2024

GUIDE TO YOUR BENEFITS

 MAKE YOUR OHLA USA INC.
BENEFITS WORK FOR YOU
BE READY FOR ENROLLMENT WHEN CAN I ENROLL?
As a benefits-eligible employee, you have the opportunity to
OHLA USA Inc. provides a full range of benefits that address
enroll in or make changes to your benefit plans during our annual
your needs now and in the future. We know how important it is
benefits enrollment period. Open Enrollment is
to have good, affordable health and group benefits. That’s why
November 20, 2023 to December 6, 2023. with your benefit
we offer competitive benefits that can provide protection, peace
choices being effective January 1, 2024. Our benefits plan year
of mind, and savings.
is January 1, 2024 to December 31, 2024.
This guide provides a general overview of your benefit choices
and enrollment information to help you select the coverage DEPENDENT ELIGIBILITY
that’s right for you. You can enroll your dependents in plans that offer dependent
coverage. Eligible dependents are defined as your legal
TO YOUR HEALTH TO YOUR WEALTH spouse or domestic partner and eligible children who reside
• Medical & Prescription Drug Insurance • Life Insurance in your household and depend primarily on you for support.
• Dental Insurance • Short-Term Disability Insurance This includes: your own children, legally adopted children,
stepchildren, a child for whom you have been appointed legal
• Vision Insurance • Long-Term Disability Insurance guardian, and/or a child for whom the court has issued a
• Critical Illness Insurance • Accident Insurance Qualified Medical Child Support Order (QMCSO) requiring you or
your spouse or domestic partner to provide coverage.
• Retirement 401(k) Savings Plan

DOMESTIC PARTNER COVERAGE

ENROLLMENT INFORMATION Domestic partners are eligible to enroll as dependents in the
benefit plans. You and your partner must meet specific criteria
to qualify for domestic partner coverage. A domestic partnership
DO I NEED TO ENROLL? is different than a marriage with an individual of the same-sex.
Before deciding whether you need to enroll in OHLA’s health and A same-sex spouse is a federal tax dependent for group health
group benefits, keep in mind that there are many good reasons plan purposes; whereas, a domestic partner often is not. If you
to take a close look at all the benefits and options OHLA offers cover a domestic partner, a domestic partner’s child or another
you, even if you’re already covered under the OHLA benefit person who is not considered an IRS tax dependent for group
plan(s). health plan purposes, OHLA is required to report income for you
that reflects the value of coverage for tax-reporting purposes.
For instance, you may experience changes from year to year. This is known as imputed income. You will receive a W-2
And there likely will be changes to what you pay for coverage annually for the value of coverage for any dependent who is not
each year. So, it’s a good idea to make sure your benefits still an IRS tax dependent.
fit you —and that you’re not paying for more coverage than you
need.
WHAT IF THINGS CHANGE?
You must enroll if you want to:
The benefits you choose will be in place for all for 2024. You
• Change your medical, dental, or vision coverage for next year. can’t change your coverage during that time unless you have a
• Contribute to your Health Savings Account (HSA) and/or your qualified life event, including:
Flexible Spending Account (FSA), if applicable.
• Marriage, legal separation, or divorce
• Change your supplemental insurance coverage; if applicable,
including Life and AD&D for yourself or your dependents • Birth, legal adoption of a child, or placement of a child with
(spouse/children), Short and Long Term Disability, Accident, you for legal adoption
Health Critical Illness and Legal insurance coverage. • Death of your spouse, domestic partner, or dependent child
All OHLA benefit eligible employees must actively enroll • Change in residence (if your current coverage is not available
or re-enroll in the 2024 offerings. 2023 benefits will not in the new location or if you are offered an option that you
automatically rollover into 2024. To enroll, visit : were not previously offered)
EMPLOYEE NAVIGATOR LINK
After a qualified life event, your new coverage will begin
immediately.*
*Within 60 days of the event if you, your spouse, or your eligible dependent child
loses coverage under Medicaid or a state Children’s Health Insurance Program
(CHIP) or becomes eligible for state-provided premium assistance.
 MEDICAL
COVERAGE
MEDICAL AND PRESCRIPTION DRUG BENEFITS
Each person’s health care needs are different. That’s why our medical plan offers employees three comprehensive, high quality
medical plan options so that you can choose the coverage level best-suited to your personal situation. OHLA offers you and your
dependents medical and prescription drug coverage through by Empire BCBS. These options feature a network of physicians who
have agreed to provide services at a discounted price. You can see providers outside of the network, but if you use in-network
providers, you’ll pay less. The information below is a summary of coverage only. For a full summary of benefits and coverage, please
visit www.empireblue.com, or e-mail [email protected] or your local Human Resources Department.

COST OF COVERAGE

HDHP 2500 PPO 1750 PPO 500

BENEFIT
In-Network Out-Of-Network In-Network Out-Of-Network In-Network Out-Of-Network
Annual/Calendar Year
$2,500 / $5,000 $5,000 / $10,000 $1,750 / $3,500 $3,500 / $7,000 $500 / $1,500 $1,500 / $3,000
Deductible
(Individual/Family)
Out-of-Pocket
$5,000 / $8,700 $10,000 / $20,000 $6,000 / $12,000 $10,000 / $20,000 $3,500 / $7,000 $7,000 / $14,000
Maximum
(Individual/Family)
Lifetime Maximum Unlimited Unlimited Unlimited
Coinsurance 30% 50% 20% 40% 15% 40%
Physician Services
30% Coinsurance 50% Coinsurance 40% Coinsurance 40% Coinsurance
Doctor’s Office Visit $35 Copay $25 Copay
after Deductible after Deductible after Deductible after Deductible
30% Coinsurance 50% Coinsurance 40% Coinsurance 40% Coinsurance
Specialist Office Visit $60 Copay $50 Copay
after Deductible after Deductible after Deductible after Deductible
50% Coinsurance 40% Coinsurance 40% Coinsurance
Preventive Care 100% Covered 100% Covered 100% Covered
after Deductible after Deductible after Deductible
30% Coinsurance 50% Coinsurance 20% Coinsurance 40% Coinsurance 15% Coinsurance 40% Coinsurance
Lab & X-ray Services
after Deductible after Deductible after Deductible after Deductible after Deductible after Deductible
30% Coinsurance 50% Coinsurance 40% Coinsurance 40% Coinsurance
Urgent Care $50 Copay $50 Copay
after Deductible after Deductible after Deductible after Deductible
Hospital Services
30% Coinsurance 50% Coinsurance 20% Coinsurance 40% Coinsurance 15% Coinsurance 40% Coinsurance
Inpatient
after Deductible after Deductible after Deductible after Deductible after Deductible after Deductible
30% Coinsurance 50% Coinsurance 20% Coinsurance 40% Coinsurance 15% Coinsurance 40% Coinsurance
Outpatient
after Deductible after Deductible after Deductible after Deductible after Deductible after Deductible
Emergency Care 30% Coinsurance after Deductible $300 Copay $300 Copay
Pregnancy & Maternity 30% Coinsurance 50% Coinsurance 20% Coinsurance 40% Coinsurance 15% Coinsurance 40% Coinsurance
Care (Prenatal) after Deductible after Deductible after Deductible after Deductible after Deductible after Deductible
PRESCRIPTION DRUGS
Retail (30-day Supply)
$10 / Prescription
Generic Not Covered $15 / Prescription Not Covered $10 / Prescription Not Covered
after Deductible
$30 / Prescription
Preferred Brand Not Covered $35 / Prescription Not Covered $25 / Prescription Not Covered
after Deductible
$50 / Prescription
Non-preferred Brand Not Covered $60 / Prescription Not Covered $50 / Prescription Not Covered
after Deductible
Mail Order (90-day Supply)
$25 / Prescription $37.50 /
Generic Not Covered Not Covered $25 / Prescription Not Covered
after Deductible Prescription
$75 / Prescription $87.50 / $62.50 /
Preferred Brand Not Covered Not Covered Not Covered
after Deductible Prescription Prescription
$125 / Prescription
Non-preferred Brand Not Covered $150 / Prescription Not Covered $125 / Prescription Not Covered
after Deductible

NOTE: Deductibles, copays and coinsurance accumulate toward the out-of-pocket maximums. Usual, Customary and Reasonable charges apply for all out-of-network
benefits.

3
 EMPIRE PROGRAMS

EMPIRE BLUE CROSS BLUE SHIELD

Empire Blue Cross Blue Shield provide services to help you keep your health and well -being on track:

TELEMEDICINE
Under the weather and need a fast doctor visit? Telemedicine gives you and your enrolled dependents access to U.S.
board-certified physicians through the convenience of your phone. Telemedicine is very useful for simple issues like cold
and flu symptoms, an infected cut, strep throat, insect bites or poison ivy, digestive issues and more. You and a doctor can
speak or video chat, and they will be able to:
• Answer your medical questions
• Make a diagnosis
• Prescribe medications to your local pharmacy if needed.
Telemedicine can save you a trip to urgent care and is often more affordable. To access, download the SydneyHealth app
or visit www.empireblue.com/member-resources/telehealth.

GYM REIMBURSEMENT PROGRAM

If you and your eligible dependents, age 18 or older, are enrolled in one of the company provided medical plans, you are
eligible to participate in Empire’s Gym Reimbursement Program, Active&Fit.
Simply exercise at a fitness center no less than 35 times during a 6 month period of the plan year. Once you’ve completed
this, you’ll need to complete a Fitness Center Visit Submission Form and submit it to Empire for processing. You will then
be reimbursed the membership fees or $200 per eligible participant – whichever is less. This reimbursement is available
twice per plan year. If you become eligible after January 1 st, your workout session requirement and reimbursement amount
will be prorated.
Enroll in the Active&Fit program through www.empireblue.com. Once you’re enrolled, the program can automatically track
your visits, manage reimbursement paperwork and submit a request for reimbursement after fitness visits are added to your
online profile.

4
 ROLLOVER YOUR
SAVINGS
HEALTH SAVINGS ACCOUNT (HSA)
If you enroll in the HDHP, you’ll have access to a HSA. You can think of your HSA as a personal savings account for your healthcare
expenses, with some impressive tax advantages.

START HERE
PAY EXPENSES
You can use your HSA to pay for eligible expenses
on a tax-free basis.**

For example:
• Copays • Prescriptions
YOUR TAX-FREE CONTRIBUTION
• Deductibles • Dental & Vision Expenses
You can contribute funds from your
paycheck before taxes are taken out A full list is available at www.irs.gov.
(up to the yearly IRS limits).

YOUR HSA

SAVING FOR THE FUTURE

You can also save your funds for the
future and allow them to earn interest.

HOW MUCH CAN YOU CONTRIBUTE? 2024 IRS CONTRIBUTION LIMIT

Employee Only Coverage $4,150*

Family Coverage $8,300*

* If an individual reaches age 55 by the end of the calendar year, he or she can contribute an additional $1,000.

LET’S BREAK IT DOWN

• You can add funds into the HSA that are not subject to federal income taxes** up to the IRS limits.
• The HSA allows you to pay for qualified medical expenses with these tax-free funds.
• The account can earn interest on a tax-free basis, and you are allowed to roll funds over year after year.
• If you leave OHLA, or retire, you can take your HSA with you.

**Any reference to taxes is at the federal level. State tax rules may vary.
5
 DENTAL AND VISION
COVERAGE

CONTROLLING HEALTH CARE COSTS

The rising cost of health insurance is a concern for all of us. Keeping costs to a minimum contributes to lower premiums in future
years. Here are tips on how you can help lower the cost of health insurance:
• Use network providers. You will receive a higher level of benefits if you use providers who participate in the network.
• Request generic rather than brand name prescription drugs. Generic medications, while just as effective, are considerably less
expensive.
• Consider seeing your family physician rather than a specialist. Family physicians can often provide the same level of care for a
variety of illnesses and conditions.
• Exercise and maintain a proper diet. The healthier you are the less vulnerable you are to disease, reducing doctor’s visits and
prescription medicines.

DENTAL BENEFITS
Dental coverage is important to your overall health and wellness. OHLA is proud to offer a choice of three dental plans through Cigna
Dental so you can choose the plan that best meets the needs of you and your family. The DPPO plans allow you to go in and out of
the network to receive services, but you will pay less when you stay in the network. The DHMO provides coverage for in-network
dentists only. Please visit www.myCigna.com for more information on network providers.

This information is only a summary of your dental coverage. Visit www.myCigna.com, or e-mail [email protected] for more
information about the dental plans. Please contact your local HR for more information on your per paycheck deductions.

BENEFIT DPPO CORE DPPO BUY-UP DHMO

Annual/Calendar Year Maximum $1,000 $1,500 N/A
Annual/Calendar Year
$50 / $150 $50 / $150 N/A
Deductible (Individual/Family)
Preventive Services 0% Coinsurance 0% Coinsurance Copay
Basic Services 20% Coinsurance 20% Coinsurance Copay
Major Services 50% Coinsurance 50% Coinsurance Copay
Orthodontia Lifetime Maximum N/A $1,000 N/A

VISION BENEFITS
OHLA offers you and your dependents vision coverage through EyeMed. This information is only a summary of your vision coverage.
Visit www.eyemed.com, or e-mail [email protected] for more information about the vision plan. Please contact your local HR for
more information on your per paycheck deductions.

BENEFIT VISION
Exam INN: $10 Copay / OON: Up to $35
Lenses INN: $0 Copay / OON: Up to $60
Frames INN: $130 Allowance / OON: Up to $65
Contact Lenses Instead of Glasses
Conventional/Disposable INN: $0 Copay; $130 Allowance; 15% Off Balance Over $130 / OON: Up to $105
Medically Necessary INN: $0 Copay; Paid in Full / OON: Up to $210

NOTE: ID Card not required for vision services.

6
 ACCESS YOUR WEALTH

FLEXIBLE SPENDING ACCOUNTS (FSAs)

You may be eligible to enroll in an FSA which enables you to put aside money for important expenses and help you reduce your
income taxes at the same time. OHLA offers two types of FSAs —a Health Care FSA and a Dependent Care FSA. If you are enrolled
in the HDHP for medical and open a Health Savings Account (HSA), you can use another type of account, a Limited Purpose FSA, for
eligible dental and vision expenses. These accounts allow you to set aside pre-tax dollars to pay for certain out-of-pocket health care
or dependent care expenses.

HEALTH DEPENDENT
CARE CARE
FSA FSA

Deductibles, copays, prescription Go to www.mywealthcareonline.com/ameriflex Babysitters, daycare, day

and over-the-counter drugs, medical for a complete list of covered expenses. camp, home nursing care, etc.
equipment, etc.

HOW FSA s WORK

1. Each year during the Open Enrollment period, you decide how much to
set aside for health care and/or dependent care expenses.
2. Your contributions are deducted from your paycheck on a before-tax basis
in equal installments throughout the calendar year.
3. As you incur health care or dependent care expenses throughout the year,
submit a claim form for reimbursement. Your claim will be processed and
you will be reimbursed from your account. Or use your FSA card to pay for
eligible expenses at the point of sale. You will not be paying out-of-pocket,
so there’s no need to fill out a claim form and wait for reimbursement.
Please note that these accounts are separate —you may choose to
participate in one, both, or neither. You cannot use money from the Health
Care FSA to cover expenses eligible under the Dependent Care FSA or vice
versa.
YOU MUST ACTIVELY RE-ENROLL IN EITHER FSA PLAN EACH YEAR. YOU ARE
NOT AUTOMATICALLY RE-ENROLLED.
HEALTH CARE ITEMS YOU MIGHT NOT
ANNUAL MAXIMUM EXAMPLES OF REALIZE ARE FSA ELIGIBLE:
PLAN
CONTRIBUTION COVERED • Sunscreen
EXPENSES • Heating and cooling pads
Health Care • First aid kits
$3,200 Copays, deductibles, • Shoe inserts and other foot grooming
Flexible
Spending orthodontia, over-the- treatments
counter medications, etc.
Account • Travel pillows
Dependent Care Daycare, nursery school, • Motion sickness bands
Flexible Spending $5,000 elder care expenses, etc.
($2,500 if single or married and
Account
filing separate tax returns)

NOTE: See IRS Publications 502 and 503 for a complete list of covered expenses.

7
 PROTECT YOURSELF FROM RISK

DISABILITY INSURANCE
If you are out of work for an extended period of time due to a
disabling injury or illness, disability insurance is designed to
replace a portion of your income and help you maintain your
lifestyle. Unfortunately, avoiding disability is becoming more and
more unlikely. According to the Social Security Administration,
just over one in every four of today’s 20 year-olds will become
disabled before they reach retirement age*. At this rate, making
sure that you have disability coverage in place now is a smart
move.

You have access to Short-Term Disability (STD) and Long-Term

Disability (LTD) through Lincoln. Depending on your role in the
company, OHLA offers either company-paid or voluntary
disability insurance. You must be employed for 1 year to be
eligible for STD. For more details, contact your local Human
Resources representative.

*U.S. Social Security Administration, Fact Sheet, January 2017

8
 GUARD YOUR FINANCES

LIFE INSURANCE
Your family depends on your income for a comfortable lifestyle and for the resources necessary to make their dreams —such as
a college education —a reality. Like anyone, you don’t like to think of the scenario where you’re no longer there for your family.
However, you do need to ensure their lives and dreams can continue if the worst does happen.

BASIC TERM LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT (AD&D)

OHLA is pleased to offer all employees a company-paid life insurance benefit reflective of their role in the company. You are
automatically enrolled in coverage. All salaried and office hourly employees will receive coverage equal to 1x your annual base pay,
up to a maximum of $200,000. Field hourly employees will receive $25,000 of coverage, regardless of annual compensation.

SUPPLEMENTAL LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT (AD&D)

You can purchase Supplemental Life Insurance for yourself, your spouse/domestic partner, and your child(ren). Life Insurance is
about more than paying for memorial services —it’s about making sure your family can maintain its standard of living over the long
run if something happens to you. How much your family needs depends on your personal situation (other income, monthly expenses,
short- and long-term debt such as credit card or mortgage expenses, etc.)

You may purchase additional Life Insurance in increments of $10,000 not to exceed the lesser of $300,000. You may also purchase
coverage for your spouse, in units of $5,000, not to exceed $150,000 (cannot exceed 50% of your elected amount). Lastly, you can
purchase coverage for your child(ren) with a flat benefit of $10,000 (up to 50% of your elected amount).
NOTE: To purchase supplemental coverage for either your spouse/domestic partner or child(ren), you must enroll in employee coverage. You pay 100% of the cost
of supplemental coverage for yourself, your spouse/domestic partner, and/or your child(ren). Eligible child(ren) must be under age 23, or under age 26 if a full-time
student.

Evidence of Insurability (EOI) may be required for certain amounts, if you enroll after your initial eligibility period or enroll your
spouse/domestic partner. Age reductions may apply to life insurance amounts.

UNIVERSAL LIFE
Interest-sensitive Universal Life Insurance is designed to provide death benefits to your beneficiaries if you pass away, but it also
builds cash value that you can utilize while you are still alive. You can choose the amount of guaranteed issue coverage you need
between $10,000 and $100,000.
PLAN FEATURES
• You have the ability to purchase Universal Life Insurance for yourself, your spouse/domestic partner, and/or your child(ren). Any
child(ren) must be under age 19 (or under age 25 if a full-time student).
• Interest-sensitive Universal Life Insurance is voluntary, which means you purchase the precise amount of coverage that is right for
your needs.
• No physical exams are required to apply for coverage (although health questions may be asked).
• Coverage is portable —you can take your policy with you if you leave the company and carry your life insurance coverage into your
retirement.
The cost of the benefit will vary depending upon your age, the amount of coverage you elect, or dependent coverage you choose, and
other such factors.

9
 PREPARE FOR THE FUTURE

VOLUNTARY BENEFITS
CRITICAL ILLNESS INSURANCE
Critical Illness Insurance is designed to protect your income and personal assets when your out-of-pocket expenses increase as a
result of an illness. Health insurance is not always enough to cover all of the unforeseen expenses associated with a serious medical
condition like a heart attack or cancer. Critical Illness Insurance pays a lump sum benefit that can be used any way you choose, and
benefits are paid in addition to any other insurance coverage you may have.

COVERED ILLNESSES PAYMENT PERCENTAGES / AMOUNTS

Heart Attack 100%
Stroke 100%
Major Organ Transplant 100%
End Stage Renal (Kidney) Failure 100%
Arterial / Vascular Disease 25%
Invasive Cancer 100%
Non-invasive cancer/cancer in situ 25%
Skin cancer (paid once per lifetime) $250

PLAN FEATURES
• You do not have to be terminally ill to receive benefits.
• Coverage options are available for your spouse/domestic partner and children as riders to your coverage.
• Coverage is portable —you can take your policy with you if you change jobs or retire.

The cost of the benefit will vary depending upon factors such as your age and the dependent coverage you choose.
NOTE: The policy/certificate of coverage has exclusions and limitations which may affect any benefits payable.

ACCIDENT INSURANCE
You don’t have to be especially clumsy to experience accidents. These events are all too common, and so are the high medical
expenses that come with them.

Accidents are unplanned and unpredictable, but the financial impact that they have on you doesn’t have to be either of those things.
Voluntary Accident Insurance pays direct benefits for a range of injuries and accident-related expenses such as:
• Fractures
• Dislocations
• Concussion
• Emergency Room Treatment
• Hospitalization
• Accidental Death
Benefit amounts are based on the type of injury and treatment needed. No matter how great your medical plan is, you will have to
share the costs of medical care and rehabilitation that follow an accident. Accident insurance is designed to help you pay for out-of-
pocket expenses that insurance doesn’t cover, like copays and deductibles, but the benefit payout can be used however you’d like.
NOTE: The policy/certificate of coverage or its provisions may vary or be unavailable in some states. The policy/certificate of coverage has exclusions and limitations
which may affect any benefits payable.

10
 KEEP THINKING AHEAD

ADDITIONAL BENEFITS
HOSPITAL INDEMNITY INSURANCE
If you’ve ever been in the hospital, you know that it may be
difficult to focus on your recovery. You’d rather be in your
own bed, eating your own food, and your family might be
spending a ton of money to stay at a hotel near you.

The last thing you want to think about is the bill you will
receive after your insurance company covers their portion
of your hospital stay. Since out-of-pocket costs including
deductibles and coinsurance can build quickly, the bills that
result from a hospital stay can be overwhelming for anyone
– with or without Medical Insurance.

Hospital Indemnity Insurance can help to ease the sticker-

shock by paying a benefit directly to you (not to the hospital,
or to an insurance company) if you or a covered family
member has to stay in the hospital.
NOTE: The policy/certificate of coverage or its provisions may vary or be
unavailable in some states. The policy/certificate of coverage has exclusions
and limitations, which may affect any benefits payable. The benefits
explained in the example above are for illustrative purposes only. Please see
your Summary Plan Description (SPD) for complete details.

11
 BENEFITS AT NO COST TO YOU

EMPLOYEE ASSISTANCE PROGRAM

EAP
We are happy to provide an EAP to our employees that
comes at no cost to you. Provided by Lincoln, the
EmployeeConnect EAP offers professional, confidential
services to help you and your loved ones improve your
quality of life.
Some matters are best resolved by meeting with a
professional in person. With our EAP, you and your
family have access to in-person help for short-term
issues (up to five session with a counselor per person,
per issue, per year).
There is unlimited 24/7 assistance online or via phone
for services such as emotional issues, relationships,
stress and anxiety, and the EAP can even provide
referrals for family matters, such as child and elder care.
It also provides online resources to research and access
on your own, Support tools are just a click away by
visiting www.GuidanceResources.com or downloading
the GuidanceNow mobile app. Use username: LFGNY,
password: LFGNY1 to get started today.
To access the EAP 24/7 call 833-475-0980.

HEALTH ADVOCATE
PATIENT ADVOCACY
Patient Advocacy through Health Advocate can assist
you with the following:
• Quickly connect to all your benefits
• Get answers to your insurance and claim questions
• Resolve billing issues
• Find the right in-network doctors
• Make appointments and transfer medical records
• Make informed decisions about medical conditions
and diagnoses
• Find and explore the latest treatment options and
arrange second opinions
• Coordinate services related to all aspects of your
care
To access this free benefit, call 866-799-2731, email
[email protected] or visit
www.healthadvocate.com/members.
12
 RESOURCES AND CONTACT INFORMATION

BENEFITS ADMINISTRATOR INFORMATION

If you have any questions regarding eligibility, benefit plans or enrollment periods or would like additional information, contact your
local Human Resources Department.

GET MORE INFORMATION

BENEFIT WHO TO WEBSITE/EMAIL PHONE NUMBER PLAN/GROUP ID
CALL
Medical: 1-844-480-2872
Medical & Prescription Drug Empire www.empireblue.com Rx: 1-833-271-2550 721338
Provider Services:1-844-235-4443
Dental Cigna www.myCigna.com 1-800-Cigna24 3345195

Vision EyeMed www.eyemed.com 1-866-723-0514 1006298

Life Insurance Lincoln www.lincolnfinancial.com 1-800-431-2958 TBD

Short & Long-Term Disability Lincoln www.lincolnfinancial.com 1-800-431-2958 TBD

Supplemental Accident,
Hospital Indemnity & Lincoln www.lincolnfinancial.com 1-800-423-2765 TBD
Critical Illness
Employee Assistance Username: LFGNY
Program Lincoln www.guidanceresources.com 1-833-475-0980 Password: LFGNY1

Patient Advocacy Health www.healthadvocate.com/members or 1-866-799-2731 N/A

Advocate email [email protected]
Supplemental Universal Life TransAmerica www.tebcs.com 1-888-763-7474 EL00061389
myameriflex.com or email
Flexible Spending Accounts Ameriflex 1-888-868-3539 N/A
[email protected]
Supplemental Legal Benefit Legal Access www.legaleaseplan.com/ 1-800-562-2929 9000375

Human Resources OHLA USA [email protected] N/A N/A

Inc.

ABOUT THIS GUIDE: This guide highlights all employee benefits. Official plan and insurance documents govern your rights and benefits under each plan. For more
details about your benefits, including covered expenses, exclusions, and limitations, please refer to the individual Summary Plan Description (SPD), plan document or
certificate of coverage for each plan. If any discrepancy exists between this guide and the official documents, the official documents will prevail.
13
Updated 11/2023
 IMPORTANT NOTICES

ABOUT THIS GUIDE NEWBORNS’ AND MOTHERS’ HEALTH

This guide highlights your benefits. Official plan and insurance documents PROTECTION ACT DISCLOSURE
govern your rights and benefits under each plan. For more details about your
benefits, including covered expenses, exclusions, and limitations, please Group health plans and health insurance issuers generally may not, under
refer to the individual summary plan descriptions (SPDs), plan document, or Federal law, restrict benefits for any hospital length of stay in connection
certificate of coverage for each plan. If any discrepancy exists between this with childbirth for the mother or newborn child to less than 48 hours
guide and the official documents, the official documents will prevail. OHLA following a vaginal delivery, or less than 96 hours following a cesarean
reserves the right to make changes at any time to the benefits, costs, and section. However, Federal law generally does not prohibit the mother’s
other provisions relative to benefits. or newborn’s attending provider, after consulting with the mother, from
discharging the mother or her newborn earlier than 48 hours (or 96 hours
as applicable). In any case, plans and issuers may not, under Federal law,
REMINDER OF AVAILABILITY OF PRIVACY require that a provider obtain authorization from the plan or the issuer for
NOTICE prescribing a length of stay not in excess of 48 hours (or 96 hours).

This is to remind plan participants and beneficiaries of the OHLA Health USERRA
and Welfare Plan (the “Plan”) that the Plan has issued a Health Plan Privacy
Notice that describes how the Plan uses and discloses protected health Your right to continued participation in the Plan during leaves of absence
information (PHI). You can obtain a copy of the OHLA Health and Welfare for active military duty is protected by the Uniformed Services Employment
Plan Privacy Notice upon your written request to the Human Resources and Reemployment Rights Act (USERRA). Accordingly, if you are absent
Department. from work due to a period of active duty in the military for less than 31
If you have any questions, please contact the OHLA Human Resources Office days, your Plan participation will not be interrupted and you will continue to
at [email protected]. pay the same amount as if you were not absent. If the absence is for more
than 31 days and not more than 24 months, you may continue to maintain
your coverage under the Plan by paying up to 102% of the full amount of
WOMEN’S HEALTH AND CANCER RIGHTS premiums. You and your dependents may also have the opportunity to elect
ACT COBRA coverage. Contact [email protected] for more information.
Also, if you elect not to continue your health plan coverage during your
If you have had or are going to have a mastectomy, you may be entitled to military service, you have the right to be reinstated in the Plan upon
certain benefits under the Women’s Health and Cancer Rights Act of 1998 your return to work, generally without any waiting periods or pre-existing
(WHCRA). For individuals receiving mastectomy-related benefits, coverage condition exclusions, except for service connected illnesses or injuries, as
will be provided in a manner determined in consultation with the attending applicable.
physician and the patient, for:
• All stages of reconstruction of the breast on which the mastectomy was
performed;
This guide contains important information about
• Surgery and reconstruction of the other breast to produce a symmetrical
appearance; the Medicare Part D creditable status of your
• Prostheses; and prescription drug coverage on page 13.
• Treatment of physical complications of the mastectomy, including
lymphedema.
These benefits will be provided subject to the same deductibles and
coinsurance applicable to other medical and surgical benefits provided under
this plan.

14
 MEDICARE PART D NOTICE OF
CREDITABLE COVERAGE

YOUR OPTIONS If you go 63 continuous days or longer without creditable prescription

drug coverage, your monthly premium may go up by at least 1% of the
Please read this notice carefully and keep it where you can find it. This Medicare base beneficiary premium per month for every month that you
notice has information about your current prescription drug coverage with did not have that coverage. For example, if you go nineteen months without
OHLA and about your options under Medicare’s prescription drug coverage. creditable coverage, your premium may consistently be at least 19% higher
This information can help you decide whether or not you want to join a than the Medicare base beneficiary premium. You may have to pay this
Medicare drug plan. If you are considering joining, you should compare higher premium (a penalty) as long as you have Medicare prescription drug
your current coverage, including which drugs are covered at what cost, with coverage. In addition, you may have to wait until the following October to
the coverage and costs of the plans offering Medicare prescription drug join.
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. FOR MORE INFORMATION ABOUT THIS NOTICE
There are two important things you need to know about your current OR YOUR CURRENT PRESCRIPTION DRUG
coverage and Medicare’s prescription drug coverage:
COVERAGE:
1. Medicare prescription drug coverage became available in 2006 to
Contact the person listed below for further information. NOTE: You’ll get this
everyone with Medicare. You can get this coverage if you join a Medicare
notice each year. You will also get it before the next period you can join a
Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO
Medicare drug plan, and if this coverage through OHLA changes. You also
or PPO) that offers prescription drug coverage. All Medicare drug plans
may request a copy of this notice at any time.
provide at least a standard level of coverage set by Medicare. Some
plans may also offer more coverage for a higher monthly premium.
FOR MORE INFORMATION ABOUT YOUR
2. OHLA has determined that the prescription drug coverage offered OPTIONS UNDER MEDICARE PRESCRIPTION
by the OHLA Medical Plan through Empire is, on average, for all plan
participants, expected to pay out as much as standard Medicare DRUG COVERAGE:
prescription drug coverage pays and is therefore considered Creditable More detailed information about Medicare plans that offer prescription
Coverage. Because your existing coverage is Creditable Coverage, you drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the
can keep this coverage and not pay a higher premium (a penalty) if you handbook in the mail every year from Medicare. You may also be contacted
later decide to join a Medicare drug plan. directly by Medicare drug plans. For more information about Medicare
prescription drug coverage:
WHEN CAN YOU JOIN A MEDICARE DRUG • Visit www.medicare.gov
PLAN? • Call your State Health Insurance Assistance Program for personalized
You can join a Medicare drug plan when you first become eligible for help. See the inside back cover of your copy of the “Medicare & You”
Medicare and each year from October 15th through December 7th. handbook for their telephone number.
However, if you lose your current creditable prescription drug coverage, • Call 1-800-MEDICARE (1-800-633-4227) TTY users should call
through no fault of your own, you will also be eligible for a two (2) month 1-877-486-2048
Special Enrollment Period (SEP) to join a Medicare drug plan. If you have limited income and resources, extra help paying for Medicare
prescription drug coverage is available. For information about this extra
WHAT HAPPENS TO YOUR CURRENT COVERAGE help, visit Social Security on the web at:
IF YOU DECIDE TO JOIN A MEDICARE DRUG • www.socialsecurity.gov
PLAN? • or call: 1-800-772-1213 (TTY: 1-800-325-0778)
If you decide to join a Medicare drug plan, your current OHLA coverage will
not be affected. If you do decide to join a Medicare drug plan and drop your
current coverage, be aware that you and your dependents may not be able Remember: Keep this Creditable Coverage notice. If you decide
to get this coverage back. 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
WHEN WILL YOU PAY A HIGHER PREMIUM not you have maintained creditable coverage and, therefore,
(PENALTY) TO JOIN A MEDICARE DRUG PLAN? whether or not you are required to pay a higher premium (a
You should also know that if you drop or lose your current coverage with penalty).
OHLA 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.

15
 YOUR ERISA RIGHTS

As a participant in the OHLA benefit plans, you ENFORCE YOUR RIGHTS

are entitled to certain rights and protections If your claim for a benefit is denied or ignored, in whole or in part, you have
a right to:
under the Employee Retirement Income Security
• Know why this was done;
Act of 1974 (ERISA), as amended. ERISA provides
• Obtain copies of documents relating to the decision without charge; and
that all plan participants shall be entitled to
• Appeal any denial.
receive information about their plan and benefits, All of these actions must occur within certain time schedules. Under ERISA,
continue group health plan coverage, and enforce there are steps you can take to enforce your rights. For instance, you may
their rights. ERISA also requires that plan file suit in a federal court if:
• You request a copy of plan documents or the latest annual report
fiduciaries act in a prudent manner. from the plan and do not receive them within 30 days, you may file
suit in a federal court. In such a case, the court may require the plan
RECEIVE INFORMATION ABOUT YOUR PLAN AND administrator to provide the materials and pay you up to $110 a day until
BENEFITS you receive the materials, unless the materials were not sent because of
You are entitled to: reasons beyond the control of the administrator;
• Examine, without charge, at the plan administrator’s office, all plan • You have followed all the procedures for filing and appealing a claim (as
documents—including pertinent insurance contracts, trust agreements, outlined earlier in this summary) and your claim for benefits is denied or
and a copy of the latest annual report (Form 5500 Series) filed by the ignored, in whole or in part. You may also file suit in a state court.
plan with the U.S. Department of Labor and available at the Public • You disagree with the plan’s decision or lack thereof concerning the
Disclosure Room of the Employee Benefits Security Administration; qualified status of a domestic relations order or a medical child support
• Obtain, upon written request to the plan’s administrator, copies of order; or
documents governing the operation of the plan, including insurance • The plan fiduciaries misuse the plan’s money, or if you are discriminated
contracts and copies of the latest annual report (Form 5500 Series), against for asserting your rights. You may also seek assistance from the
and updated summary plan description. The administrator may make a U.S. Department of Labor.
reasonable charge for the copies. The court will decide who should pay court costs and legal fees. If you are
• Receive a summary report of the plan’s annual financial report. The plan successful, the court may order the person you have sued to pay these
administrator is required by law to furnish each participant with a copy of costs and fees. If you lose, the court may order you to pay these costs and
this Summary Annual Report. fees. This should occur if the court finds your claim frivolous.

CONTINUED GROUP HEALTH PLAN COVERAGE ASSISTANCE WITH YOUR QUESTIONS

You are entitled to: If you have questions about how your plan works, contact the Human
• Continued health care coverage for yourself, spouse, or dependents Resources Department. If you have any questions about this statement or
if there is a loss of coverage under the plan as a result of a qualifying your rights under ERISA, or if you need assistance in obtaining documents
event. You or your dependents may have to pay for such coverage. from the plan administrator, you should contact the nearest office listed on
Review this summary plan description governing the plan on the rules EBSA’s website:
governing your COBRA continuation coverage rights. https://www.dol.gov/agencies/ebsa/about-ebsa/about-us/regional-
offices.
• Reduce or eliminate exclusionary periods of coverage for pre-existing
conditions under your group health plan, if you have credible coverage Or you may write to the:
from another plan. You should be provided a certificate of credible Division of Technical Assistance and Inquiries
coverage, free of charge, from your group health plan or health insurance Employee Benefits Security Administration
issuer when: U.S. Department of Labor
– You lose coverage under the plan; 200 Constitution Avenue, NW
Washington, DC 20210
– You become entitled to elect COBRA continuation coverage;
You may also obtain certain publications about your rights and
– You request it up to 24 months after losing coverage.
responsibilities under ERISA by calling the Employee and Employer Hotline
of the Employee Benefits Security Administration at:1-866-444-3272.
PRUDENT ACTIONS BY PLAN FIDUCIARIES You may also visit the EBSA’s website on the Internet at:
In addition to creating rights for plan participants, ERISA imposes duties https://www.dol.gov/agencies/ebsa.
upon the people who are responsible for the operation of the plans. The
people who operate your plans are called “fiduciaries,” and they have a duty
to act prudently and in the interest of you and other plan participants and
beneficiaries. No one, including your employer or any other person, may fire
you or otherwise discriminate against you in any way to prevent you from
obtaining a benefit or exercising your rights under ERISA.

16
 CONTINUATION COVERAGE RIGHTS
UNDER COBRA

INTRODUCTION Your dependent children will become qualified beneficiaries if they lose
coverage under the Plan because any of the following qualifying events
You are receiving this notice because you have recently become covered happen:
under a group health plan (the Plan). This notice contains important • The parent-employee dies;
information about your right to COBRA continuation coverage, which is a
• The parent-employee’s hours of employment are reduced;
temporary extension of coverage under the Plan. This notice generally
explains COBRA continuation coverage, when it may become available • The parent-employee’s employment ends for any reason other than his or
to you and your family, and what you need to do to protect the right to her gross misconduct;
receive it. • The parent-employee becomes entitled to Medicare benefits (Part A, Part
The right to COBRA continuation coverage was created by a federal law, B, or both);
the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). • The parents become divorced or legally separated; or
COBRA continuation coverage can become available to you when you would • The child stops being eligible for coverage under the plan as a
otherwise lose your group health coverage. “dependent child.”
It can also become available to other members of your family who are
covered under the Plan when they would otherwise lose their group health WHEN IS COBRA COVERAGE AVAILABLE?
coverage. For additional information about your rights and obligations under The Plan will offer COBRA continuation coverage to qualified beneficiaries
the Plan and under federal law, you should review the Plan’s Summary Plan only after the Plan Administrator has been notified that a qualifying event
Description or contact the Plan Administrator. has occurred. When the qualifying event is the end of employment or
You may have other options available to you when you lose group health reduction of hours of employment, death of the employee, or the employee’s
coverage. For example, you may be eligible to buy an individual plan through becoming entitled to Medicare benefits (under Part A, Part B, or both), the
the Health Insurance Marketplace (www.healthcare.gov). By enrolling in employer must notify the Plan Administrator of the qualifying event.
coverage through the Marketplace, you may qualify for lower costs on your
monthly premiums and lower out-of-pocket costs. Additionally, you may YOU MUST GIVE NOTICE OF SOME QUALIFYING
qualify for a 30-day special enrollment period for another group health
plan for which you are eligible (such as a spouse’s plan), even if that plan
EVENTS
generally doesn’t accept late enrollees. For the other qualifying events (divorce or legal separation of the employee
and spouse or a dependent child’s losing eligibility for coverage as a
WHAT IS COBRA CONTINUATION COVERAGE? dependent child), you must notify the Plan Administrator within 60 days
after the qualifying event occurs. You must provide this notice to: OHLA
COBRA continuation coverage is a continuation of Plan coverage when
Human Resources or COBRA Administrator.
coverage would otherwise end because of a life event known as a
“qualifying event.” Specific qualifying events are listed later in this notice.
After a qualifying event, COBRA continuation coverage must be offered to
HOW IS COBRA COVERAGE PROVIDED?
each person who is a “qualified beneficiary.” You, your spouse, and your Once the Plan Administrator receives notice that a qualifying event has
dependent children could become qualified beneficiaries if coverage under occurred, COBRA continuation coverage will be offered to each of the
the Plan is lost because of the qualifying event. Under the Plan, qualified qualified beneficiaries. Each qualified beneficiary will have an independent
beneficiaries who elect COBRA continuation coverage must pay for COBRA right to elect COBRA continuation coverage. Covered employees may elect
continuation coverage. COBRA continuation coverage on behalf of their spouses, and parents may
elect COBRA continuation coverage on behalf of their children. Any qualified
If you are an employee, you will become a qualified beneficiary if you lose
beneficiary who does not elect COBRA within the 60-day election period
your coverage under the Plan because either one of the following qualifying
specified in the election notice will lose his or her right to elect COBRA.
events happens:
COBRA continuation coverage is a temporary continuation of coverage
• Your hours of employment are reduced, or
that generally lasts for 18 months due to employment termination or
• Your employment ends for any reason other than your gross misconduct. reduction of hours of work. When the qualifying event is the death of the
If you are the spouse of an employee, you will become a qualified employee, the employee’s becoming entitled to Medicare benefits (under
beneficiary if you lose your coverage under the Plan because any of the Part A, Part B, or both), your divorce or legal separation, or a dependent
following qualifying events happens: child’s losing eligibility as a dependent child, COBRA continuation coverage
lasts for up to a total of 36 months. When the qualifying event is the end
• Your spouse dies;
of employment or reduction of the employee’s hours of employment, and
• Your spouse’s hours of employment are reduced; the employee became entitled to Medicare benefits less than 18 months
• Your spouse’s employment ends for any reason other than his or her before the qualifying event, COBRA continuation coverage for qualified
gross misconduct; beneficiaries other than the employee lasts until 36 months after the date
• Your spouse becomes entitled to Medicare benefits (under Part A, Part B, of Medicare entitlement. For example, if a covered employee becomes
or both); or entitled to Medicare 8 months before the date on which his employment
terminates, COBRA continuation coverage for his spouse and children can
• You become divorced or legally separated from your spouse. last up to 36 months after the date of Medicare entitlement, which is equal
to 28 months after the date of the qualifying event (36 months minus 8
months). Otherwise, when the qualifying event is the end of employment
or reduction of the employee’s hours of employment, COBRA continuation
coverage generally lasts for only up to a total of 18 months. There are two
ways in which this 18-month period of COBRA continuation coverage can be
extended.

17
 CONTINUATION COVERAGE RIGHTS
UNDER COBRA

DISABILITY EXTENSION OF 18-MONTH PERIOD CAN I ENROLL IN MEDICARE INSTEAD OF

OF CONTINUATION COVERAGE COBRA CONTINUATION COVERAGE AFTER MY
If you or anyone in your family covered under the Plan is determined by GROUP HEALTH PLAN COVERAGE ENDS?
the Social Security Administration to be disabled and you notify the Plan
In general, if you don’t enroll in Medicare Part A or B when you are first
Administrator in a timely fashion, you and your entire family may be entitled
eligible because you are still employed, after the Medicare initial enrollment
to receive up to an additional 11 months of COBRA continuation coverage,
period, you have an 8-month special enrollment period to sign up for
for a total maximum of 29 months. The disability would have to have started
Medicare Part A or B, beginning on the earlier of:
at some time before the 60th day of COBRA continuation coverage and must
last at least until the end of the 18-month period of continuation coverage. The month after your employment ends; or
The disability extension is available only if you notify the Plan Administrator The month after group health plan coverage based on current employment
in writing of the Social Security Administration’s determination of ends.
disability within 60 days after the latest of the date of the Social Security If you don’t enroll in Medicare and elect COBRA continuation coverage
Administration’s disability determination; the date of the covered employee’s instead, you may have to pay a Part B late enrollment penalty and you
termination of employment or reduction in hours; and the date on which may have a gap in coverage if you decide you want Part B later. If you
the qualified beneficiary loses (or would lose) coverage under the terms of elect COBRA continuation coverage and later enroll in Medicare Part A or
the Plan as a result of the covered employee’s termination or reduction in B before the COBRA continuation coverage ends, the Plan may terminate
hours. You must also provide this notice within 18 months after the covered your continuation coverage. However, if Medicare Part A or B is effective
employee’s termination or reduction in hours in order to be entitled to this on or before the date of the COBRA election, COBRA coverage may not be
extension. discontinued on account of Medicare entitlement, even if you enroll in the
other part of Medicare after the date of the election of COBRA coverage.
SECOND QUALIFYING EVENT EXTENSION If you are enrolled in both COBRA continuation coverage and Medicare,
OF 18-MONTH PERIOD OF CONTINUATION Medicare will generally pay first (primary payer) and COBRA continuation
coverage will pay second. Certain plans may pay as if secondary to
COVERAGE Medicare, even if you are not enrolled in Medicare.
If your family experiences another qualifying event while receiving 18 For more information visit https://www. medicare.gov/medicare-and-you.
months of COBRA continuation coverage, the spouse and dependent
children in your family can get up to 18 additional months of COBRA IF YOU HAVE QUESTIONS
continuation coverage, for a maximum of 36 months, if notice of the
Questions concerning your Plan or your COBRA continuation coverage
second qualifying event is properly given to the Plan. This extension may be
rights should be addressed to the contact or contacts identified below.
available to the spouse and any dependent children receiving continuation
For more information about your rights under ERISA, including COBRA,
coverage if the employee or former employee dies, becomes entitled to
the Health Insurance Portability and Accountability Act (HIPAA), and other
Medicare benefits (under Part A, Part B, or both), or gets divorced or legally
laws affecting group health plans, contact the nearest Regional or District
separated, or if the dependent child stops being eligible under the Plan as
Office of the U.S. Department of Labor’s Employee Benefits Security
a dependent child, but only if the event would have caused the spouse or
Administration (EBSA) in your area or visit the EBSA website at
dependent child to lose coverage under the Plan had the first qualifying
https://www.dol.gov/agencies/ebsa. (Addresses and phone numbers of
event not occurred.
Regional and District EBSA Offices are available through EBSA’s website.)
OTHER COVERAGE OPTIONS KEEP YOUR PLAN INFORMED OF ADDRESS
Instead of enrolling in COBRA continuation coverage, there may be other
coverage options for you and your family through the Health Insurance
CHANGES
Marketplace, Medicaid, or other group health plan coverage options (such as In order to protect your family’s rights, you should keep the Plan
a spouse’s plan) through what is called a “special enrollment period.” Some Administrator informed of any changes in the addresses of family members.
of these options may cost less than COBRA continuation coverage. you can You should also keep a copy, for your records, of any notices you send to
learn more about many of these options at www.healthcare.gov. the Plan Administrator.

PLAN CONTACT INFORMATION

For further information regarding the plan and COBRA continuation, please
contact your local Human Resources Department.

SUMMARIES OF BENEFITS AND COVERAGE (SBC s)

As required by the Affordable Care Act, Summaries of Benefits and Coverage (SBCs) are available through your local Human Resources Department.
OHLA is required to make SBCs available that summarize important information about health benefit plan options in a standard format, to help you compare
across plans and make an informed choice. The health benefits available to you provide important protection for you and your family and choosing a health
benefit option is an important decision.

18
 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 either of these programs, contact your State Medicaid or CHIP office or dial
coverage from your employer, your state may have a premium assistance program that 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify,
can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or ask your state if it has a program that might help you pay the premiums for an
your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these employer-sponsored plan.
premium assistance programs but you may be able to buy individual insurance
coverage through the Health Insurance Marketplace. For more information, visit If you or your dependents are eligible for premium assistance under Medicaid or CHIP,
www.healthcare.gov. 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”
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a opportunity, and you must request coverage within 60 days of being determined
State listed below, contact your State Medicaid or CHIP office to find out if premium eligible for premium assistance. If you have questions about enrolling in your employer
assistance is available. If you or your dependents are NOTcurrently enrolled in plan, contact the Department of Labor at www.askebsa.dol.gov or call
Medicaid or CHIP, and you think you or any of your dependents might be eligible for 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
July 31, 2022. Contact your State for more information on eligibility –
1. ALABAMA – Medicaid 11. KENTUCKY – Medicaid 23. NORTH CAROLINA – Medicaid
Website: http://myalhipp.com/ Kentucky Integrated Health Insurance Premium Payment Website: https://medicaid.ncdhhs.gov/
Phone: 1-855-692-5447 Program (KI-HIPP) Phone: 1-919-855-4100
2. ALASKA – Medicaid Website: https://chfs.ky.gov/agencies/dms/member/Pages/ 24. NORTH DAKOTA – Medicaid
The AK Health Insurance Premium Payment Program kihipp.aspx Website: http://www.nd.gov/dhs/services/medicalserv/
Website: http://myakhipp.com/ Phone: 1-855-459-6328 medicaid/
Phone: 1-866-251-4861 Email: [email protected] Phone: 1-844-854-4825
Email: [email protected] KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx 25. OKLAHOMA – Medicaid and CHIP
Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/ Phone: 1-877-524-4718 Website: http://www.insureoklahoma.org
medicaid/default.aspx Kentucky Medicaid Website: https://chfs.ky.gov Phone: 1-888-365-3742
3. ARKANSAS – Medicaid 12. LOUISIANA – Medicaid 26. OREGON – Medicaid
Website: http://myarhipp.com/ Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Website: http://healthcare.oregon.gov/Pages/index.aspx
Phone: 1-855-MyARHIPP (1-855-692-7447) Phone: 1-888-342-6207 (Medicaid hotline) or http://www.oregonhealthcare.gov/index-es.html
4. CALIFORNIA – Medicaid 1-855-618-5488 (LaHIPP) Phone: 1-800-699-9075
Health Insurance Premium Payment (HIPP) Program 13. MAINE – Medicaid 27. PENNSYLVANIA – Medicaid
Website: http://dhcs.ca.gov/hipp Enrollment Website: https://www.maine.gov/dhhs/ofi/ Website: https://www.dhs.pa.gov/providers/Providers/
Phone: 1-916-445-8322 applications-forms Pages/Medical/HIPP-Program.aspx
Fax: 1-916-440-5676 Phone: 1-800-442-6003 Phone: 1-800-692-7462
Email: [email protected] TTY: Maine relay 711 28. RHODE ISLAND – Medicaid and CHIP
5. COLORADO – Health First Colorado (Colorado’s Private Health Insurance Premium Webpage: Website: http://www.eohhs.ri.gov/
Medicaid Program) & Child Health Plan Plus (CHP+) https://www.maine.gov/dhhs/ofi/applications-forms Phone: 1-855-697-4347, or 1-401-462-0311
Health First Colorado Website: Phone: 1-800-977-6740 (Direct RIte Share Line)
https://www.healthfirstcolorado.com/ TTY: Maine relay 711 29. SOUTH CAROLINA – Medicaid
Health First Colorado Member Contact Center: 14. MASSACHUSETTS – Medicaid and CHIP Website: https://www.scdhhs.gov
1-800-221-3943/ State Relay 711 Website: https://www.mass.gov/masshealth/pa Phone: 1-888-549-0820
CHP+: https://www.colorado.gov/pacific/hcpf/child- Phone: 1-800-862-4840 TTY: 1-617- 886-8102 30. SOUTH DAKOTA – Medicaid
health-plan-plus 15. MINNESOTA – Medicaid Website: http://dss.sd.gov
CHP+ Customer Service: 1-800-359-1991/ State Relay 711 Website: https://mn.gov/dhs/people-we-serve/children- Phone: 1-888-828-0059
Health Insurance Buy-In Program (HIBI): and-families/health-care/health-care-programs/programs- 31. TEXAS – Medicaid
https://www.colorado.gov/pacific/hcpf/health-insurance- and-services/other-insurance.jsp Website: http://gethipptexas.com/
buy-program Phone: 1-800-657-3739 Phone: 1-800-440-0493
HIBI Customer Service: 1-855-692-6442 16. MISSOURI – Medicaid 32. UTAH – Medicaid and CHIP
6. FLORIDA – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/ Medicaid Website: https://medicaid.utah.gov/
Website: https://www.flmedicaidtplrecovery.com/ hipp.htm CHIP Website: http://health.utah.gov/chip
flmedicaidtplrecovery.com/hipp/index.html Phone: 1-573-751-2005 Phone: 1-877-543-7669
Phone: 1-877-357-3268 17. MONTANA – Medicaid 33. VERMONT – Medicaid
7. GEORGIA – Medicaid Website: http://dphhs.mt.gov/ Website: http://www.greenmountaincare.org/
GA HIPP Website: https://medicaid.georgia.gov/health- MontanaHealthcarePrograms/HIPP Phone: 1-800-250-8427
insurance-premium-payment-program-hipp Phone: 1-800-694-3084 34. VIRGINIA – Medicaid and CHIP
Phone: 1-678-564-1162, Press 1 Email: [email protected] Website: https://www.coverva.org/en/famis-select
GA CHIPRA Website: https://medicaid.georgia.gov/ 18. NEBRASKA – Medicaid https://www.coverva.org/en/hipp
programs/third-party- liability/childrens-health-insurance- Website: http://www.ACCESSNebraska.ne.gov Medicaid Phone: 1-800-432-5924
program-reauthorization- act-2009-chipra Phone: 1-855-632-7633 CHIP Phone: 1-800-432-5924
Phone: 1-678-564-1162, Press 2 Lincoln: 1-402-473-7000 35. WASHINGTON – Medicaid
8. INDIANA – Medicaid Omaha: 1-402-595-1178 Website: https://www.hca.wa.gov/
Healthy Indiana Plan for low-income adults 19-64 19. NEVADA – Medicaid Phone: 1-800-562-3022
Website: http://www.in.gov/fssa/hip/ Medicaid Website: http://dhcfp.nv.gov 36. WEST VIRGINIA – Medicaid and CHIP
Phone: 1-877-438-4479 Medicaid Phone: 1-800-992-0900 Website: https://dhhr.wv.gov/bms/
All other Medicaid 20. NEW HAMPSHIRE – Medicaid http://mywvhipp.com/
Website: https://www.in.gov/medicaid/ Website: : https://www.dhhs.nh.gov/programs-services/ Medicaid Phone: 1-304-558-1700
Phone 1-800-457-4584 medicaid/health-insurance-premium-program CHIP Toll-free phone: 1-855-MyWVHIPP
9. IOWA – Medicaid and CHIP (Hawki) Phone: 1-603-271-5218 (1-855-699- 8447)
Medicaid Website: https://dhs.iowa.gov/ime/members Toll free number for the HIPP program: 37. WISCONSIN – Medicaid and CHIP
Medicaid Phone: 1-800-338-8366 1-800-852-3345, ext 5218 Website: https://www.dhs.wisconsin.gov/
Hawki Website: http://dhs.iowa.gov/Hawki 21. NEW JERSEY – Medicaid and CHIP badgercareplus/p-10095.htm
Hawki Phone: 1-800-257-8563 Medicaid Website: http://www.state.nj.us/humanservices/ Phone: 1-800-362-3002
HIPP Website: https://dhs.iowa.gov/ime/members/ dmahs/clients/medicaid/ 38. WYOMING – Medicaid
medicaid-a-to-z/hipp Medicaid Phone: 1-609-631-2392 Website: https://health.wyo.gov/healthcarefin/medicaid/
HIPP Phone: 1-888-346-9562 CHIP Website: http://www.njfamilycare.org/index.html programs-and-eligibility/
10. KANSAS – Medicaid CHIP Phone: 1-800-701-0710 Phone: 1-800-251-1269
Website: https://www.kancare.ks.gov/ 22. NEW YORK – Medicaid
Phone: 1-800-792-4884 Website: https://www.health.ny.gov/health_care/medicaid/
Phone: 1-800-541-2831
To see if any other states have added a premium assistance program since July 31, 2022, or for more information on special enrollment rights, contact either:
U.S. Department of Labor U.S. Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services 19
www.dol.gov/ agencies/ ebsa www.cms.hhs.gov
1-866-444-EBSA(3272) 1-877-267-2323, Menu Option 4, Ext. 61565
 GLOSSARY

AFFORDABLE CARE ACT AND PATIENT PROTECTION (ACA)

Also called Health Care Reform, the ACA requires health plans to comply with certain requirements. The ACA became law in March 2010. Since then,
the ACA has required some changes to medical coverage—like covering dependent children to age 26, no lifetime limits on medical benefits, reduced FSA
contributions, covering preventive care without cost-sharing, etc, among other requirements.

BRAND NAME DRUG

The original manufacturer’s version of a particular drug. Because the research and development costs that went into developing these drugs are reflected in
the price, brand name drugs cost more than generic drugs.

COINSURANCE
A percentage of costs you pay “out-of-pocket” for covered expenses after you meet the deductible.

COPAYMENT (COPAY)
A fee you have to pay “out-of-pocket” for certain services, such as a doctor’s office visit or prescription drug.

DEDUCTIBLE
The amount you pay “out-of-pocket” before the health plan will start to pay its share of covered expenses.

EMPLOYER CONTRIBUTION
The company provides you with an amount of money that you can apply toward the cost of your health care premiums. The amount of the employer
contribution depends on who you cover. You can see the amount you’ll receive when you enroll. If you’re enrolling as a new hire, the employer contribution
amount will be prorated based on your date of hire.

GENERIC DRUG
Lower-cost alternative to a brand name drug that has the same active ingredients and works the same way.

HIGH-DEDUCTIBLE HEALTH PLANS (HDHP)

High-deductible health plans (HDHPs) are health insurance plans with lower premiums and higher deductibles than traditional health plans. Only those
enrolled in an HDHP are eligible to open and contribute tax-free to a health savings account (HSA).

HEALTH SAVINGS ACCOUNT (HSA)

A health savings account (HSA) is a portable savings account that allows you to set aside money for health care expenses on a tax-free basis. You must be
enrolled in a high-deductible health plan in order to open an HSA. An HSA rolls over from year to year, pays interest, can be invested, and is owned by you—
even if you leave the company.

OUT-OF-POCKET MAXIMUM
The most you pay each year “out-of-pocket” for covered expenses. Once you’ve reached the out-of-pocket maximum, the health plan pays 100% for covered
expenses.

PLAN YEAR
The year for which the benefits you choose during Annual Enrollment remain in effect. If you’re a new employee, your benefits remain in effect for the
remainder of the plan year in which you enroll, and you enroll for the next plan year during the next Annual Enrollment.

PREVENTIVE CARE
Health care services you receive when you are not sick or injured—so that you will stay healthy. These include annual checkups, gender- and age-appropriate
health screenings, well-baby care, and immunizations recommended by the American Medical Association.

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