSAs, regardless of the number of children you may have in day care. A company can decide to implement a Health FSA and choose not to implement a Dependent Care FSA. If the company implements both types of FSAs, each account stands alone. You cannot borrow money from your Health FSA to make up a shortfall in your Dependent Care FSA, nor can you borrow from your Dependent Care FSA to make up a shortfall in your Health FSA. How does an FSA work? You must decide whether and how much to contribute to each FSA prior to the beginning of the year. This amount should be

7

based on the expenses you feel certain you will incur during the upcoming year. A set amount is deducted from your paychecks on a regular basis, and when you incur a cafeteriacovered expense, you submit documentation to the cafeteria plan administrator and receive a reimbursement. Total reimbursements cannot exceed the amounts you designate to your FSAs. What does that mean? For example, say you spend $300 a year on contact lenses. Contact lenses are not covered under our medical plan. However, you can set aside $25 a month in your Health FSA. At the beginning of July when you reorder your contacts, you may submit a request for reimbursement to get $300 back from the cafeteria plan administrator. Keep in mind, you will still be contributing to the cafeteria plan for the rest of the year – $25 a month – but you can receive reimbursement up front because you’ve made the commitment to set aside $300.

OPEN ENROLLMENT

Are over-the-counter medications part of this program?

Should you use your FSA to cover unexpected expenses?


No. The Affordable Care Act excludes over-the-counter medications as a reimbursable expense under FSAs unless you have a prescription for the OTC medication.

If you decide to have Lasik eye surgery next year and know that surgery runs $2,400, you might want to set aside $200 per month to cover this operation since elective surgery is not covered under Ergon’s medical plan.

What’s in it for you? You know how much you spend each year on contact lenses. With an FSA, you now buy them on a pre-tax basis, conceivably saving $60 when federal, state, and social security taxes are figured into the equation.

Since you don’t know if you will have an emergency surgery, you would not want to set aside any money for unexpected, unplanned medical procedures for reasons that are explained below. What’s the down side?

Is this too good to be true? Under IRS rules, the full amount you elect for the plan year must be available to reimburse your medical expenses at all times during the year (less any amount already reimbursed). This is the “uniform reimbursement” rule. The example of buying $300 contact lenses in July fits this example. You have only had $150 deducted by the end of June, but you receive your full $300 reimbursement because you have committed to a $300 deduction over the course of the year.

8

The elected amount cannot be changed during the plan year unless you experience a “change in status” (such as the birth or death of a dependent, marriage, divorce, etc.). Unused funds remaining in your account at the end of the plan year may not be refunded or carried over to the next year. This is the “use it or lose it” rule. If you commit to put money away on the off chance you may have to have surgery, and then don’t have this surgery, you forfeit what you haven’t spent (unless, of course you spend it on another legitimate expense covered by a cafeteria plan).

OPEN ENROLLMENT

What about child care? Can money be put away for that on a pre-tax basis?


Anything else I need to know before I commit?

Dependent Care FSAs are not subject to the “uniform reimbursement” requirement. For example, if you know child day care runs $300 a month and designate $300 a month for your Dependent Care FSA, you cannot receive the full $3,600 in January. You have to have the money in your Dependent Care FSA before you can be reimbursed. However, Dependent Care FSAs are subject to the “use it or lose it” and “change in status” rules. Who at Ergon makes the decision on what is covered or what is not covered?
 Ergon contracts with a third party to administer our FSAs. There are companies in the marketplace that specialize in cafeteria plan administration, and they make the call on what qualifies as a covered expense.

While cafeteria plans have advantages for both you and Ergon, some drawbacks exist. The “uniform reimbursement rule” can put Ergon at risk if you resign before contributing the full amount to your Health FSA. For example, let’s say you designate $2,400 ($200 a month) to go into your Health FSA. You then have Lasik eye surgery in January, and resign in February. The Cafeteria Plan still owes you $2,400 even though you’ve only contributed $200. Under the “use it or lose it” rule, you must forfeit unused FSA contributions. You would not want to put money in your Health FSA in the off chance that you might have to have an appendectomy, because if you don’t spend that money on medical bills, you lose it. It stays with the Cafeteria Plan to offset expenses. So, do I commit to a little or to a lot? We should all be conservative savers when it comes to a Flexible Spending Account in a Cafeteria Plan. A good guideline: only commit to the amount you know you will be spending.

9

OPEN ENROLLMENT

Cafeteria Plan Reimbursable Items Health Flexible Spending Account

Cafeteria Plan Reimbursable Items Dependent Care Account Qualifying Expenses (See IRS Publication 503)

Acupuncture Ambulance Artificial Teeth, Artificial Limbs Birth Control Pills Braces Braille Books & Magazines Cab Fare in Obstetrical Cases Care for Mentally Handicapped Chiropractors Coinsurance Contact Lenses & Contact Solution Cost of Operations & Related Illness Confinement Cost of Physical or Mental Illness Confinement Crutches Deductible Dental Fees Dentures Diagnostic Fees
 Drug & Medical Supplies Eyeglasses, Including Exam Fees
 Fee of Practical Nurse Fees of Licensed Osteopaths
Hair Transplants (if not Cosmetic) Hearing Devices & Batteries Home Improvements Motivated by Medical Consideration Hospital Bills Insulin
 Laboratory Fees Lasik Eye Surgery

10

Obstetrical Expenses Orthodontia Orthopedic Shoes Oxygen Physician Fees Prescription Drugs Psychiatric Care Psychologist Fees Radial Keratotomy Routine Physical & Other Non-Diagnostic Services or Treatments Smoking Cessation Programs Special Communication Equipment for the Deaf Special Education for the Blind Special Plumbing for the Handicapped Sterilization Fees Surgical Fees Therapeutic Care for Drug & Alcohol Addiction Therapy Treatments
 Transportation Expense for Medical Services Tuition at Special School for Handicapped Wheelchair Wigs X-rays

Work-Related Expenses: • Expenses incurred that allow you (and your spouse, if married) to work or look for work • Expenses must be for the well-being and protection of a qualifying person Types of Allowed Expenses: • Housekeeper, maid, or cook – only if their services were performed while caring for a qualifying person (does not include food, clothing, education, or entertainment) • Expenses paid to a dependent care center if the center complies with all applicable state and local regulations

Non-Covered Expenses: • Cannot count cost of clothing, entertainment, food, or schooling unless incidental to and not easily separated from total cost (e.g., preschool child care service) • If the situation for the child is educational (e.g., kindergarten), the expense should not be reimbursed under dependent childcare (ineligible) • Cannot count expenses incurred while you are off work due to illness, regardless of whether or not you receive sick pay • Cannot count payments made to your child under age 19 at the end of the year • Cannot count payments made to a relative if the person is a legal dependent • Cannot count expenses to send your child to an overnight camp

More information can be found on the HR Portal.

Note: Cosmetic medical expenses are not eligible. (Example: whitening or bleaching your teeth, surgery to improve appearance.) Vitamins and supplements are not eligible.

OPEN ENROLLMENT

11

OPEN ENROLLMENT

If you are already enrolled in medical or dental coverage and do not need to make changes, no further action is required.

Medical Benefits $21,250,938. That’s how much the Ergon Medical Plan paid out in benefits and fees for the year ending June 30, 2016. Taxes alone under the Affordable Care Act amounted to $230,158. Health insurance is expensive and getting costlier every year. Insurance companies are implementing double digit rate increases for 2017 on their individual policies. Ergon realizes medical coverage is an important fringe benefit to you and your family. Therefore, Ergon has chosen to maintain coverage rates for employees and their dependents without any additional increases from the rates initiated on January 1, 2015. The medical deductible of $300 per calendar year per covered person and out-of-pocket amounts of $1,200 per calendar year per covered person will remain the same.

• Employee Only - $75 per month • Each Covered Dependent - $75 per month Employees who add a dependent during open enrollment will need to provide proof of dependent status to cover a dependent under our medical plan. A copy of a marriage certificate, birth certificate, or adoption certificate will satisfy this requirement. If you have declined or are declining enrollment for yourself or your dependents (including your spouse) because of other

OPEN ENROLLMENT

We will continue to share the cost of company-provided medical coverage with you in employee meetings held throughout the year. Remember, you can take an active role in containing your medical costs while reducing your taxable income by contributing to a Flexible Spending Account (FSA). Benefit change forms are available on the HR Portal, from the contact person at your facility, or from the Corporate Human Resources Department. Please return all completed forms by November 30, 2016, to the contact person at your facility or to:

2017 Medical Insurance Premium

12

health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 30 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

13

Human Resources
 Ergon, Inc.
 P.O. Box 1639
 Jackson, MS 39215-1639 [email protected] • Fax: 601-933-3373 For more information about your coverage and costs, visit bcbsms.com.

OPEN ENROLLMENT

Blue Cross Tobacco Cessation Benefit

Ergon Tobacco Cessation Benefit

Tobacco Cessation programs are now covered under the Ergon Medical Benefits Plan.

If you choose not to take advantage of the Blue Cross Tobacco Cessation Benefit, Ergon also offers a Tobacco Cessation Benefit for employees. This benefit is only available for Ergon employees.

No Deductibles and No Out-of-Pocket Expenses This program has no deductibles and no out-of-pocket expenses. In other words, there is no cost to you or your dependents to use this benefit, but you must register with Blue Cross to have your plan of treatment covered. Additional details are listed below: • Two attempts to stop using tobacco in any 12-month period are now covered. • The first attempt covers an office visit with your physician where you discuss a treatment plan and receive a prescription for your choice of a tobacco cessation method. This can occur at your Healthy You! wellness visit or at a separate visit with your doctor. Both prescription and over-thecounter tobacco cessation medications are covered as long as they are FDA approved. In addition, up to nine calls to the tobacco quitline, IQH, are covered during the first 90 days of your tobacco cessation program. Please note that five of those calls are counseling calls, meaning a counselor will call you. • The second attempt during the same 12-month period is covered if you fail to quit after the initial 90-day treatment and are ready for re-treatment. A second visit to your physician is covered if needed, where you will discuss your treatment plan and obtain a prescription. Once again, both prescription and over-the-counter tobacco cessation medications are covered as long as they are FDA approved. Up to 4 IQH counseling calls and 3 follow up IQH calls are covered during this second attempt. 14

• If these two attempts are unsuccessful, you can re-enroll in the tobacco cessation program 12 months following your most recent enrollment date. The physician’s office visits must be with a network physician. Group counseling is not covered. In-person, individual counseling is available only during the allotted physician office visit or Healthy You! visit, but not through the IQH quitline. This program is designed for adults, including dependent children age 18 and older. Dependent children between the ages of 16 and 18 only have access to the tobacco quitline. Dependent children under age 16 only have access to the quitline with parental consent. You must enroll with Blue Cross to take advantage of this benefit.

Tobacco Cessation Reimbursement Program: • You choose the program: No prior approval is required before beginning a program • You complete the program: Program may be selfdirected or medically supervised • You submit your expenses: Hold all receipts until program is completed and send to Corporate HR • You receive a check: Ergon will provide reimbursement for reasonable expenses • Limitations: Employees have only one opportunity to receive reimbursement

Tobacco cessation medications will not be covered if you fail to enroll. To enroll, access your myBlue website at bcbsms.com. Once you have logged into your myBlue site, click on the “Enroll Now” button under the “Be Tobacco-free” tab at the bottom of the webpage. Complete the enrollment forms online and start your journey toward a life free of tobacco. If you prefer, you can contact customer service at Blue Cross & Blue Shield of Mississippi to enroll. The customer service number is 601-664-4690. Or, you can contact the Human Resources Department and we will instruct Blue Cross to enroll you in the tobacco cessation program.

OPEN ENROLLMENT

More information can be found on the HR Portal.

15

OPEN ENROLLMENT

When Smokers Quit

Call 1-800-Quit-Now (1-800-784-8669)

Within 20 minutes of smoking your last cigarette, your body begins a series of changes that continues for years. Take advantage of Ergon’s Tobacco Cessation Reimbursement Program to become tobacco-free.

1 Year • Excess risk of coronary heart disease is half that of a smoker 5 Years • Lung cancer death rate for average former smoker (one pack a day) decreases by almost half • Stroke risk is reduced to that of a nonsmoker 5-15 years after quitting
 • Risk of cancer of the mouth, throat and esophagus is half that of a smoker’s

20 Minutes • Blood pressure drops to normal
 • Pulse rate drops to normal
 • Body temperature of hands and feet increases to normal 8 Hours • Carbon monoxide level in blood drops to normal • Oxygen level in blood increases to normal

10 Years • Lung cancer death rate similar to that of nonsmokers
 • Precancerous cells are replaced
 • Risk of cancer of mouth, throat, esophagus, bladder, kidney, and pancreas decreases

24 Hours • Chance of heart attack decreases 48 Hours • Nerve endings start re-growing • Ability to smell and taste is enhanced

15 Years • Risk of coronary heart disease is that of a nonsmoker

2 Weeks to 3 Months • Circulation improves
 • Walking becomes easier • Lung function increases

Source: American Cancer Society; Centers for Disease Control and Prevention

1 to 9 Months • Coughing, sinus congestion, fatigue, shortness of breath decrease • Cilia re-grow in lungs, increasing ability to handle mucus, clean the lungs, reduce infection • Body’s overall energy increases 16

OPEN ENROLLMENT

17

Visit these websites for more information: cancer.org cdc.gov quitlinems.com

OPEN ENROLLMENT

Dental Benefits During open enrollment, you may choose to sign up for the voluntary payroll-deduction dental program provided by Assurant Employee Benefits. The 2017 rates for dental insurance remain the same as those from 2016: • $24.44 a month for single coverage • $46.39 for two party coverage
 • $75.71 for family coverage Coverage for eligible employees will begin the first day of the month following the eligibility period. Visit the HR Portal for more information, or visit assurantemployeebenefits.com.

401(k) While our 401(k) is not subject to open enrollment, you should know the maximum annual deferral for 2017 is $18,000 (or $24,000 for anyone 50 or older). Participants can begin or change their deferrals and investment selections at any time by visiting myretirement.americanfunds.com or by calling 1-800-204-3731.

UBS Financial Services is the advisor for Ergon’s 401(k) Plan. If you have questions about your 401(k) investments, feel free to contact them at 601-957-5225, or by emailing [email protected], [email protected], [email protected] or [email protected].

If you are already enrolled in medical or dental coverage and do not need to make changes, no further action is required. More information can be found on the HR Portal.

18

OPEN ENROLLMENT 18

OPEN ENROLLMENT

19

EMPLOYEE BENEFITS 19

OPEN ENROLLMENT

Women’s Health and Cancer Rights Act of 1998 In October 1998, Congress enacted the Women’s Health and Cancer Rights Act of 1998. This notice explains some important provisions of the Act. Please review this information carefully. As specified in the Women’s Health and Cancer Rights Act, a plan participant or beneficiary who elects to have breast reconstruction in connection with a mastectomy is also entitled to the following benefits: • Reconstruction of the breast on which the mastectomy was performed • Surgery and reconstruction of the other breast to produce a symmetrical appearance • Prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas Health plans must determine the manner of coverage in consultation with the attending physician and the patient. Coverage for breast reconstruction and related services may be subject to deductibles and coinsurance amounts that are consistent with those that apply to other benefits under this plan.

20

OPEN ENROLLMENT

21

OPEN ENROLLMENT

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed on the next page, contact your state Medicaid or CHIP office to find out if premium assistance is available.

22

OPEN ENROLLMENT

23

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your state Medicaid or CHIP office or dial 1-877-KIDS NOW or insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at askebsa.dol.gov or call 1-866-444-EBSA (3272).

OPEN ENROLLMENT

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2016. Contact your state for more information on eligibility.

ALABAMA – Medicaid

LOUISIANA – Medicaid Website: www.dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

Website: www.myalhipp.com Phone: 1-855-692-5447

NORTH CAROLINA – Medicaid

Website: www.myakhipp.com Phone: (Outside of Anchorage) 1-866-251-4861 Email: [email protected] Medicaid Eligibility: www.dhss.alaska.gov/dpa/pages/medicaid/default.aspx ARKANSAS - Medicaid

Website: www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TT: Maine relay 711 MASSACHUSETTS – Medicaid and CHIP Website: www.mass.gov/MassHealth Phone: 1-800-462-1120

Website: www.myarhipp.com Phone: 1-855-MyARHIPP (855-692-7447)

MINNESOTA – Medicaid Website: www.mn.gov/dhs/ma Phone: 1-800-657-3739

COLORADO – Medicaid Website: www.colorado.gov/hcpf Medicaid Customer Contact Center: 1-800-221-3943

Website: www.nd.gov/dhs/services/medicalserv/medicaid Phone: 1-844-854-4825

Website: www.dss.mo.gov/mhd/participants Phone: 573-751-2005

Website: www.flmedicaidtplrecovery.com/hipp Phone: 1-877-357-3268 GEORGIA – Medicaid Website: www.dch.georgia.gov/medicaid Click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507 INDIANA – Medicaid

Website: www.oregonhealthykids.gov Website: www.hijossaludablesoregon.gov Phone: 1-800-699-9075 PENNSYLVANIA – Medicaid

NEW HAMPSHIRE – Medicaid Website: www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218

Website: www.dhs.state.ia.us/hipp Phone: 1-888-346-9562

NEW JERSEY – Medicaid and CHIP

KANSAS – Medicaid

Medicaid Website: www.state.nj.us/humanservices/dmahs/clients/medicaid Medicaid Phone: 609-631-2392 CHIP Website: www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

Website: www.kdheks.gov Phone: 1-785-296-3512 KENTUCKY – Medicaid Website: www.chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

NEW YORK – Medicaid Website: www.nyhealth.gov/health_care/medicaid Phone: 1-800-541-2831 24

OPEN ENROLLMENT

WYOMING – Medicaid Website: www.wyequalitycare.acs-inc.com/ Phone: 307-777-7531

RHODE ISLAND – Medicaid Website: www.eohhs.ri.gov Phone: 401-462-5300

To see if any states have added a premium assistance program since July 31, 2016, or for more information on special enrollment rights, you can contact:

SOUTH CAROLINA – Medicaid Website: www.scdhhs.gov Phone: 1-888-549-0820 SOUTH DAKOTA – Medicaid

U.S. Department of Labor Employee Benefits Security Administration dol.gov/ebsa 1-866-444-EBSA (3272)

Website: dss.sd.gov Phone: 1-888-828-0059

Website: www.dwss.nv.gov/ Phone: 1-800-992-0900

IOWA – Medicaid

WISCONSIN – Medicaid and CHIP Website: www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002

Website: www.dhs.pa.gov/hipp Phone: 1-800-692-7462

NEVADA – Medicaid

Website: www.hip.in.gov Phone: 1-877-438-4479 Website: www.indianamedicaid.com Phone: 1-800-403-0864

WEST VIRGINIA – Medicaid Website: www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspx Phone: 1-877-598-5820, HMS Third Party Liability

OREGON – Medicaid

NEBRASKA – Medicaid Website: www.dhhs.ne.gov/children_family_services/accessnebraska/pages Phone: 1-855-632-7633

Website: www.hca.wa.gov/medicaid/premiumpymt/pages/index.aspx Phone: 1-800-562-3022 ext. 15473

Website: www.insureoklahoma.org Phone: 1-888-365-3742

MONTANA – Medicaid Website: www.dphhs.mt.gov/montanahealthcareprograms Phone: 1-800-694-3084

WASHINGTON – Medicaid

OKLAHOMA – Medicaid and CHIP

MISSOURI – Medicaid

FLORIDA – Medicaid

Medicaid Website: www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282

NORTH DAKOTA – Medicaid

MAINE – Medicaid

ALASKA – Medicaid

VIRGINIA – Medicaid and CHIP

Website: www.ncdhhs.gov/dma Phone: 919-855-4100

TEXAS – Medicaid Website: www.gethipptexas.com Phone: 1-800-440-0493

U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565

UTAH – Medicaid and CHIP Medicaid Website: www.health.utah.gov/medicaid CHIP Website: www.health.utah.gov/chip Phone: 1-877-543-7669 VERMONT– Medicaid

OMB Control Number 1210-0137 (expires 10/31/2016)

Website: www.greenmountaincare.org Phone: 1-800-250-8427

25

OPEN ENROLLMENT

Benefit Providers/Administrators Summary MEDICAL INSURANCE

FLEX SPENDING ACCOUNT

Blue Cross Blue Shield of Mississippi

Glynn Griffing & Associates, Administrators

601-664-4590 or 1-800-942-0278

601-982-0331

bcbsms.com

glynn.info

DENTAL INSURANCE

401(k) PLAN FINANCIAL ADVISORS

Assurant Employee Benefits

UBS Financial Services, Inc.

Group Policy # 5472848

Rush Mosby, Wade Watts, Will Mosby & Kristy Launius

1-800-733-7879

601-957-5225

assurantemployeebenefits.com

financialservicesinc.ubs.com/team/cwm

LIFE AND DISABILITY INSURANCE

401(k) PLAN ADMINISTRATOR

Life Insurance Company of North America

American Funds

Life Group Policy # FLX-960228000

1-800-204-3731

LTD Group Policy # LK-960216000

myretirement.americanfunds.com

Daphne Williams, HR Manager 601-933-3329

HR PORTAL • Employee Benefits Forms • Payroll Information Sheets • Federal Labor Law Posters • Managers Help Page [email protected]

Disclaimer: The enclosed information is designed to provide an overview of available company benefits and is subject to change without notice. For more information or specific coverage details, employees may contact Ergon’s Human Resources Department (601-933-3000) or consult the SPDs provided on the HR Portal. 26

OPEN ENROLLMENT

27

OPEN ENROLLMENT

More information can be found on the HR Portal.

P.O. Box 1639 Jackson, MS 39215-1639 phone: 601-933-3000 fax: 601-933-3373 email: [email protected] ergon.com © 2016 - Ergon, Inc. LPS1016 28

OPEN ENROLLMENT

Please return this form to [email protected] or to P.O. Box 1639 | Jackson, MS 39215

FSA Election Menu Ergon and Its Subsidiaries January 1, 2017 COMPANY NAME__________________________________________________________________ EFFECTIVE DATE ___________________ EMPLOYEE NAME _________________________________________________________________ SOCIAL SECURITY # _____________________________ STREET ADDRESS _________________________________________________________ CITY, STATE, ZIP _________________________________________ DATE OF BIRTH ___________________________________________________________ OFFICE LOCATION ______________________________________ SPENDING ACCOUNTS

Annual Election

Medical Reimbursement

$_________________________

[$2,600 is maximum amount]

Dependent Care Reimbursement

$_________________________

[$5,000 is maximum amount]

Medical Care Reimbursement I understand that: a) Expenses cannot be claimed if paid by any other health plan; b) I must submit a Reimbursement Claim itemizing the expenses to be reimbursed and include supporting evidence as set forth in the Plan; c) Expenses must be incurred within the Plan Year, regardless of when I actually pay the expense.

Dependent Care Reimbursement I understand that: a) Child must be under 13 years of age; b) Cannot be claimed on Federal Income Taxes if claimed under Flex Plan; c) Must be necessary in order to work; d) The tax savings derived by including dependent care expenses in this Plan should be compared to the tax credit allowed on my income tax return; e) File Form 2441.

PARTICIPATION AGREEMENT I understand that selection of new insurance coverage does not automatically provide coverage and I must complete an application for insurance. I understand that any election made under the Cafeteria Plan herein is irrevocable and may only be changed at enrollment prior to the start of the new Plan Year, or in the event of a change in family status (i.e., change in marital or dependent status, death of employee’s spouse, or dependent, or a spouse’s change in employment status). • I cannot change or revoke this agreement prior to the first day of the next plan year, except as permitted by the Plan and/or the Internal Revenue Code. • The Plan Administrator may modify or cancel the amount of my salary reduction under this Agreement if necessary to satisfy certain provisions of the Internal Revenue Code. • The reduction in my cash compensation under this Agreement will be in addition to pay reductions under other agreements or benefit plans. • Benefits under the Plan may be reduced or cancelled by the Employer at any time. I also understand that if changes in premiums are not made at enrollment, I will be treated as having continued the same elections in effect for subsequent plan years. At enrollment, elections must be made in the Spending Accounts or they will be terminated. I am aware that any expenses paid through the Cafeteria Plan are no longer eligible as deductions for federal or state income tax purposes and participation may reduce my future Social Security entitlement. I hereby agree my cash compensation will be reduced per pay period by my annual election during the Plan Year. Prior to December 1 each year, I will be offered the opportunity to change my election. I understand that if I do not claim the total balance in my Spending Accounts within 60 days (last day of February of each year) after the Plan Year ends as set forth in the Plan Document, I will forfeit my right to the remaining balance in the accounts.

Signature___________________________________________________________________________________ Date_________________

WAIVER OF PARTICIPATION I understand that all benefit coverages now offered by the above mentioned employer through payroll deduction are available to me under the above mentioned employer’s Cafeteria Plan and that the intent of Plan participation is to reduce the cost of these benefit coverages to me. I have been offered the opportunity to participate in this Plan and do hereby decline this opportunity and elect to receive current compensation. I understand if changes are not made at enrollment, I will be treated as having continued to waive my participation for subsequent plan years.

Signature___________________________________________________________________________________ Date_________________

Ergon, Inc. P.O. Box 1639 Jackson, MS 39215-1639 USA 601-933-3000 ergon.com

HR FSAINFO 11/2016 - LM/ST

ERGON EMPLOYEE MEDICAL BENEFIT PLAN Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 9/1/2016 - 8/31/2017 Coverage for: Individual + Family | Plan Type: PPO

 

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbsms.com or by calling 1-800-222-8046. Important Questions

Answers

Why this Matters:

What is the overall deductible?

$300 per Individual. Doesn’t apply to preventive care.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

Yes. $100 per Individual for prescriptions. There are no other specific deductibles.

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

Is there an out–of–pocket limit on my expenses?

Yes. Coinsurance out-of-pocket limit for Network and Non-Network: $1,200 per Individual. Maximum out-of-pocket limit for Network and Non-Network is $6,350 for Individuals and $12,700 for Families.

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in the out–of–pocket limit?

Balance-billed charges, premiums, and healthcare this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Is there an overall annual limit on what the plan pays?

No.

The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

Yes. See www.bcbsms.com or call 1-800-222-8046 for a list of Network Providers

If you use an in-network doctor or other healthcare provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to see No. You don’t need a referral to see a a specialist? specialist.

You can see the specialist you choose without permission from this plan.

Are there services this plan doesn’t cover?

Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services.

Yes.

Questions: Call 1-800-222-8046 or visit us at www.bcbsms.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary on the secure myBlue Member portal at www.bcbsms.com. BCBS 25773

1 of 8  C229

ERGON EMPLOYEE MEDICAL BENEFIT PLAN Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 9/1/2016 - 8/31/2017 Coverage for: Individual + Family | Plan Type: PPO

 

 Co-payments are fixed dollar amounts (for example, $15) you pay for covered healthcare, usually when you receive the service.  Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s

allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.  The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)  This plan may encourage you to use Network Providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event

If you visit a healthcare provider’s office or clinic

If you have a test

Services You May Need

Your Cost If You Use a Network Provider

Your Cost If You Use a Non-Network Provider

Limitations & Exceptions

Primary care visit to treat an injury or illness

20% Co-insurance

40% Co-insurance

–––––––––––none–––––––––––

Specialist visit

20% Co-insurance

40% Co-insurance

–––––––––––none–––––––––––

40% Co-insurance

Physical and Occupational Therapy are only available through Care Management. Routine vision and podiatry is not covered.

Other practitioner office visit

20% Co-insurance

Preventive care/screening/immunization

No charge

Not covered

Services must be rendered by a Healthy You! Network Provider in that Provider’s clinical setting. Covered Services are based upon age and gender guidelines and must be included in the Grade A and B recommendations of the US Preventive Services Task Force.

Diagnostic test (x-ray, blood work)

20% Co-insurance

40% Co-insurance

–––––––––––none–––––––––––

Imaging (CT/PET scans, MRIs)

20% Co-insurance

40% Co-insurance

–––––––––––none–––––––––––

Questions: Call 1-800-222-8046 or visit us at www.bcbsms.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary on the secure myBlue Member portal at www.bcbsms.com. BCBS 25773

2 of 8  C229

ERGON EMPLOYEE MEDICAL BENEFIT PLAN Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 9/1/2016 - 8/31/2017 Coverage for: Individual + Family | Plan Type: PPO

 

Common Medical Event

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbsms.com.

If you have outpatient surgery

If you need immediate medical attention

If you have a hospital stay

Category One Drugs Category Two Drugs Category Three Drugs Category Four Drugs Category One Drugs Category Two Drugs Category Three Drugs Category Four Drugs Category One Mail-Order Maintenance Drugs Category Two Mail-Order Maintenance Drugs Category Three Mail-Order Maintenance Drugs Category Four Mail-Order Maintenance Drugs

$15/prescription $35/prescription $75/prescription $100/prescription $30/prescription $70/prescription $150/prescription $200/prescription $30/prescription $70/prescription $150/prescription $200/prescription

Your Cost If You Use a Non-Network Provider $15/prescription $35/prescription $75/prescription $100/prescription $30/prescription $70/prescription $150/prescription $200/prescription Not covered Not covered Not covered Not covered

Facility fee (e.g., ambulatory surgery center)

20% Co-insurance

40% Co-insurance

–––––––––––none–––––––––––

Physician/surgeon fees

20% Co-insurance

40% Co-insurance

–––––––––––none–––––––––––

Services You May Need

Your Cost If You Use a Network Provider

Limitations & Exceptions

Limited to a 1-30 day retail supply 

Limited to a 31-90 day retail supply

Limited to a 90 day mail-order supply

Emergency room services

20% Co-insurance after a $50 co-pay

20% Co-insurance after a $50 co-pay

Emergency medical transportation

20% Co-insurance

40% Co-insurance

Your cost if you use a Non-Network Provider for non-emergency services will be 40%. The co-pay is waived if services are provided for accident or emergency services or if admitted to the hospital within 24 hours. –––––––––––none–––––––––––

Urgent care

20% Co-insurance

40% Co-insurance

–––––––––––none–––––––––––

40% Co-insurance

Inpatient Rehabilitation Services are limited to 30 days per year and not covered if services received from nonnetwork provider.

Facility fee (e.g., hospital room)

20% Co-insurance

Questions: Call 1-800-222-8046 or visit us at www.bcbsms.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary on the secure myBlue Member portal at www.bcbsms.com. BCBS 25773

3 of 8  C229

ERGON EMPLOYEE MEDICAL BENEFIT PLAN Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 9/1/2016 - 8/31/2017 Coverage for: Individual + Family | Plan Type: PPO

 

Common Medical Event

If you have mental health, behavioral health, or substance abuse needs

If you are pregnant

If you need help recovering or have other special health needs

If your child needs dental or eye care

Physician/surgeon fee

20% Co-insurance

Your Cost If You Use a Non-Network Provider 40% Co-insurance

Mental/Behavioral health outpatient services

Not covered

Not covered

Mental/Behavioral health inpatient services

Not covered

Not covered

Substance use disorder outpatient services

Not covered

Not covered

Substance use disorder inpatient services

Not covered

Not covered

Prenatal and postnatal care

20% Co-insurance

40% Co-insurance

Delivery and all inpatient services

20% Co-insurance

40% Co-insurance

Home health care

20% Co-insurance

Not covered

Rehabilitation services

Inpatient: Not Inpatient and covered; Outpatient: 20% CoOutpatient: 40% insurance Co-insurance

Habilitation services

Not covered

Not covered

Available only through Care Management. Inpatient Rehabilitation limited to 30 days per year by Network Provider. Physical and Occupational Therapy are available only through Care Management. Inpatient Speech Therapy is not covered. Speech Therapy limited to 20 visits per calendar year. Habilitation services are not available.

Skilled nursing care

Not covered

Not covered

Skilled nursing care is not available.

Durable medical equipment

20% Co-insurance

40% Co-insurance

Hospice service

20% Co-insurance

40% Co-insurance

–––––––––––none––––––––––– Available only through Care Management.

Eye exam

Not covered

Not covered

Glasses

Not covered

Not covered

Dental check-up

Not covered

Not covered

Services You May Need

Your Cost If You Use a Network Provider

Limitations & Exceptions –––––––––––none––––––––––– Mental/Behavioral health services are not available. Mental/Behavioral health services are not available. Substance use disorder services are not available. Substance use disorder services are not available. Maternity coverage is not available for dependent children.

Routine dental and eye care are not available.

Questions: Call 1-800-222-8046 or visit us at www.bcbsms.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary on the secure myBlue Member portal at www.bcbsms.com. BCBS 25773

4 of 8  C229

ERGON EMPLOYEE MEDICAL BENEFIT PLAN Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 9/1/2016 - 8/31/2017 Coverage for: Individual + Family | Plan Type: PPO

 

Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) 

Acupuncture



Bariatric Surgery



Cosmetic Surgery



Dental Care



Habilitation Services



Hearing Aids



Infertility Treatment



Routine Eye Care



Long-term Care



Routine Foot Care



Mental/Nervous Health Services



Substance Use Disorder Services



Non-emergency care when traveling outside the U.S.



Weight Loss Programs

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) 

Chiropractic Care



Private-duty nursing (limited to $5,000 per year)

Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: the plan, Blue Cross & Blue Shield of Mississippi at 1-800-222-8046 or the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa.

Questions: Call 1-800-222-8046 or visit us at www.bcbsms.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary on the secure myBlue Member portal at www.bcbsms.com. BCBS 25773

5 of 8  C229

ERGON EMPLOYEE MEDICAL BENEFIT PLAN Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 9/1/2016 - 8/31/2017 Coverage for: Individual + Family | Plan Type: PPO

 

Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al1-800-222-8046. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-222-8046. Chinese (中文): 如果需要中文的帮助,请拨打这个号码1-800-222-8046. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne'1-800-222-8046.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

Questions: Call 1-800-222-8046 or visit us at www.bcbsms.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary on the secure myBlue Member portal at www.bcbsms.com. BCBS 25773

6 of 8  C229

ERGON EMPLOYEE MEDICAL BENEFIT PLAN Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 9/1/2016 - 8/31/2017 Coverage for: Individual + Family | Plan Type: PPO

 

About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples.

Having a baby

Managing type 2 diabetes

(normal delivery)

(routine maintenance of a well-controlled condition)

 Amount owed to providers: $7,540  Plan pays $5,870  Patient pays $1,670

 Amount owed to providers: $5,400  Plan pays $3,660  Patient pays $1,740

Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) Anesthesia Laboratory tests Prescriptions Radiology Vaccines, other preventive Total

$2,700 $2,100 $900 $900 $500 $200 $200 $40 $7,540

Sample care costs: Prescriptions Medical Equipment and Supplies Office Visits and Procedures Education Laboratory tests Vaccines, other preventive Total

$2,900 $1,300 $700 $300 $100 $100 $5,400

Patient pays: Deductibles Co-pays Coinsurance Limits or exclusions Total

$320 $0 $1,200 $150 $1,670

Patient pays: Deductibles Co-pays Coinsurance Limits or exclusions Total

$400 $600 $370 $370 $1,740

Questions: Call 1-800-222-8046 or visit us at www.bcbsms.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary on the secure myBlue Member portal at www.bcbsms.com. BCBS 25773

7 of 8  C229

ERGON EMPLOYEE MEDICAL BENEFIT PLAN Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 9/1/2016 - 8/31/2017 Coverage for: Individual + Family | Plan Type: PPO

 

Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples?  

    

Costs don’t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. The patient’s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from inNetwork Providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Does the Coverage Example predict my own care needs?

 No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

Questions: Call 1-800-222-8046 or visit us at www.bcbsms.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary on the secure myBlue Member portal at www.bcbsms.com. BCBS 25773

8 of 8  C229