Benefits Enrollment Guide
October 1, 2018 – September 30, 2019
OVERVIEW ............................................................................................................... 3
IMPORTANT REMINDERS ............…………………..………………….…………………….…..…. 4
ELIGIBILITY AND ENROLLMENT ………………………………………………………………………...…….. 5
MEDICAL INSURANCE ……………………………………………………………………………………….…… 6
HEALTH SAVINGS ACCOUNT (HSA) ……………………………………………………….……..…. 10
HOW TO OPEN AN (HSA) ACCOUNT ……………………………………………………….……..…. 11
HEALTH REIMBURSEMENT ACCOUNT (HRA) ……………………………………………………….……..…. 12
FLEXIBLE SPENDING ACCOUNT (FSA) ..............................…………...……………...…..…… 15
DENTAL INSURANCE ……………………………………………………………………………………...…….. 16
VISION INSURANCE ………………………………………………………………………………....…….….. 17
EMPLOYEE CONTRIBUTIONS ............................................................................................................. 18
DISABILITY ......……………………………………………………………………. ……………….. 19
BASIC LIFE AND AD&D ……………………………………………………………………..…………….…… 20
VOLUNTARY TERM LIFE INSURANCE ................................................................................................... 21
RETIREMENT PLANS .............................................................................. 22
BANKING SERVICES ..................................................................... 23
ADDITIONAL BENEFITS ................................................................................... 24
BENEFITS CONCIERGE ............................................................................................... 26
ADDITIONAL INFORMATION ............................................................................................ 27
REQUIRED NOTICES ............................................................................................. 28
DEFINITIONS ................................................................................................. 37
CONTACT INFORMATION .................................................................................................. 39
TABLE OF CONTENTS
3
OVERVIEW
When it comes to health
insurance, Graham
Windham continues to offer
you choices in a broad
range of benefit areas,
including health care, life
insurance, disability
insurance, dependent care
and much more. This guide
is designed to help you
understand your benefit
enrollment options for the
2018 / 2019 plan year.
Included are summaries of
your plan choices, such as
medical, dental, vision, life
insurance, accidental death
& dismemberment and
retirement options.
We encourage you to use
this guide as a reference
throughout the year. If you
have questions, please
contact Mildred Powers in
our Human Resources
Department.
Core Benefits
Medical:
Oxford Health
• POS
• EPO
• HDHP
Medical; Health Savings
Account: Optum Bank
• HSA
Medical; Health
Reimbursement Arrangement:
The Seneca Group
• HRA
Dental:
Aetna Health Plans
• DMO
• PPO
Vision:
United Healthcare
• PPO
Disability:
Prudential
• Voluntary STD
• Voluntary LTD
Basic Life Insurance:
Prudential
• Voluntary Life Insurance
• Accidental Death and
Dismemberment
Flexible Spending Account:
Benefits Resources, Inc. • Dependent Care FSA
Commuter Benefit Plan:
Benefits Resources, Inc.
• Transit
• Parking
Employee Assistance
Program:
• ComPsych
Retirement Plans: • Mutual of America
Important Note: The purpose of this guide is to
summarize our benefit programs and provide required
notifications. Your specific rights to benefits under the
Plans are governed solely, and in every aspect by the
official Plan Documents and insurance contracts and
not by this guide. If there is any discrepancy between
the description in this guide and the official Plan
Documents, the language of the official Plan
Documents shall take precedent.
Before Enrollment:
Before enrollment begins, take the time to educate yourself on the benefit options that are available to you. Review this
Guide carefully as you consider your plan choices.
If you are electing to cover your dependents on medical, dental or vision benefits, proof of dependent eligibility is required.
If you are enrolling dependent children, a copy of their Birth Certificate is required. To enroll your lawful spouse, a copy of
your Marriage Certificate is required. These documents must accompany your enrollment forms or your dependents will
not be enrolled.
During Enrollment:
You will be required to make your elections during the Benefits Orientation within the first 30 days of employment. If you
do not make elections, then you may not be able to get coverage until the next open enrollment period.
After Enrollment:
Your benefits will be effective on your 90th day of employment.
Medical coverage: If you elect coverage, you will receive an ID card in the mail that you should use for all medical and
prescription services. New ID cards will only be sent when an employee first elects coverage or makes changes to their
current election.
Your ID card contains important information about you, your employer group, and the benefits to which you are entitled.
Always remember to carry your ID card with you, present it when receiving health care services or supplies, and make
sure your provider always has an updated copy of your ID card.
Dental coverage: If you elect coverage, you are required to call Aetna at 877-238-6200 to identify a dentist for you and
your family. Once you are assigned to a dentist, an ID card will be mailed to you.
Vision coverage: If you elect coverage, on or after your 90th day of employment, you can obtain an ID card by logging on
to www.myuhcvision.com.
Note: New hires are not required to provide proof of health status to enroll in any benefits.
General:
The plan year runs from: October 1-September 30
Our plans are administered on a pre-tax basis. Deductions for these plans are taken before taxes and are therefore
reducing your taxable income (and saving money on taxes for that amount). Per IRS regulation, you are only able to make
future changes to your elections during Open Enrollment or if you have a qualifying life event. (Please see definition of
Qualifying Life Events on page 5.) Please choose your benefit elections carefully.
Note: New hires are not required to provide proof of health status to enroll in voluntary life or disability benefits. Existing
employees who choose to elect or add addition coverage will be required to complete a health questionnaire (evidence of
insurability).
4
IMPORTANT REMINDERS
All full time employees scheduled to work 21 hours or more, per week, are eligible for the Health and Welfare
benefits offered by Graham Windham. Eligibility is extended to the qualified dependents of our eligible
employees.
Dependents include the following:
• Any lawful spouse
• Your biological, adopted, step or foster children who has not reached the age of 26
• Dependents who are over age 27, primarily supported by and incapable of self-sustaining employment
by reason of mental or physical handicap.
Changing benefit elections:
As previously mentioned, you are allowed to make changes to your medical, dental, and vision plan choices
during the annual open enrollment period. After the open enrollment period ends, you will not be allowed to
make changes to your elections unless you experience a qualifying event.
Some qualifying events include:
5
ELIGIBILITY AND ENROLLMENT
Life Events
Change in marital status (marriage, death of spouse, legal separation)
Change in number of dependents (birth, death, adoption, eligibility status, child support order)
Change in employment status for you or your spouse (new employment, termination, leave of
absence, full-time to part-time or vice versa)
Special enrollment rights under HIPAA
Medicare coverage
As a Graham Windham employee, you have access to
comprehensive medical coverage which is meant to protect you and
your family from catastrophic medical costs. In this section, you will
find information on these plans. Take the time to understand how
they work, the coverage each provides, and how to use them to best
meet the needs of you and your family.
Oxford Health High POS Plan
The High POS Plan is a network-based program that exclusively
offers access to Oxford's Liberty network of physicians, facilities,
and pharmacies. The plan provides benefits for expenses incurred
both in and out-of-network with no referral requirement. Graham
Windham will reimburse employees enrolled in the High POS Plan
half of the in-network deductible. After members meet the first half of
their deductible, Graham Windham will reimburse the second half
through the HRA (Seneca).
Oxford Health Middle EPO Plan
The Middle EPO Plan is a network-based program that exclusively
offers access to Oxford's Liberty network of physicians, facilities,
and pharmacies. The plan provides benefits for expenses incurred
in-network with no referral requirement. Graham Windham will
reimburse employees enrolled in the Middle EPO Plan half of the in-
network deductible. After members meet the first half of their
deductible, Graham Windham will reimburse the second half through
the HRA (Seneca).
Oxford Health Base High Deductible Health Plan (HDHP)
The Base HDHP Plan is a network-based program that exclusively
offers access to Oxford's Liberty network of physicians, facilities,
and pharmacies. The plan provides benefits for expenses incurred
in-network with no referral requirement. Members who enroll in the
High Deductible Health Plan are offered the opportunity to set aside
pre-tax funds into a Health Savings Account (HSA). These accounts
are individually owned by each employee and can be carried over in
the event of termination of employment from Graham Windham.
6
MEDICAL INSURANCE
Important Terms
to Understand
Deductible:
The amount you pay for covered services before
the plan begins to pay benefits. Once a covered
family member reaches the individual deductible,
he or she will have satisfied their deductible
requirement for the plan year.
Coinsurance:
The percentage of covered medical expenses that
you are required to pay after you meet your
deductible. After you pay your coinsurance, the
plan pays the remainder of
the covered expense.
Annual Out of Pocket Maximum:
The most you have to pay for covered medical care
in a calendar year (excluding copays). Once a
covered family member reaches the individual out-
of-pocket maximum, his or her eligible expenses
are covered in full for the rest of the calendar year.
Deductible and Out of Pocket Maximums reset every plan year, on October 1st. Graham Windham employees enrolled in this plan will be
responsible for the first 50% of the deductible [($1,000 (Individual)/ $2,000 (Family)] for in-network services, then Graham Windham will
reimburse the second 50% of the deductible through the HRA. Out-of-network deductibles do not qualify for reimbursement.
7
MEDICAL INSURANCE
Oxford Health High POS Plan
In Network Out of Network
Annual Deductible*
Individual / Family
$2,000 / $4,000 $4,000 / $8,000
Annual Out-of-pocket Maximum*
Individual / Family
$4,000 / $8,000 $8,000 / $16,000
Coinsurance 10% 30%
Office Visit Copay PCP / Specialist $30 / $50
Subject to
Deductible &
Coinsurance
Preventive Care / Well Women Care/Routine Physicals
(For both Adult and Children)
Covered in Full
Lab, X-Ray or Other Preventive Tests Covered in Full
Major Diagnostics CT, MRI, PET Scans and Nuclear Medicine Out Patient
Subject to
Deductible &
Coinsurance
Emergency Room
Subject to
Deductible &
Coinsurance
Hospital Inpatient
Subject to
Deductible &
Coinsurance
Urgent Care Facility $50 copay
Mental Health Inpatient
Subject to
Deductible &
Coinsurance
Mental Health Outpatient $50 Copay
Retail Prescription Benefits
Deductible
Individual / Family
$100 / $200 Per
Member
(Waived for Tier 1
medications)
Covered at
Participating
Pharmacies Only
Generic (Tier 1) $15 copay
Preferred-Brand (Tier 2) $35 copay
Non-Preferred Brand (Tier 3) $75 copay
Mail Order Prescription Benefits (90 Day Supply)
Generic (Tier 1)
$37.50 copay
Covered at
Participating
Pharmacies Only
Preferred-Brand (Tier 2)
$87.50 copay
Non-Preferred Brand (Tier 3)
$187.50 copay
Deductible and Out of Pocket Maximums reset every plan year, on October 1st.
Graham Windham employees enrolled in this plan will be responsible for the first 50% of the deductible [($1,250
(Individual)/ $2,500 (Family)], then Graham Windham will reimburse the second 50% of the deductible through the HRA.
8
MEDICAL INSURANCE
Oxford Middle EPO (In-Network Benefits Only)
In Network
Annual Deductible
Individual / Family
$2,500 / $5,000
Annual Out-of-pocket Maximum
Individual / Family
$6,350 / $12,700
Coinsurance 40%
Office Visit Copay PCP / Specialist
$30 / $50
Preventive Care / Well-women Care Routine Physical Exams / Immunizations
(Adult and Child)
Covered in Full
Lab, X-Ray or Other Preventive Tests Covered at 100%
Major Diagnostics
CT, MRI, PET Scans and Nuclear Medicine Out Patient
Subject to Deductible & Coinsurance
Emergency Room $200 Copay
Hospital-Inpatient Subject to Deductible & Coinsurance
Urgent Care Facility $50 copay
Mental Health Inpatient Subject to Deductible & Coinsurance
Mental Health Outpatient $50 copay
Retail Prescription Benefits (31 Day Supply)
Deductible
Individual / Family
$100 Per Member
(Waived for Tier 1 medications)
Generic (Tier 1) $15
Preferred-Brand (Tier 2) $35
Non-Preferred Brand (Tier 3) $75
Mail Order Prescription Benefits (90 Day Supply)
Generic (Tier 1) $37.50
Preferred Brand (Tier 2) $87.50
Non-Preferred Brand (Tier 3) $187.50
*Once you have fulfilled your portion of the deductible, it is your
responsibility to submit any claims that have deductible exposure to
The Seneca Group HRA for payment.
Deductible and Out of Pocket Maximums reset every plan year, on October 1st.
Members who enroll in the High Deductible Health Plan are offered the opportunity to set aside pre-tax funds
into a Health Savings Account (HSA). The organization will be offering an annual contribution in the amount of
$750 (Employee Only) and $1,500 (Family) for those employees who elect to enroll in the HDHP.
9
MEDICAL INSURANCE
Oxford Base HDHP (In-Network Benefits Only)
In Network
Annual Deductible
Individual / Family
$2,850 / $5,700
Annual Out-of-pocket Maximum
Individual / Family
$4,000 / $8,000
Coinsurance 10%
Office Visit Copay PCP / Specialist
Subject to Deductible & Coinsurance
Preventive Care / Well-women Care Routine Physical Exams / Immunizations
(Adult and Child)
Covered in Full
Lab, X-Ray or Other Preventive Tests
Subject to Deductible & Coinsurance
Major Diagnostics
CT, MRI, PET Scans and Nuclear Medicine Out Patient
Emergency Room
Hospital-Inpatient
Urgent Care Facility
Mental Health Inpatient
Mental Health Outpatient
Retail Prescription Benefits (31 Day Supply)
Deductible
Individual / Family
Subject to Medical Plan Deductible
(Waived for Tier 1 medications)
Generic (Tier 1) $15
Preferred-Brand (Tier 2) $35
Non-Preferred Brand (Tier 3) $75
Mail Order Prescription Benefits (90 Day Supply)
Generic (Tier 1) $37.50
Preferred Brand (Tier 2) $87.50
Non-Preferred Brand (Tier 3) $187.50
A Health Savings Account (HSA) allows members to put money aside to pay for current and future qualified medical
expenses using pre-tax dollars. An HSA allows dollars to “roll over” annually. In addition, your HSA provides a triple tax
savings: contributions are pre-tax, balances grow tax free and all withdrawals for qualified expenses are tax free. Optum
Health Bank is the administrator for the HSA.
Eligibility Requirements
• Must be enrolled in the High Deductible Health Plan (HDHP)
• Must not be enrolled in or entitled to Medicare, Tricare of VA benefits (in the past 3 months)
• Must not be covered by any other non-HDHP qualified medical insurance plans
• Spouse not contributing to/participating in a general-purpose FSA through his / her employer
• You must not be claimed as a dependent on another person’s tax return
Maximum Pre-Tax Contributions to an HSA
For 2018:
• Individual: $3,450 (minus any employer contributions)
• Family: $6,900 (minus any employer contributions)
For 2019:
• Individual: $3,500 (minus any employer contributions)
• Family: $7,000 (minus any employer contributions)
• If you are over the age of 55, you can contribute an additional $1,000
Employer Contributions
• Once you enroll in the HDHP medical plan and open an HSA, Graham Windham will make an annual employer
contribution to your account in the amount of $750 for an individual and $1,500 for a family.
• An initial funding of $225 (Employee Only) / $450 (Family) will be deposited into employees’ HSA within 2 weeks of
opening the account, as long as the account is open prior to December 31st, 2018. Three additional employer
contributions of $175 (Employee Only) / $350 (Family) each will be deposited in the HSA throughout the year on the
following dates: March 31st, June 30th, and September 30th.
HSA Benefits
• HSAs may be used to pay for all eligible medical, dental and vision expenses.
• Any contributions made to an HSA roll over from year to year.
• Unlike the FSA, you never lose the money you contribute to your HSA account.
• The funds are yours and can be taken with you, regardless of your employer.
• Deposits into the account can be made through regular or lump-sum payroll contributions.
• Once your HSA balance reaches a certain threshold, you can invest any amounts in excess.
• Easy access to funds with an HSA debit card.
10
HEALTH SAVINGS ACCOUNT (HSA) OVERVIEW
To start saving in an HSA, you must first enroll in the HDHP and open an HSA through Optum Bank.
Remember that Graham Windham is contributing to your HSA, but you will first need to open the
account to collect the employer contributions.
How to Enroll:
• Go to www.optumbank.com and click on the “Open An HSA” link in the top right corner. This
will open a new window in your browser. Once you have read through the enrollment site
information, click “Next” on the bottom of your screen.
• Complete all of the required Account Holder Information. Enter the group number where
asked: GW5658
• In order to open an account, you will be required to complete the online application, agree to
accept Optum Bank’s terms and conditions and provide an electronic signature.
• Follow the directions to enroll and open an account. Be sure to have your HDHP
information handy.
• An enrollment kit will be sent to you within 10 business days of the account opening.
New Account Holder Checklist
Use this list to make sure you have taken all the first steps to opening and funding your HSA. If
you have questions about aspects of managing your account, visit www.optumbank.com.
Open your account.
Record your account number and file it in a safe place.
Register online at optumbank.com for online banking.
Designate a beneficiary for your account. Log in to optumbank.com and select “Beneficiary
Designation” from the “Forms and Information” section.
Start saving so you can pay for, or be reimbursed for, qualified medical expenses.
Activate your Optum Bank Health Savings Account Debit MasterCard.
Review your privacy notice included in your welcome kit.
Become familiar with qualified expenses.
Review how to use optumbank.com to pay bills or be reimbursed for qualified expenses paid
out-of-pocket.
Save all receipts for qualified medical expenses.
11
HOW TO OPEN AN (HSA) ACCOUNT
The Seneca Group
What is a Health Reimbursement Arrangement (HRA)?
A Health Reimbursement Arrangement (HRA) is an IRS approved, tax-advantaged benefit that reimburses
employees for certain in-network out-of-pocket medical expenses. This is paid for by Graham Windham and is
meant to coordinate with the medical plan to provide payment to offset certain medical expenses. All members
enrolled in the medical plan through Oxford are enrolled in the HRA program.
Graham Windham will reimburse members, through the HRA, for unreimbursed deductible and coinsurance
expenses once each member pays the first 50% of the total deductible exposure. The amount you will be
responsible for is as follows:
• Single: $1,000 (High POS Plan) / $1,250 (Middle EPO Plan)
• Family: $2,000 (High POS Plan) / $2,500 (Middle EPO Plan)
Once you have met the first 50% of the plan deductible, as noted above, you will be eligible to be reimbursed
for the remainder of the deductible and coinsurance (to the coinsurance maximum) associated with the
medical plan you choose. The details follow:
12
A HEALTH REIMBURSEMENT ARRANGEMENT
(HRA)
EPO Plan
Medical Plan Benefit
Oxford
In-Network Benefit
Graham Windham /
Seneca Group
Reimburses
You Pay
PCP Office Visit $30 $0 $30
Specialist Visit $50 $0 $50
Emergency Room Copay $200 $0 $200
Individual Deductible (In-Network) $2,500 $1,250 $1,250
Family Deductible (In-Network) $5,000 $2,500 $2,500
Preventive Care Covered in Full $0 $0
Diagnostic Laboratory
(at a participating location)
$0 $0 $0
Prescription Drug Deductible
(Per Member; Waived for Tier 1)
$100 $0 $100 Per Member
Prescription Drug Copays $15 / $35 / $75 $0 $15 / $35 / $75
*For HRA reimbursements, please note that you do need to submit the EOB and provider invoice to Seneca Group
for reimbursement.
How do you receive the HRA reimbursement?
Once the claim has been adjudicated by Oxford, an Explanation of Benefits will be received in the mail. This
document will highlight how much Oxford paid of the claim and what your responsibility, as the insured, is. In
similar time, you should receive an invoice from your provider or facility.
Once both the EOB and the invoice from the provider have been received, you must submit both of those
along with the HRA Reimbursement Form to the Seneca Group. The Seneca Group will then process your
request and will pay any reimbursable charges directly to the facility / provider. You will be responsible for
your portion (if applicable).
13
A HEALTH REIMBURSEMENT ARRANGEMENT
(HRA)
PPO Plan
Medical Plan Benefit
Oxford
In-Network
Benefit
Graham
Windham /
Seneca Group
Reimburses*
You Pay
Oxford
Out-of-Network
Benefit**
PCP Office Visit $30 $0 $30
Subject to Out-of-
Network
Deductible &
Coinsurance
Specialist Visit $50 $0 $35
Individual Deductible (In-Network) $2,000 $1,000 $1,000 $4,000
Family Deductible (In-Network) $4,000 $2,000 $2,000 $8,000
Preventive Care Covered in Full $0 $0
Subject to Out-of-
Network
Deductible &
Coinsurance
Diagnostic Laboratory (at a
participating location)
Covered in Full $0 $0
Prescription Drug Deductible (Per
Member; Waived for Tier 1)
$100 $0 $100 Per Member
N/A (In-Network
Benefit Only)
Prescription Drug Copays $15 / $35 / $75 $0 $15 / $35 / $75
*For HRA reimbursements, please note that you do need to submit the EOB and provider invoice to Seneca Group for
reimbursement.
**Please note that if you choose to use Out-of-Network benefits, you are responsible for all Out of Network costs. The
HRA does not reimburse for Out-of-Network expenses.
How to submit a claim:
Once you have incurred a claim that is subject to the In-Network Deductible and/or coinsurance and
Oxford has processed the claim, you will receive an Explanation of Benefits (EOB) from Oxford. You
will also receive an invoice from the provider. In order to submit the claim to The Seneca Group,
follow the below steps.
Submit the EOB, Provider Invoice and the Seneca Group Reimbursement Form to Seneca Group.
Claims can be submitted via mail, email, or fax to:
Mail: The Seneca Group
PO Box 1043
Matthews, NC 28106
Fax: (866) 223-6521
Email: Service@thesenecagroup.com
Seneca Group will issue a check directly to the provider for the applicable reimbursement.
Members have 90 days after the plan year ends (12/31/2019) to submit claims from the 2018 / 2019
plan year, for reimbursement. After that date, no reimbursements for the prior plan year will be
administered. Now is a good time to submit claims for the current plan year. All claims for the 2017 /
2018 plan year must be submitted no later than 12/31/2018 for consideration.
Please Note: It is your responsibility to submit any deductible/coinsurance expenses to Seneca
Group for reimbursement.
14
A HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
Dependent Care FSAs
A Dependent Care FSA can be used to reimburse dependent care expenses for a qualified person that enable
you to be gainfully employed and, if married, enable your spouse to be gainfully employed, look for work or
attend school full-time. The qualified person must spend at least 8 hours per day in your home and is one of
the following:
• A dependent child under the age of 13 and for whom you can claim a tax exemption
• A spouse or dependent who is physically or mentally incapable of self-cate, has the same principal place
of abode as you for more than half of the year, and for whom you can claim an exemption
Once enrolled, you may access your FSA via the BRI website provides access 24/7 for account activity, forms,
plan documentation and much more. You can access the website at www.BenefitResource.com and log in as
follows:
Company Code: graham
Login ID: Default Login ID (typically the Social Security Number (SSN) or Employee ID) is selected and
provided by Graham. You may change this upon initial login.
Password: Default Password is set to your 5-digit home zip code. You will be prompted to change this
password upon initial login.
You may elect to defer up to $5,000 of your salary into a dependent care FSA per household. If you are a
highly compensated employee (HCE), defined by the IRS as an employee with annual compensation greater
than $120,000, your election will be capped at $3,600 and may be reduced during the year, if necessary, to
ensure that the plan passes required discrimination testing. The amount available for reimbursement for
dependent care expenses is limited to the cash balance in your Dependent Care FSA. Elections cannot be
changed during the year unless you have a “qualified change in family status.”
Please note that for expenses to qualify for reimbursement, both you and your spouse (if applicable) must be working,
looking for work or attending school full-time during the period for which you are requesting reimbursement.
15
FLEXIBLE SPENDING ACCOUNTS
Good dental health is important to your overall
well-being. At the same time, we all need different
levels of dental treatment. It is for this reason that
Graham Windham is offering eligible employees a
comprehensive dental plan through Aetna.
Aetna PPO Plan
The Aetna Dental PPO Plan offers a balance of
savings and choice. This plan gives participants the
freedom to receive care from participating Aetna
providers or to visit any dentist of their choice outside
of the network. The Aetna Dental PPO Plan puts into
action two strengths:
1) managing a network that focuses on patient
satisfaction and savings and
2) fast, accurate claims processing
Aetna DMO Plan
The Aetna Dental DMO Plan only offers In-Network
Benefits only. Employees have the ability to switch
plans within Aetna month to month.
16
DENTAL INSURANCE
Plan
Details
PPO Plan DMO Plan
In Network Out of Network In Network Benefits Only
Annual Deductible
(Single / Family)
$50 / $150
None
Calendar Year Maximum $2,000
None
Class I Preventative &
Diagnostic
100%, no deductible
100%
Class II Basic
Restorative Care
80% after deductible 80% after deductible
100%
Class III Major
Restorative Care
50% after deductible 50% after deductible
50%
Class IV Orthodontia
$50 deductible
$1,000 lifetime
maximum
$50 deductible
$1,000 lifetime
maximum
50%
Participation in United Healthcare Vision is also available to all eligible associates. United Healthcare offers
vision benefits through a large national network of providers. You can select to use a UHC participating
provider or select an out of network facility.
17
VISION INSURANCE
Benefit
Frequency
(based on your last
date of service)
In Network
Copay
Out of Network Provider
Exam 12 months
$10 Reimbursed up to $40
Lenses 12 months
Covered in full after
copay
Reimbursed up to $40 / single vision
Reimbursed up to $60 / bifocal
Reimbursed up to $80 / trifocal & standard
lenticular
Frames 24 months
Up to $130 retail
allowance
Reimbursed up to $45
Eye Exam
Covered in full after
copay
Reimbursed up to $40
Contact Lenses (necessary)
Covered in full after
copay
Reimbursed up to $210
Elective Contact Lenses
Up to $105 (copay does
not apply)
Reimbursed up to $105
18
EMPLOYEE CONTRIBUTIONS
Aetna Dental Bi-Weekly Contributions
DMO PPO
Single:
$2.50 $2.50
Employee + 1:
$6.00 $6.00
Family:
$8.00 $8.00
United Health Care Vision Monthly Contributions
Single:
$5.18
Employee + Spouse:
$9.55
Employee + Child(ren):
$10.00
Family:
$14.97
Oxford Medical Bi-Weekly Contributions
Salary Band High POS Plan Middle EPO Plan Base HDHP
< $35,000
Employee
$78.22 $20.31 $8.00
Family
$200.78 $60.54 $20.81
$35,001 - $44,999
Employee
$81.07 $24.31 $12.80
Family
$207.79 $70.83 $33.29
$45,000 - $69,999
Employee
$104.18 $40.38 $27.21
Family
$255.28 $106.32 $66.58
$70,000 - $89,999
Employee
$122.51 $59.39 $48.01
Family
$313.66 $161.50 $124.83
$90,000 - $119,999
Employee
$128.54 $71.74 $64.02
Family
$352.58 $200.14 $166.44
>$120,000
Employee $134.96 $84.21 $80.02
Family $370.21 $232.82 $208.05
Graham Windham offers both a short term and long term disability benefit through Prudential. This benefit
provides an income in the event you become disabled due to an injury or illness that is not work-related.
Voluntary Short Term Disability Benefit Highlights
Consider what would happen financially if you became disabled and could no longer work due to an injury or
illness. It’s likely that it would be a financial challenge to replace enough income to meet your monthly
expenses. That’s why Graham Windham provides Voluntary Short-Term Disability (STD) benefits to eligible
employees who are absent from work due to substantiated disabilities.
19
DISABILITY
Voluntary Long Term Disability Benefit Highlights
With Voluntary Long Term Disability (LTD) coverage provided by Graham Windham, you can receive a benefit
equal to 60% of your monthly salary in the event you are unable to work due to a non-work-related injury or
illness. With LTD there is a 180-day elimination period. Graham Windham’s LTD coverage has a monthly
maximum benefit of $7,500.
STD Coverage Type STD Benefits
Short-Term Disability
(STD)
• Available to all full-time and part-time staff working 21 hours or more a week
• Offered on a voluntary basis; you are responsible for the full cost of this coverage
• STD benefits is calculated at 60% of your pre-disability earnings to a maximum weekly
benefit of $1,500 with a 25-week maximum period of payment
• There is a 15 day elimination period for accident or sickness
LTD Coverage Type LTD Benefits
Long-Term Disability (LTD)
• Available to all full-time and part-time staff working 30 hours or more a week
• Offered on a voluntary basis; you are responsible for the full cost of this coverage
• 180 day elimination period
• LTD benefit is calculated at 60% of your monthly pre-disability earnings up to a
maximum of $7,500 monthly
No one likes to think about illness and not being able to
provide for their family in the same manner that they do
today. That includes day-to-day expenses as well as future
goals like a college education. But sometimes death or
disability does happen, and you’ll want to ensure your
family’s lives and dreams can move forward – even if the
worst happens. Please remember to input your beneficiary
information for all life and accidental death and
dismemberment (AD&D) insurance coverage areas into
ADP. You are able to update your beneficiary information at
any time throughout the year.
Basic Life Insurance
Graham Windham provides eligible employees with Basic
Term Life Insurance at no cost to you. This coverage is equal
to one and a half times your salary with a maximum
coverage of $300,000. This benefit is available to all non-
union full-time and part-time staff working 21 hours or more a
week. Additionally, benefits for accidental death or
dismemberment will be paid up to $300,000. Premiums are
paid entirely by Graham Windham; coverage is provided at
no cost to you.
20
BASIC TERM LIFE INSURANCE AND AD&D
(ACCIDENTAL DEATH & DISMEMBERMENT)
Basic Life
1.5x your salary, up to a maximum coverage of $300,000
Basic Accidental Death
and Dismemberment
Matches Basic Life coverage
For your spouse
Not eligible
For your child(ren)
Not eligible
This benefit is available to a full-time and part-time staff working 21 hours or more a week. Provided through
Prudential and offered on a voluntary basis; you are responsible for the full cost of this coverage. You may
elect up to 7 times your annual earning up to a maximum of $500,000, coverage terminates at age 65.
Voluntary Spousal Life is available for 50% of employee coverage to a maximum of $100,000. Voluntary Child
Life [for children age 14 days to 19 years; 25 is full time student] is available in increments of $1,000 up to a
max of $10,000. Coverage limits are based on age of child.
21
VOLUNTARY TERM LIFE INSURANCE
Thrift Savings Plan
You can contribute any percentage of your salary provided that you do not contribute more than the maximum
permitted by law. The maximum contribution permitted by the Internal Revenue Code is $18,500 for 2018.
Additionally, if you have attained age 50, you are eligible to make an additional catch-up contribution of $6,000
in 2018. As a savings incentive, Graham Windham will make a matching contribution on your behalf equal to
the lesser of 50% of the salary reduction amount you are contributing during the plan year or 1% of your
Compensation received during the plan year. If you are a full-time or part-time employee but are not yet eligible
for the pension plan, and would like to enroll in the Thrift Plan, you may do so; however you will only qualify for
the Graham Windham matching contribution when you have met all of the pension plan eligibility requirements.
The investment options in this plan are identical to those for the pension plan.
Vesting Cycle:
• 20% vested after two years of employment
• 60% vested after three years of employment
• 80% vested after four years of employment
• 100% vested after five years of employment
22
RETIREMENT PLANS
Employee Contribution None
Graham Windham Contribution Amount equal to 5.75% of compensation
Vesting Cycle
20% vested after two years of employment
60% vested after three years of employment
80% vested after four years of employment
100% vested after five years of employment
Investment Options
36 investment options available: stocks, bonds, money market, balanced,
global, etc.
Eligibility Requirements
• 21 years of age
• Full time employment (part-time and seasonal must work at least 1,000
hours in a calendar year to become eligible)
• One year waiting period (may be waived if you have completed one
year on non-profit work experience within the past three years)
Date Eligible First day of the month after meeting the eligibility requirement
Pension Plan
Graham Windham provides, at no cost to you, a Defined Contribution Pension Plan (401A) for all non-union
full-time, part-time and seasonal employees who work at least 1,000 hours per year. Mutual of America offers
36 investment vehicles to provide for high diversification and flexibility. Upon your retirement, you may
purchase an annuity to ensure a lifetime monthly income, withdraw the entire accumulation in a lump sum or
choose a pay-out option. For specific questions regarding your account with Mutual of America, please email
nyc@mutualofamerica.com or call (212) 587-9045.
Direct Deposit
You may have some or all of your paycheck directly deposited into your already established checking, savings,
or money market account in the bank or credit union to which you belong. This “wire transfer” system is safe
and convenient, and it may save you important time each day.
Credit Union—Municipal Credit Union
You are eligible for membership in the Municipal Credit Union, one of the oldest and largest credit unions in the
United States. You may open an account at any time during your employment.
Joining MCU is Easy
• Applying Online: go to www.nymcu.org to apply OR
• Apply in Person: visit one of the MCU branches during their operating hours and bring the
following:
1. Your Graham ID
2. Federal and/or State Issued ID
3. Proof of Address Bearing your Name (e.g. utility bill, credit card bill) dated within the last
30 days
• Apply by Phone: Call 1-866-JOIN-MCU
The following is a brief list of additional products and services:
23
BANKING SERVICES
• Checking/Savings Accounts
• Money Market Accounts
• CDs
• IRAs
• Online Banking
• Vacation clubs
• Auto Loans
• Credit Cards
• Mortgages
• Personal Loans
• Convenient ATMs
24
ADDITIONAL BENEFITS
Graham Windham is proud to offer several additional benefits at no cost to you. The following benefits are in
place to help make your life easier and less stressful.
Employee Assistance Program (EAP)
Your Employee Assistance Program (EAP) is offered through GuidanceResources. Employee assistance
services are designed to help with the pressures of everyday life. At no cost to you, the EAP provides an
opportunity to talk with counselors face-to-face or by telephone about personal concerns such as stress,
anxiety, depression, couples’ issues, and substance use or abuse 24 hours a day, seven days a week. The
EAP also offers free confidential telephone consultation and referral services for career issues, child care,
elder care, legal, financial, fitness and nutritional concerns. When a legal issue arises, our attorneys are
available to provide confidential support. If you require representations, you can also be referred to a qualified
attorney in your area for a free 30-minute consultation with a 25% reduction in customary legal fees thereafter.
Note: The EAP is strictly confidential. Because of privacy laws, Graham Windham does not have access to
information about who uses the EAP.
• Call: 800-311-4327
• TDD: 800-697-0353
• Website:
guidanceresources.com
• Web ID: GEN311
If you need help using GuidanceResources Online, email:
25
ADDITIONAL BENEFITS
Commuter Benefit Plan (CBP)
Through Graham Windham we offer a Commuter Benefit Plan (CBP) through third party administrator Benefit
Resource, Inc. (BRI). This is a tax free account for workplace commuting expenses (including mass transit
and parking expenses / excluding taxis, tolls and fuel). You can elect to contribute up to $260 per month for
mass transit expenses and up to $260 per month for parking expenses. BRI will issue employees a Beniversal
Card which will store your payroll deductible mass transit funds.
To claim reimbursement for a parking or vanpool expense, you can log onto benefitresource.com and submit
your claims online. You may also send your claim by fax or regular mail. At this time, receipts for parking
expenses are not required to be submitted to BRI for Parking Reimbursement claims only.
At this time, Mass Transit Commuter Expense Reimbursements can not be transferred to another account. If
you would like to pay with your Mass Transit expenses with your CBP funds, you must use the BRI eTRAC
MasterCard.
To make any changes to your CBP Account, please contact Mildred Powers
(
powersm@graham-windham.com).
You do not need to elect this benefit during Open Enrollment. You can participate in the Commuter Benefit
Plan by enrolling with Graham Windham at any time.
26
BENEFITS CONCIERGE
As an employee participating in Graham
Windham's Benefit Plans, you have access to
NFP's Benefit Concierge Team. They provide a
one-stop contact center for answering your
benefit plan questions and help resolve benefit
claim issues.
Answers At Your Fingertips!
Your dedicated Benefits Concierge
representatives are here to assist with regard
to all the benefits your company provides. For
example: medical, dental, vision, life, disability
and COBRA.
Areas We Can Help
• Benefits Questions
• ID Card Issues
• Bills/Claims Resolutions
• Prescription Network Questions
• And Much More!
Contact Us
For personal service that is confidential and
responsive, call 877-835-1361 or email
Business Hours: 9 a.m.—5 p.m. Eastern Time.
27
ADDITIONAL INFORMATION
Affordable Care Act (ACA) - Frequently Asked Questions
Employees Eligible for the Company-Sponsored Medical Plan
Q. What is the Affordable Care Act?
A. The Patient Protection and Affordable Care Act, commonly called the Affordable Care Act (ACA) is a
United States federal statute signed into law by President Obama in March 2010.
The ACA includes subsidies, health insurance exchanges, and mandates, including an individual mandate
that, with certain exceptions, requires all individuals beginning January 1, 2014 to have health insurance or pay
a penalty. The law includes subsidies to help individuals with low incomes comply with the mandate.
Coverage through the health insurance exchange is guaranteed; even if you have a pre-existing medical
condition, your cost for coverage will be the same as all other applicants of the same age living in the same
geographic location.
Q. Who is required to have health insurance?
A. Beginning January 1, 2014, all Americans – with some exceptions – are required to have medical
insurance coverage or incur a penalty. Qualified health insurance plans that meet the ACA requirements may
include:
• Government-sponsored plans, such as:
– Medicare or Medicaid
– Children’s Health Insurance Program (CHIP)
– TRICARE
– Veterans health care programs
• Employer-based or sponsored health care plans- the Transamerica Limited Benefit Hospital Indemnity
Insurance is NOT considered qualified health insurance
• Individual private coverage
Q. Will the Company continue to offer medical coverage in 2018 / 2019?
A. Yes, we will continue to offer medical coverage to eligible employees and their eligible family members in
2018 / 2019.
Q. What is the health insurance exchange?
A. The health insurance exchange, sometimes called the Exchange or Marketplace, is a resource where
individuals can learn about private health coverage options, compare private health insurance plans, and enroll
in private health insurance coverage. The health insurance exchange also provides information on programs
that help individuals with low to moderate incomes, and resources to pay for private health insurance
coverage.
You can get help online at www.healthcare.gov, or call 1-800-318-2596, 24 hours a day, 7 days a week.
28
REQUIRED NOTICES
Newborns’ and Mothers’ Health Protection Act
Under federal law, health care plans may not restrict any hospital length of stay in connection with childbirth for
the mother or newborn child to less than 48 hours following a normal delivery, or less than 96 hours following a
Cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending
provider, after consulting with the mother and with the mother’s consent, from discharging the mother or her
newborn earlier than 48 hours (or 96 hours as applicable).
Continued Coverage Under COBRA
Under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), you and your covered
dependents may be able to continue your medical and dental coverage if you lose your health care coverage
as the result of certain qualifying events. Contact the Human Resources Department for more information.
Women’s Health and Cancer Rights Act of 1998
Under the Women’s Health and Cancer Rights Act, group health plans must make certain benefits available to
participants of health plans who have undergone a mastectomy. In particular, a plan must offer mastectomy
patients benefits for:
• Reconstruction of the breast on which the mastectomy was performed
• Any necessary surgery and reconstruction of the other breast to produce a symmetrical appearance
• Prostheses
• Treatment of physical conditions related to the mastectomy, including lymphedema.
Our medical plans comply with these requirements. Benefits for these items are similar to those provided under
the plan for similar types of medical services and supplies.
HIPAA Regulations Help to Protect Your Privacy
The privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) help to
ensure that your health care-related information stays private. New employees will receive a Privacy Practice
Notice which outlines the ways in which the medical plan may use and disclose protected health information
(PHI). The notice also describes your rights. For more information, contact the Human Resources Department.
Your Rights under Michelle’s Law
Effective January 1, 2010, full-time students covered under the group health plan, that would otherwise lose
eligibility under the plan because of a reduction in their full-time class status due to a medically necessary
leave of absence from school, may be eligible to extend their coverage under the plan for up to one year, or to
age 26, whichever occurs first. The child must be a dependent child of a plan participant and be enrolled in the
company group health plan on the basis of being a student at a postsecondary educational institution
immediately before the first day of the leave.
29
REQUIRED NOTICES
Mental Health Parity
Effective January 1, 2010, the Company sponsored medical plans were modified to cover mental health and
substance abuse expenses subject to the same treatment limits, deductibles, copayments, co-insurance and
out-of-pocket requirements that apply to other medical and surgical expenses. This change applies to both
inpatient and outpatient services.
Creditable Coverage Disclosure Notice
If you are Medicare-eligible, there are two important things you need to know about your current coverage and
Medicare’s prescription drug coverage. First, 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. Second, it was determined that the
prescription drug coverage offered by Express Scripts is, 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. If you are considering joining
Medicare’s prescription drug coverage, 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. For more information about Medicare’s prescription drug coverage please visit:
www.medicare.gov.
Children’s Health Insurance Program Reauthorization Act of 2009 (CHIP)
Signed into expand state CHIP eligibility to more children and expectant mothers with an extended 60-day time
frame to coordinate any changes to employer health elections in the event of gain or loss of eligibility and/or a
subsidy under Medicaid or CHIP.
Uniformed Services Employment and Reemployment Rights Act (USERRA)
USERRA protects the job rights of individuals who voluntarily or involuntarily leave employment positions to
undertake military service or certain types of service in the National Disaster Medical System. USERRA also
prohibits employers from discriminating against past and present members of the uniformed services, and
applicants to the uniformed services. The Act also states that if an employee leaves their job to perform military
service, they have the right to elect to continue existing employer-based health plan coverage for the employee
and their eligible dependents for up to 24 months while in the military. Even if the employee doesn’t elect to
continue coverage during their military service, they have the right to be reinstated in their employer’s health
plan when they are reemployed, generally without any waiting periods or exclusions (e.g. pre-existing condition
exclusions) except for service-connected illnesses or injuries.
30
REQUIRED NOTICES
Notice of HIPAA 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 and 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 new dependent as a result of marriage, birth, adoption, or placement for adoption,
you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days
after the marriage, birth, adoption, or placement for adoption.
To request special enrollment or obtain more information, contact Human Resources at (508) 999-9920.
Termination of Health Coverage for Cause, Including Fraud or Intentional Misrepresentation
P.A.C.E. reserves the right to terminate health care coverage for you and/or your dependent prospectively
without notice for cause (as determined by the Plan Administrator), or if you and/or your dependent are
otherwise determined to be ineligible for coverage under the plan. In addition, if you or your covered dependent
commits fraud or intentional misrepresentation in an application for health coverage under the plan, in
connection with a benefit claim or appeal, or in response to any request for information by P.A.C.E. or it’s
delegees (including the Plan Administrator or a claims administrator), the Plan Administrator may terminate
your coverage retroactively upon 30-days’ notice.
Failure to inform any of such persons that you or your dependents are covered under another group health
plan or knowingly providing false information in order to obtain or continue coverage for an eligible dependent
are examples of actions that constitute fraud under the plan.
31
FLSA / EXCHANGE NOTICE
32
FLSA / EXCHANGE NOTICE
33
FLSA / EXCHANGE NOTICE
34
MEDICAID / CHIP CONTACT INFORMATION
State Plan
Phone / Website
Alabama Medicaid
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: CustomerService@MyAKHIPP.com
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
Medicaid Website: http://www.colorado.gov/hcpf
Medicaid Customer Contact Center: 1-800-221-3943
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
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
Louisiana Medicaid
Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331
Phone: 1-888-695-2447
Maine Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-
assistance/index.html
Phone: 1-800-442-6003
TTY: Maine relay 711
Massachusetts
Medicaid /
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
Missouri Medicaid
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: 573-751-2005
35
MEDICAID / CHIP CONTACT INFORMATION
State Plan
Phone / Website
Montana Medicaid
Website:
http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
Phone: 1-800-694-3084
Nebraska Medicaid
Website:
http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pag
es/accessnebraska_index.aspx
Phone: 1-855-632-7633
Nevada Medicaid
Medicaid Website: http://dwss.nv.gov/
Medicaid 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 /
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
New York 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 /
CHIP
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
Oregon
Medicaid /
CHIP
Website: http://healthcare.oregon.gov/Pages/index.aspx
http://www.oregonhealthcare.gov/index-es.html
Phone: 1-800-699-9075
Pennsylvania Medicaid
Website: http://www.dhs.pa.gov/hipp
Phone: 1-800-692-7462
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
Website: http://dss.sd.gov
Phone: 1-888-828-0059
Texas Medicaid
Website: http://gethipptexas.com/
Phone: 1-800-440-0493
Utah
Medicaid /
CHIP
Website:
Medicaid: http://health.utah.gov/medicaid
CHIP: http://health.utah.gov/chip
Phone: 1-877-543-7669
Vermont Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
36
MEDICAID / CHIP CONTACT INFORMATION
State Plan
Phone / Website
Virginia
Medicaid /
CHIP
Medicaid Website:
http://www.coverva.org/programs_premium_assistance.cfm
Medicaid Phone: 1-800-432-5924
CHIP Website:
http://www.coverva.org/programs_premium_assistance.cfm
CHIP Phone: 1-855-242-8282
Washington Medicaid
Website: http://www.hca.wa.gov/free-or-low-cost-health-
care/program-administration/premium-payment-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
Website:
https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf
Phone: 1-800-362-3002
Wyoming Medicaid
Website: https://wyequalitycare.acs-inc.com/
Phone: 307-777-7531
37
DEFINITIONS
Affordable Care Act (ACA): The Patient Protection and Affordable Care Act, commonly called the Affordable
Care Act (ACA) is a United States federal statute signed into law by President Obama in March 2010. The law
puts in place comprehensive health insurance reforms.
Annual Maximum: Total dollar amount a plan pays during a calendar year toward the covered expenses of
each person enrolled.
Out-of-Pocket Maximum: The maximum amount of coinsurance a Plan member must pay towards covered
medical expenses in a calendar year for both network and non-network services. Once you meet this out-of-
pocket maximum, the Plan pays the entire coinsurance amount for covered services for the remainder of the
calendar year. Deductibles and copays apply to the annual out-of-pocket maximum.
Coinsurance: A percentage of the medical costs, based on the allowed amount, you must pay for certain
services after you meet your annual deductible.
Conversion: An Associate changes or “converts” her/his Group Life coverage to an Individual Life Insurance
policy without having to answer any medical questions. Conversion is for an Associate who is leaving her/his
job, reducing hours, or has reached the age when coverage may be reduced or eliminated, and still wants to
maintain the protection that life insurance provides.
Copayment: A set dollar amount you pay for network doctors’ office visits, emergency room services and
prescription drugs.
Deductible: Total dollar amount, based on the allowed amount, you must pay out of pocket for covered
medical expenses each calendar year before the plan pays for most services. The deductible does not apply to
network preventive care and any services where you pay a copayment rather than coinsurance. Some of your
dental options also have an annual deductible, generally for basic and major dental care services.
Brand Formulary Drugs: The brand formulary is an approved, recommended list of brand-name medications.
Drugs on this list are available to you at a lower cost than drugs that do not appear on this preferred list.
Generic Drugs: These drugs are usually most cost-effective. Generic drugs are chemically identical to their
brand-name counterparts. Purchasing generic drugs allows you to pay a lower out-of-pocket cost than if you
purchase formulary or non-formulary brand name drugs.
38
DEFINITIONS
Maintenance Drugs: Prescriptions commonly used to treat conditions that are considered chronic or long-
term. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are
those used to treat high blood pressure, heart disease, asthma and diabetes.
Non-Formulary Drugs: These drugs are not on the recommended formulary list. These drugs are usually
more expensive than drugs found on the formulary. You may purchase brand-name medications that do not
appear on the recommended list, but at a significantly higher out-of pocket cost.
PDP Fee: PDP Fee refers to the fees that participating PDP dentists have agreed to accept as payment in full,
subject to any copayments, deductibles, cost sharing and benefits maximums.
Portability: An Associate carries or “ports” her/his current Group Life coverage after employment ends, without
having to answer any medical questions. Portability is for an Associate who is leaving her/his job and still
wants to maintain the protection that life insurance provides.
Pre-tax Plan: A plan for active employees that is paid for with pre-tax money. The IRS allows for certain
expenses to be paid for with tax-free dollars. The state takes premiums out of your check before taxes are
calculated, increasing your spendable income and reducing the amount you owe in income taxes.
Consequently, the IRS has tax laws that require you to stay in the plans you select for a full plan year (January
through December). You can only make changes during Open Enrollment or if you have a Qualifying event.
Primary Care Physician (PCP): The health care professional who monitors your health needs and
coordinates your overall medical care, including referrals for tests or specialists.
Provider: Any type of health care professional or facility that provides services under your plan.
Network: A group of health care providers, including dentists, physicians, hospitals and other health care
providers, that agrees to accept pre-determined rates when serving members.
Qualifying Event: An occurrence that qualifies the Subscriber to make an insurance coverage change outside
of the Open Enrollment. (For example: marriage, divorce, birth, adoption, loss of other coverage, etc.)
Reasonable and Customary Charge (R&C): R & C fee refers to the Reasonable and Customary (R&C)
charge, which is based on the lowest of (1) the dentist’s actual charge, (2) the dentist’s usual charge for the
same or similar services, or (3) the charge of most dentist’s in the same geographic area for the same or
similar services as determined by Metlife.
Specialty Drugs: Prescription medications that require special handling, administration or monitoring. These
drugs may be used to treat complex, chronic and often costly conditions.
39
CONTACT INFORMATION
Plan Group Number Website Phone Numbers
Oxford Health GW5658 www.oxhp.com 1-800-444-6222
Aetna Dental Group # 876735 www.aetna.com 1-800-225-3375
United Health Care Vision Group # 752887 www.uhc.com 1-800-638-3120
Prudential Ancillary Benefits Group # P12831A www.prudential.com 1-800-496-1035
ComPsych
GuidanceResources Employee
Assistance Program (EAP)
www.guidanceresources.com 1-800-311-4327
Benefit Resource, Inc. FSA &
Commuter Benefit Plan
www.BRI.com 1-800-882-4462
Seneca Group HRA Group # 1012013 www.thesenecagroup.com 1-866-487-4157
Optum Bank HSA GW5658 www.optumbank,com 1-800-791-9361
