Teen Challenge Benefit Guide - Full Time Employees

Teen Challenge Benefit Guide - Full Time Employees

OPEN ENROLLMENT benefits guide

2022 PLAN YEAR

FULL TIME EMPLOYEES

Introduction

Dear Employee

Teen Challenge offers a comprehensive suite of benefits to promote health and financial security for you and your family. This guide provides you with a summary of your benefits.

Please review it carefully so you can choose the coverage that’s right for you.

TABLE OF CONTENTS Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 2 How to Enroll . . . . . . . . . . . . . . . . . . . . . . . . . 4 Member Advocate . . . . . . . . . . . . . . . . . . . . . . 6 Medical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Basic Life AD&D . . . . . . . . . . . . . . . . . . . . . . . 10 Disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Supplemental Coverage . . . . . . . . . . . . . . . . . 12 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Legal Notices. . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Medicare Part D . . . . . . . . . . . . . . . . . . . . . . . . 18 COBRA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Exchange Notices. . . . . . . . . . . . . . . . . . . . . . 20 Contact Information . . . . . . . . . . . . . . . . . . 23

About Deductions

Premiums for Medical, Dental, and Vision coverage will be deducted on a pre - tax basis because it is covered under your Cafeteria Plan under Section 125 of the Internal Revenue Service Code. Once you elect to enroll in this plan, you will not be allowed to drop or change your election until the Company’s next Annual Enrollment unless you have a Qualifying Event.

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Qualifying Life Events Qualifying events are events that cause an individual to lose his or her group health coverage. The type of qualifying event determines who the qualified beneficiaries are for that event and the period of time that a plan must offer continuation coverage.

Qualifying events include:

• Marriage • Divorce or legal separation • Birth or adoption of a child • Death of spouse or dependent child • Change in employment status • Loss of other coverage • Entitlement to Medicare or Medicaid • Child turning 26 years old

Information Needed for Enrollment

All Eligibility

As a Teen Challenge employee, you may be eligible for enrollment in a variety of insurance products. You may enroll your eligible dependents for coverage once you are eligible. Your eligible dependents include: • Your legal spouse • Your children up to age 26 (as identified in the plan document). 

In preparation of your enrollment, please have the following information readily available for you and your dependent(s):

• Date(s) of birth

• Social Security Number(s): Mandatory

• Full name, relationship, and Social Security Number(s) for Life Beneficiary(ies). (Beneficiaries must be at least 18 years old or you will be required to name a guardian for him/her.)

Once your elections are effective, they will remain in effect through the plan year. You may only change coverage within 30 days of a qualifying life event.

You must notify Human Resources within 30 days of the qualifying life event. Depending on the type of event, you may be asked to provide proof of the event. If you do not contact Human Resources within 30 days of the qualifying event, you will have to wait until the next annual enrollment period to make changes.

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How to Enroll

Step 1: Creating your Employee Navigator Account

Welcome Email:

• You will receive a Welcome email from Employee Navigator • Click on the “Registration Link” in the email • Create an account with username and password of your choice

Option 2:

• Go to https://www.employeenavigator.com/benefits/Account/Register • Enter [First Name], then [Last Name] • Enter your Company Identifier [TeenChallenge] • PIN: Last four of your SSN • Enter your birthdate: MM/DD/YYY • Click “Next” to continue • When prompted, your username will be as follows: [First Name].[Last Name]

Step 2: Complete HR Tasks

• Once your account is set up, you will be taken to your employee homepage.

• On the homepage, click the “Complete HR Tasks” to begin your new hire tasks first.

• The first few tasks require you to put in demographic information and e-sign for online acknowledgement.

T I P If you hit “Dismiss, complete later” you’ll be taken to your Home Page. You’ll still be able to start enrollments again by clicking “Start Enrollments”

Step 3: Benefit Elections

• To enroll dependents in a benefit, click the checkbox next to the dependent’s name under “Who am I enrolling?” If you do not click on their name(s), they will not get the insurance. • Below your dependents you can view your available plans and the cost per pay period. To elect a benefit, click Select Plan underneath the plan cost.

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Step 4: Forms

• If you have elected benefits that require a beneficiary designation, Primary Care Physician or completion of an Evidence of Insurability form, you will be prompted or required to complete.

Step 5: Review & Confirm Elections

• Review the benefits you selected on the enrollment summary page to make sure they are correct then click “Sign & Agree” to complete your enrollment. Print a summary of your elections for your records.

T I P If you miss a step you’ll see Enrollment Not Complete in the progress bar with the incomplete steps highlighted. Click on any incomplete steps in the drop down bar to complete them. ALL STEPS MUST BE COMPLETED!

Step 6: HR Tasks (if applicable)

• To complete any required HR tasks, click “Start Tasks”. If your HR department has not assigned any tasks, you’re finished!

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M ember C laims A dvocate

Employee Benefit Assistants You Can Count on

Teen Challenge provides you and your familymembers a complimentarymember claims service to help with claims, billing, missing ID cards and more.

give member claims advocate a call if :

• You received a provider bill or EOB and feel the claim was processed incorrectly • You are at the doctor or pharmacy and having trouble with your coverage • You need to confirm if a provider is In-Network • You are missing your ID card Y ou can reach the M ember C laims A dvocate team by phone or email

Monday through Friday, 8:00 AM EST - 5:00 PM EST Resa Carter - [email protected] - (706) 323-1600 Anna Meadows - [email protected] - (706) 323-1600

Available 24/7 for any requests Cosby Cartledge - [email protected] - (706) 593-6424

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Medical and Pharmacy Coverage

Teen Challenge offers the following plans through Aetna. Please reference the Summary Plan Description for more details.

Insurance Carrier: Medical Plan Number:

Aetna Medical Insurance

Copay plan - $5k / 80%

HDHP w/HSA - $5k / 100%

In-Network: Office Visit Copay - Primary Care Office Visit Copay - Specialist Care

$45 Copay $80 Copay $75 Copay

Deductible; then 100% Coinsurance Deductible; then 100% Coinsurance Deductible; then 100% Coinsurance

Urgent Care Copay Emergency Room Care Preventative Visit Copay

$425 Copay; then 80% Coinsurance Deductible; then 100% Coinsurance

$0

$0

Diagnostic Testing & Blood Work

Deductible; then 80% Coinsurance Deductible; then 100% Coinsurance Deductible; then 80% Coinsurance Deductible; then 100% Coinsurance

Advanced Imaging

Coinsurance

80%

100%

Employee Deductible Family Deductible

$5,000 $10,000

$5,000 $10,000

Employee Out-of-Pocket Max Family Out-of-Pocket Max

$7,500 (includes deductible) $15,000 (includes deductible)

$5,500 (includes deductible) $11,000 (includes deductible)

Inpatient Hospital

Deductible; then 80% Coinsurance Deductible; then 100% Coinsurance Deductible; then 80% Coinsurance Deductible; then 100% Coinsurance

Outpatient Hospital or Facility

Out-of-Network: Coinsurance

70%

70%

Employee Deductible Family Deductible

$10,000 $20,000 $20,000 $40,000

$10,000 $20,000 $20,000 $40,000

Employee Out-of-Pocket Max Family Out-of-Pocket Max

Prescription Drugs: ( 30 Day Supply) Rx Deductible

$0

Combined with Medical Deductible; then $10 Copay Deductible; then $30 Copay Deductible; then $60 Copay Deductible; then $250 Copay

Tier 1 - Generic Tier 2 - Preferred

$15 Copay $35 Copay $65 Copay $250 Copay

Tier 3 - Non-Preferred

Tier 4 - Specialty

Employee Bi-Weekly Deduction Employee Only

$54.28

$50.44

Employee + Spouse Employee + Child(ren)

$325.64 $298.51 $597.03

$302.61 $277.39 $554.78

Family

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Dental Coverage

Regular dental exams can help you and your dentist detect problems in the early stages when treatment is simpler and costs are lower.

Keeping your teeth and gums clean and healthy will prevent most tooth decay and periodontal disease, and is an important part of maintaining your medical health.

Your PPO dental plan is through Sun Life and offers “in and out-of-network” benefits.

Please see chart below for information on waiting periods for dental work.

Insurance Carrier:

Sun Life Dental Insurance

Plan Type:

Basic Plan

Enhanced Plan

Calendar Year Deductible Calendar Year Maximum

$50 Individual / $150 Family

$50 Individual / $150 Family

$1,000

$2,000

Preventive Services

100%

100%

Basic Services Major Services

80% 50% 50%

90% 60% 90%

Endo/Perio

Orthodontic Lifetime (dependent children only) Important information

N/A

$2,000

Out-of-Network Reimbursement Employee Bi-Weekly Deduction Employee Only

90th UCR

90th UCR

8 We will not pay for treatments subject to the late entrant limitation, and started or completed during the late entrant limitation period. Teen Challenge 2022 Enrollment Guide TIME INSURED CONTINUOUSLY UNDER THE POLICY BENEFITS PROVIDED FOR ONLY THESE SERVICES Less than 6 months Preventive Services At least 6 months but less than 12 months Preventive Services and fillings under Basic Services At least 12 months Preventive, Basic, Major and Ortho Services $11.58 $22.81 Benefit adjustments Benefits will be coordinated with any other dental coverage. Under the Alternative Treatment provision, benefits will be payable for the most economical services or supplies meeting broadly accepted standards of dental care. Late entrant If you or a dependent apply for dental insurance more than 31 days after you become eligible, you or your dependent are a late entrant. The benefits for the first 12 months for late entrants will be limited as follows: $18.67 $36.55 Employee + Spouse Employee + Child(ren) $32.84 $44.07 $47.99 $65.88 Family

Vision Coverage

The vision plan covers routine eye exams and also pays for all or a portion of the cost of glasses or contact lenses if you need them.

Your PPO vision plan is through Sun Life and offers “in and out-of-network” benefits.

To find an in-network provider, visit vsp.com/eye-doctor

Insurance Carrier:

Sun Life Vision Insurance

Plan Type:

VSP

In-Network $10 Copay $25 Copay $25 Copay $25 Copay $25 Copay $25 Copay

Out-of-Network

Exam Services

up to $52 up to $55 up to $75 up to $95 up to $125 up to $210

Lenses - Single lined Lenses - Bifocal lined Lenses - Trifocal Lenses - Lenticular

Medically Necessary Contacts

$60 contact lens exam $150 allowance

Contacts / Lenses

up to $105

$150 retail allowance; then 20% off remaining balance $80 allowance at Costco and Walmart

Frames

up to $57

Frequency for Exam / Lenses / Frames

12 months / 12 months / 24 months

Employee Bi-Weekly Deduction Employee Only

$3.23 $7.38 $7.38

Employee + Spouse Employee + Child(ren)

Family

$11.54

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Basic Life and AD&D Coverage

Teen Challenge provides all Full Time employees with Basic Life and Accidental Death & Dismemberment coverage. Rates will be automatically calculated and shown in Employee Navigator during enrollment process.

Insurance Carrier:

Mutual of Omaha Basic Life Insurance

Basic Life w/ AD&D Eligibility Requirement Life Insurance Benefit

All Full Time Employees

$25,000

Guarantee Issue

Yes

Accidental Death & Dismemberment Benefit (AD&D)

$25,000

Voluntary Term Life Coverage

As a supplemental benefit, Teen Challenge allows eligible employees to purchase additional life insurance coverage for yourself and your dependents. This coverage is paid for by you and is offered through Mutual of Omaha. Rates will be automatically calculated and shown in Employee Navigator during enrollment process.

Insurance Carrier:

Mutual of Omaha Basic Life Insurance

Voluntary Life w/ AD&D Eligibility Requirement Employee Benefit Amounts Employee

All Full Time Employees

minimum of $10,000 / up to $300,000 in increments of $10,000 no more than 5 times your annual income minimum of $5,000 / 100% of employees benefit, up to $150,000 minimum of $2,000 / 100% of employees benefit, up to $10,000

Spouse

Child(ren)

Guarantee Issue Employee

5 times annual income, up to $100,000 100% of employees benefit, up to $25,000 100% of employees benefit, up to $10,000

Spouse

Child(ren)

Accidental Death & Dismemberment Benefit (AD&D)

equal to the amount of Voluntary Life elected

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Disability Coverage

The goal of Teen Challenge’s Disability Insurance Plan is to provide you with income replacement should you be unable to work due to a non-work- related illness or injury. The company provides employees with the option to purchase voluntary “Short and Long Term Disability” income benefits. Both the short term and long term disability coverages are offered through Mutual of Omaha. Rates will be automatically calculated and shown in Employee Navigator during enrollment process.

Insurance Carrier:

Mutual of Omaha Short-Term Disability Insurance

Plan Type:

Voluntary

Voluntary

Eligibility Requirement Benefit Percentage Waiting Period - Accident Waiting Period - Sickness Maximum Weekly Benefit Pre-Existing Condition

All Full Time Employees

All Full Time Employees

60%

60%

0 Days 7 Days $1,000

0 Days 7 Days $1,000

3/6

3/6

Benefit Duration

13 Weeks

26 Weeks

Insurance Carrier:

Mutual of Omaha Long-Term Disability Insurance

Plan Type:

Voluntary

Eligibility Requirement

All Full Time Employees

Waiting Period

90 Days

Benefit Percentage

60%

Maximum Monthly Benefit

$5,000 SSNRA 2 Years

Benefit Duration

Own Occupation Definition Partial Disability Benefit

99% during Own Occ; then 85%

Mental Disorders Drug & Alcohol

24 Months per Lifetime 24 Months per Lifetime

Pre-Existing Condition

12/12

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Supplemental Coverage

Group Accident Insurance When you face the financial impact of an injury, Sun Life is here to help.

If you have a covered accident, major medical insurance will help with any medical expenses, but you could be left with out-of-pocket expenses. Accident Insurance can be used however you want, and it pays in addition to any other coverage you may already have. Sun Life group accident insurance plans are designed to provide you with cash benefits throughout the different stages of care, such as: • Emergency treatment • Hospital admission • Intensive care unit • Ambulance transportation • Travel expenses to treatment centers • Everyday living expenses, like your rent or mortgage, utility bills, groceries, and more This plan provides 24-hour coverage and has a wellness benefit.

Group Critical Illness Insurance

You can count on Sun Life to help ease the financial impact of surviving a critical illness.

If you have been diagnosed with a covered condition, you can receive a cash benefit to help pay unexpected costs not covered by your health plan.

Would you have the money to cover the out-of-pocket expenses such as: • Transportation to a distant medical facility • Specialized treatment costs • Living expenses like rent, mortgage, and utility bills

Sun Life group critical illness insurance plans are designed to provide you with cash benefits, such as the following: • Lump sum benefit for a covered critical illness: cancer, heart attack, stroke, major organ transplant, end-stage renal failure, and more • Health screening benefit

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Supplemental Coverage

Group Hospital Indemnity Insurance Sun Life is here to help if you are facing a hospital stay.

While health plans may cover direct costs associated with an illness or injury, you can use your hospital indemnity benefits to help cover related expenses like lost income, child care, deductibles and copays.

Sun Life is designed to help families plan for the health care bumps ahead and take some of the uncertainty and financial insecurity out of getting better.

This plan provides the following benefits: • Hospital Confinement Benefit • Hospital Admission Benefit • Hospital Intensive Care Benefit • Intermediate Intensive Care Step-Down Unit Benefit • Health Screening Benefit and more

This is a brief product overview only. The plans have limitations and exclusions that affect benefits payable. Refer to the plans for complete details.

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FAQ

Frequently Asked Questions

What is included in the Medical Out-of-Pocket maximum? What is included in the Pharmacy Out-of- Pocket maximum? The Medical Out-of-Pocket maximum is the maximum amount a member must pay during the policy year for covered essential health benefits. The OOP includes a member’s deductible and any coinsurance member responsibility. The Pharmacy OOP includes only pharmacy co-pays. The Medical OOP does NOT include monthly premiums, or billing from out-of-network providers. What is an in-network vs out-of-network provider? Aetna contracts with a wide range of doctors, as well as specialists, hospitals, labs, radiology facilities and pharmacies. These are the providers that are considered “in your network”. Specifically, each of these providers has agreed to accept Aetna’s contracted rate for your medical care and services rendered. The contracted rate includes both Aetna’s share of the cost, and the member’s. Your share may be in the form of a co-payment, deductible, or co-insurance. For example, Aetna’s contracted rate for a primary care visit might be $125. The Plan has a $25 co-payment for the visit; the member will pay $25 of the cost and your insurance plan will pay the remaining $100. An “out-of-network” provider is a medical doctor or facility that is not in contract with Aetna. This means that the provider may charge members higher rates for medical services and care, outside of the standard “in-network” rates. For example, a out-of-network provider may charge $200 for a primary care visit. Aetna may pay an adjustment of an out-of-network benefit of $80 dollars to the provider, so the member may be balance-billed for the remaining $120 cost of the visit. When can I change my beneficiary information for my Basic Life Insurance? Any time! It is important that all beneficiary information be kept up-to-date. You may need to change it after a marriage, divorce, or birth of a child. You can go into Employee Navigator anytime to update your beneficiary.

Term

Definition

The “per visit” co-pay cost for a primary care or standard network doctor.

Network Office Visit (PCP)

The “per visit” co-pay cost for a specialized doctor (cardiologist, OB/GYN, orthopedic, gastrointestinal, etc.)

Specialist Office Visit

The amount of money a member owes for any In-network health care services before co-insurance coverage begins. These are generally services that are NOT covered under a standard co-pay (inpatient surgery, outpatient surgery, MRI, etc.) Deductibles run on a calendar year basis. After any applicable deductible is met, the remaining cost of any in-network health care service is divided between the insurance carrier and the member. A 70% / 30% network co-insurance would divide the cost of a service with 70% paid by the insurance carrier and 30% paid by the member. These are generally services that are NOT covered under a standard co-pay (inpatient surgery, outpatient surgery, MRI, etc.) The maximum amount a member must pay during the policy year for covered essential health benefits. The OOP includes a member’s deductible, any co-insurance member responsibilty, primary care and specialist office visit co-pays, ER or Urgent Care co-pays, and prescription co-pays / costs. The OOP does NOT include monthly premiums, billing from out-of-network providers, or spending for non-essential health benefits. The cost of a one month supply of a prescription drug. All covered drugs are designated into tiered levels based on drug usage, cost, and clinical effectiveness. Tier 1 usually includes generics, while Tier 2 generally includes preferred brand name medications. Tier 3 typically includes non- preferred brand name medications, Tier 4 usually includes higher cost drugs and Speciality Drugs are covered under a separate tier.

Network Deductible

Co-Insurance

Network Out-of-Pocket Maximum (OOP)

Prescription Drug Tiers and Monthly Co-Pays

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Legal Notices

Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free or Low-Cost Health Coverage to Children and Families

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow. gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer- sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2021. Contact your State for more information on eligibility –

ALABAMA - Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447 ALASKA - Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: Customer [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default. aspx ARKANSAS - Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447) COLORADO - Medicaid Website: http://www.colorado.gov/hcpf Customer Contact Center: 1-800-221-3943 KANSAS - Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512 KENTUCKY - Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570 LOUSIANA - Medicaid Website: http://dhh.louisiana.gov/index.cfm/ subhome/l/n/331 Phone: 1-888-695-2447

FLORIDA - Medicaid Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268 GEORGIA - Medicaid Website: http://dch.georgia.gov/medicaid - click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507 INDIANA - Medicaid Healthy Indiana Plan for Low-Income Adults 19-64 Website: http://www.hip.in.gov Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone: 1-800-403-0864 IOWA - Medicaid Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 MAINE - Medicaid Website: http://maine.gov/dhhs/ofi/public-assistance/ index.html Phone: 1-800-442-6003 TTY: Maine relay 711

MASSACHUSETTS - Medicaid and CHIP Website: http://www.mass.gov/MassHealth

Phone: 1-800-462-1120 MINNESOTA - Medicaid Website: http://mn.gov/dhs/ma/ Phone: 1-800-657-3739

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Legal Notices

MISSOURI - Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp. htm

RHODE ISLAND - Medicaid Website: http://www.eohhs.ri.gov/ Phone: 401-462-5300 SOUTH CAROLINA - Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 SOUTH DAKOTA - Medicaid

Phone: 573-751-2005 MONTANA - Medicaid Website: http://dphhs.mt.gov/ MontanaHealthcarePrograms/HIPP

Phone: 1-800-694-3084 NEBRASKA - Medicaid

Website: http://dss.sd.gov Phone: 1-888-828-0059 TEXAS - Medicaid Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 UTAH - Medicaid and CHIP Medicaid Website: http://health.utah.gov/medicaid CHIP Website: http://health.utah.gov/chip

Website: http://www.dhhs.ne.gov/Children_Family_ Services/AccessNebraska/Pages/accessnebraska_ index.aspx Phone: 1-855-632-7633 NEVADA - Medicaid Website: http://dwss.nv.gov/ Phone: 1-800-992-0900 NEW HAMPSHIRE - Medicaid Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 NEW JERSEY - Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/dmahs/ clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 NEWYORK - Medicaid Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA - Medicaid Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100 NORTH DAKOTA - Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825 OKLAHOMA - Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 OREGON - Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075 PENNSYLVANIA - Medicaid Website: http://www.dhs.pa.gov/hipp Phone: 1-800-692-7462

Phone: 1-877-543-7669 VERMONT - Medicaid Website: http://www.greenmountaincare.org Phone: 1-800-250-8427 VIRGINIA - Medicaid and CHIP Medicaid & CHIP Website: http://www.coverva.org/programs_ premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282 WASHINGTON - Medicaid Website: http://www.hca.wa.gov/free-or-low-costhealth-care/ program-administration/premiumpayment- program Phone: 1-800-562-3022 ext. 15473 WEST VIRGINIA - Medicaid Website: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/ Pages/default.aspx Phone: 1-877-598-5820, HMS Third Party Liability WISCONSIN - Medicaid and CHIP Website: http://www.dhs.wisconsin.gov/publications/p1/p10095. pdf

Phone: 1-800-362-3002 WYOMING - Medicaid Website: http://wyequalitycare.acs-inc.com/ Phone: 307-777-7531

To see if any more States have added a premium assistance program since January 31, 2021, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/ebsa 1-866-444-EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565

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Legal Notices

Important Notices about Medical Coverage

HIPPA Special Enrollment Rights If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself or your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a newdependent as result ofmarriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must enroll within 30 days after the marriage, birth, adoption, or placement for adoption. Effective April 1, 2009 special enrollment rights also exist in the following circumstances: • If you or your dependents experience a loss of eligibility for Medicaid or your State Children’s Health Insurance Program (SCHIP) coverage; or • If you or your dependents become eligible for premium assistance under an optional state of Medicaid or SCHIP program that would pay the employee’s portion of the health insurance premium. NOTE: In the two above listed circumstances only, you or your dependents will have sixty (60) days to request special enrollment in the group health plan coverage. An individual must request this special enrollment within sixty (60) days of the loss of coverage described at bullet one, and within sixty (60) days of when eligibility is determined as described in bullet two. Women’s Health and Cancer Rights Act of 1998 Annual Notice If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for all stages of reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses; and treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and co-insurance applicable to other medical and surgical benefits provided under this plan. Our plan complies with these requirements. Benefits for these items generally are compatible to those provided under our plan for similar types of medical services and supplies. Of course, the extent to which any of these items is appropriate following mastectomy is a matter to be determined by consultation between the attending physician and the patient. Our plan neither imposes penalties (for example, reducing or limiting reimbursements) nor provides incentives to induce attending providers to provide care inconsistent with these requirements. If you would like more information on WHCRA benefits, call Yates, Knight - Rawls at (706)323-1600. Paperwork Reduction Act Statement 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 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 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 information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, not withstanding any other provisions of law, no person shall be subject to 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. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged 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. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210-0137.

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Medicare Part D Medicare Part D Notice of Creditable Coverage Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Teen Challenge and about your options under Medicare’s prescription drug coverage. This information can help you decidewhether or not youwant to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your currant coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Teen Challenge has determined that the prescription drug coverage offered by Aetna plans are on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join a Medicare Drug Plan? You can join a Medicare drug planwhen you first become eligible forMedicare and each year from October 15th through December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens to Your Current Coverage if You Join a Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Teen Challenge coverage may or may not be affected. See pages 7-9 of the CMS Disclosure of Creditable Coverage to Medicare Part D Eligible Individuals Guidance (available at https://www.cms.hhs.gov/Creditable Coverage/ ), which outlines the prescription drug plan provisions / options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D. If you do decide to join a Medicare drug plan and drop your current Teen Challenge coverage, be aware that you and your dependents may or may not be able to get this coverage back.

When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Teen Challenge and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without a creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For further information, call Yates, Knight - Rawls at (706) 323- 1600. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Teen Challenge changes. You may also request a copy of this notice at any time. More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Medicare Part D Notice of Creditable Coverage, cont. Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help. Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity. gov , or call them at 1-800-772- 1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium.

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COBRA

What is COBRA continuation health coverage? The Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions amend the Employee Retirement Income Security Act, the Internal Revenue Code and the Public Health Service Act to require group health plans to provide a temporary continuation of group health coverage that otherwise might be terminated. What does COBRA do? COBRA requires continuation coverage to be offered to covered employees, their spouses, former spouses, and dependent children when group health coverage would otherwise be lost due to certain specific events. COBRA continuation coverage is often more expensive than the amount that active employees are required to pay for group health coverage, since the employer usually pays part of the cost of employees’ coverage and all of that cost can be charged to individuals receiving continuation coverage. What group health plans are subject to COBRA? The law generally applies to all group health plans maintained by private-sector employers with 20 or more employees, or by state or local governments. The law does not apply to plans sponsored by the Federal Government or by churches and certain church-related organizations. In addition, many states have laws similar to COBRA, including those that apply to health insurers of employers with less than 20 employees (sometimes called mini-COBRA). Check with your state insurance commissioner’s office to see if such coverage is available to you. Who is entitled to continuation coverage under COBRA? In order to be entitled to elect COBRA continuation coverage, your group health planmust be covered byCOBRA; a qualifying event must occur; and you must be a qualified beneficiary for that event. Plan Coverage - COBRA covers group health plans sponsored by an employer (private-sector or state/local government) that employed at least 20 employees on more than 50 percent of its typical business days in the previous calendar year. Both full- and part-time employees are counted to determine whether a plan is subject to COBRA. Each part-time employee counts as a fraction of a full-time employee, with the fraction equal to the number of hours that the part-time employee worked divided by the hours an employee must work to be considered full time. Qualified Beneficiaries - A qualified beneficiary is an individual covered by a group health plan on the day before a qualifying event occurred that caused him or her to lose coverage. Only certain individuals can become qualified beneficiaries due to a qualifying event, and the type of qualifying event determines who can become a qualified beneficiary when it happens. A qualified beneficiary must be a covered employee,

the employee’s spouse or former spouse, or the employee’s dependent child. In certain cases involving the bankruptcy of the employer sponsoring the plan, a retired employee, the retired employee’s spouse or former spouse, and the retired employee’s dependent children may be qualified beneficiaries. In addition, any child born to or placed for adoption with a covered employee during a period of continuation coverage is automatically considered a qualified beneficiary. An employer’s agents, independent contractors, and directors who participate in the group health plan may also be qualified beneficiaries. Are there alternatives for health coverage other than COBRA? If you become entitled to elect COBRA continuation coverage when you otherwise would lose group health coverage under a group health plan, you should consider all options you may have to get other health coverage before you make your decision. There may be more affordable or more generous coverage options for you and your family through other group health plan coverage (such as a spouse’s plan), the Health Insurance Marketplace, or Medicaid. If you become entitled to elect COBRA continuation coverage when you otherwise would lose group health coverage under a group health plan, you should consider all options you may have to get other health coverage before you make your decision. There may be more affordable or more generous coverage options for you and your family through other group health plan coverage (such as a spouse’s plan), the Health Insurance Marketplace, or Medicaid. Under the Health Insurance Portability and Accountability Act (HIPAA), ifyou oryour dependents are losing eligibility for group health coverage, including eligibility for continuation coverage, you may have a right to special enroll (enroll without waiting until the next open season for enrollment) in other group health coverage. For example, an employee losing eligibility for group health coverage may be able to special enroll in a spouse’s plan. A dependent losing eligibility for group health coverage may be able to enroll in a different parent’s group health plan. To have a special enrollment opportunity, you or your dependent must have had other health coverage when you previously declined coverage in the plan in which you now want to enroll. You must request special enrollment within 30 days from the loss of your job-based coverage. Losing your job-based coverage is also a special enrollment event in the Health Insurance Marketplace (Marketplace). The Marketplace offers “one-stop shopping” to find and compare private health insurance options. In the Marketplace, you could be eligible for a tax credit that lowers your monthly premiums and cost-sharing reductions (amounts that lower your out-of- pocket costs for deductibles, coinsurance and copayments), and you can see what your premium, deductibles, and out-of- pocket costs will be before you make a decision to enroll.

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Exchange Notices

New Health Insurance Marketplace Coverage Options and Your Health Coverage

Form Approved OMB No. 1210-0149 (expires 6-30-2023)

PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance : the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employmentbased health coverage offered by your employer. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014. Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. 1 Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact . The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by

the plan is no less than 60 percent of such costs.

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Exchange Notices

PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application. 3. Employer name 4. Employer Identification Number (EIN)

Teen Challenge Southeast Region

59-2479228

5. Employer address

6. Employer phone number

(706)596-8731

15 W 10th Street

8. State

9. ZIP code

7. City

Columbus

GA

31901

10. Who can we contact about employee health coverage at this job?

Debra Roberts

11. Phone number (if different from above)

12. Email address

[email protected]

(706)596-8731 X: 210

Here is some basic information about health coverage offered by this employer: • As your employer, we offer a health plan to: All employees. Eligible employees are:

X

Full-time

Some employees. Eligible employees are:

• With respect to dependents:

X

We do offer coverage. Eligible dependents are:

We do not offer coverage.

If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages.

** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums.

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