active_benefits_guide_2020_04.03.2020

Benefits Guide 2020 2020 BENEFITS GUIDE CONTENTS 2020 BENEFIT PROGRAMS .1 ELIGIBILITY .2 WHEN TO ENROLL 2020 BENEFIT RATES MEDICAL INSURANCE .4 MEDICAL PLAN COMPARISON .7 CITY EMPLOYEE MEDICAL CLINIC CITY EMPLOYEE PHARMACY PRESCRIPTION COVERAGE 10 DENTAL INSURANCE .11 VISION INSURANCE .12 WELLNESS AND DISEASE MANAGEMENT 13 SPENDING ACCOUNTS 19 LIFE INSURANCE 20 DISABILITY INSURANCE .22 LONG TERM CARE (LTC) .24 RETIREMENT 25 PAID TIME OFF .27 PARKING 28 BIKE SHARE PROGRAM 28 TUITION ASSISTANCE 28 EMPLOYEE PERKS 28 FAQ’S .29 HELPFUL REMINDERS 30 HEALTH CARE REFORM .31 NOTICES 32 VENDOR DIRECTORY 46 2020 BENEFIT PROGRAMS We know how important the City’s employee benefit programs are to you and we strive to improve the benefits we offer You play an important part in this as well; your efforts to become a savvy healthcare consumer help keep you and your family healthier, keep our costs low and improve our programs We are proud to offer this extensive selection of benefits to meet the needs of our employees and their families As part of the effort, we are providing you with resources that help guide your decisions and ensure you select the best plans and coverages needed for you and your family We are committed to keeping the focus on YOU by providing: • • • • Carefully selected networks, providers and programs Access to top-quality care that is affordable, convenient and effective Free or low-cost care (e.g TelaDoc and City Employee Medical Clinic) Added resources to help you find and receive care In 2020 we invite you to make (or enhance) your personal commitment to you and your families health and become wise health care consumers Please get engaged in the city’s wellness program, health management programs, and be sure you understand how you can seek better health care value by using quality and cost comparison tools Please review your benefit options and think carefully about your choices and your family needs You will find further details in this guide and on the Benefits & Wellness Intranet page Mike Sullivan Chief Human Resource and Risk Officer ABOUT THIS BENEFITS GUIDE This benefits guide is not intended to include all benefit details It is an outline of available coverage and is not intended to be a legal contract If a discrepancy exists between this document and the Plan Documents, the Plan Documents govern The benefit summaries apply to all City of Colorado Springs Civilian, Police, and Fire department employees, unless otherwise noted NOTE: ANNUAL APPROPRIATIONS REQUIREMENT: Other than those benefits specifically required by federal or state law, the benefit plans provided by the City of Colorado Springs for employees are subject to annual review and budget appropriations by City Council The City and employee contributions toward the cost of the benefit plans, as well as the benefit plan designs, may be changed or discontinued altogether at the Mayor’s discretion Specific details are available at coloradosprings.gov in the Policy and Procedures Manual (PPM) WE ARE HERE TO HELP HR SOLUTIONS CENTER If you need help with your benefits or have questions, please contact the HR Solutions Center at (719) 385-5125 or HR@coloradosprings.gov ADDITIONAL BENEFITS INFORMATION Learn even more about your City benefits by visiting the Benefits and Wellness Intranet page ELIGIBILITY All regular, probationary, and special employees scheduled to work 20 hours or more each week may participate in the City of Colorado Springs’ Benefit Programs unless otherwise noted Employees who elect coverage for themselves are eligible to elect coverage for their eligible spouse and eligible dependents after providing proof of dependent eligibility Eligible dependents include spouse and children (up to age 26), as defined by the City’s medical plan Additionally, you are required to provide social security numbers for dependents enrolled in the medical plan to comply with employer reporting requirements to the IRS for form 1095 NOTE: Hourly employees may be eligible for medical benefits as mandated by Patient Protection and Affordability Care Act WHEN TO ENROLL NEW HIRES If you are new employee to the City of Colorado Springs, you must make your benefit elections within your first 30 days of hire Benefits are effective the first of the month after you submit your benefit elections OPEN ENROLLMENT Open Enrollment is held annually and allows for employees to make changes without a qualifying life event During Open Enrollment, you should review your current benefit elections, review the benefit offerings for the next year, and make your benefit elections any time during this period BENEFIT CHANGES Due to IRS regulations, once you have made your elections for 2020, you cannot change your benefits until the next annual enrollment period, unless you have a qualified change in family status Election changes must be consistent with your status change Qualifying Events Marriage Change in Civil Union Status Change in a dependent’s benefits eligibility (e.g., a dependent child exceeding maximum age for coverage) Legal Separation or Divorce (you may be held liable for any claims expenses for ineligible dependents remaining on the plan over 30 days A significant change in the cost or coverage of your spouse’s benefits Birth or adoption of a child Change in place of residence causing a loss of eligibility (i.e moving outside of the service area) Retirement Change in the cost of dependent care (only for the dependent care FSA) Reduction of hours of service Loss of a dependent (death) Change in employment status for you or your spouse Enrollment in a Qualified Health Plan through the Health Insurance Marketplace To change your benefits, you must notify the HR Solutions Center within 30 days of the event in writing by completing and submitting a Benefits Change Form and providing documentation of the qualifying event NOTE: Benefits are effective the first of the month after the HR Solutions Center receives all necessary paperwork 2020 BENEFIT RATES City of Colorado Springs City Employee Benefit Rate Chart Regular, probationary and special employees regularly scheduled to work 20 or more hours weekly and Hourly Employees who meet eligibility requirements for medical benefits Key: EE Only = Employee Only; EE/Sp = Employee + Spouse; EE/Ch = Employee + Child(ren); EE/Family = Employee + Family *Note: There is an additional $50 per month surcharge for employees on the medical plan who are tobacco users To get your rates per pay period please divide Employee Share by There are 24 payments during the year Civil Union cost may have Pre-Tax and Post Tax implications Premier Medical Plan Rates - Monthly Level of Coverage Employee Share* EE Only EE/Sp EE/Ch EE/Family $161 $417 $369 $557 Total Plan Employer Cost Share $693 $532 $1,376 $959 $1,294 $925 $1,957 $1,400 Advantage Medical Plan Rates - Monthly Level of Coverage Total Plan Cost EE Only EE/Sp EE/Ch EE/Family $565 $1,142 $1,088 $1,649 Employer Share $532 $959 $925 $1,400 Employee Share* $33 $183 $163 $249 Annual HRA Funding (Employer Only) $500 $750 $750 $750 Delta Hi-Option PPO Dental Plan Rates - Monthly Level of Coverage Total Plan Cost Employer Share Employee Share EE Only $48 $34 $14 EE/Sp $110 $44 $66 EE/Ch $89 $44 $45 EE/Family $135 $44 $91 Delta Standard Option PPO Dental Plan Rates - Monthly Level of Coverage EE Only EE/Sp EE/Ch EE/Family Total Plan Cost $34 $82 $66 $100 Employer Share $34 $44 $44 $44 Employee Share $0 $38 $22 $56 Vision Service Plan Rates - Monthly Level of Coverage EE Only EE/Sp EE/Ch EE/Family Total Plan Cost $7.58 $15.16 $16.23 $25.93 Employer Share $0 $0 $0 $0 Employee Share $7.58 $15.16 $16.23 $25.93 MEDICAL INSURANCE MEDICAL The City offers two self-funded medical plans: The Premier Plan and the Advantage Plan coupled with a Health Reimbursement Account (HRA) component Both plans feature an in-network and out-of-network benefit The medical plans give you the option to pay your premiums with pre-tax dollars Anthem Blue Cross Blue Shield is our PPO Network for both plans AmeriBen is the medical claims administrator MEDICAL PLAN TERMS TO KNOW Premium Deductible The amount you and your employer pay each month in order to be enrolled in medical, dental, and vision insurance The amount you must pay each year for certain covered health services before the insurance plan will begin to pay Out-of-Pocket Max Deductible Out-of-Pocket MAXIMUM Coinsurance Your share of the cost of covered health care services, after you meet your deductible Insurance pays The most you will pay for covered health services during the plan year Copays, deductible, coinsurance all apply toward the Out-of-Pocket Maximum Copay A fixed amount you pay for certain covered health services Typically, your copay is due at time of service You Pay $25 Copay You pay Coinsurance Insurance Pays Remaining Medical Bill Office visit Coordination of Benefits —When a member is covered by another group health plan in addition to the City’s coverage, one plan pays its benefits first and the other plan applies its benefits to the remaining balance Covered Services — Services for which benefits are payable If you receive care for services not covered under the plan, the amount you pay for those services will not apply toward your deductible or out of-pocket maximum Formulary — The list of medicines covered by a health plan Prior Authorization —Review performed by Ameriben Medical Management for certain procedures and services before they are provided to determine if the services are approved for coverage under a benefit plan YOU MAKE A DIFFERENCE WITH A SELF-FUNDED PLAN Can one person really make a difference in the cost of premiums to all employees? Yes! With a self-funded plan, all of the employee and employer premiums are placed into a fund to pay for members’ claims throughout the year If members spend more in claims than what has been collected in premiums, our fund will be in the negative and premiums would likely need to increase Smart consumers shop for high quality, affordable health care using Castlight’s transparency tool (available on mycastlighthealth.com), receive their preventive care benefits, and use the correct facility or provider for services When you are a smart consumer of health care, you make a difference Get peace of mind Clearly see what’s covered by your plan, how much services will cost, and where you’ve spend your healthcare dollars Find doctors you’ll love Search ratings and reviews from real people, and find high-quality doctors or specialists in your network and near you Feel great about your benefits Discover your health and well-being resources and see all of your perks in one place WAYS TO SAVE – FIND THEM ON CASTLIGHT Enhanced Person Health Care (EPHC) Primary Care Providers – You will pay a lower co-pay, and have your deductible waived when you see these providers Tier I Specialists – Using these specialists will reduce your out of pocket expenses and you will pay a lower co-pay and have your deductible waived Site of Service program – Save money on advanced imaging and outpatient surgery The Site of Service program helps you get quality care for less money Just choose a free-standing, independent imaging provider or ambulatory surgery center from the Anthem network UCHealth Savings - Increased benefit coverage for utilizing UCHealth Inpatient facilities TELEMEDICINE Teladoc® is a convenient, affordable option for a variety of medical services when enrolled on the medical plan, including General Medical and Behavioral Health Access quality healthcare from the comfort of home, during your lunch break, or while traveling You can even get a prescription sent to your local pharmacy when medically necessary • Connect with a licensed doctor or therapist by web, phone or mobile app • Over 1,000,000 telehealth visits performed • 95% member satisfaction • Speak with a doctor in minutes • Teladoc doctors average 20 years of experience Teladoc gives you access 24 hours, days a week to a U.S board certified doctor through the convenience of phone, video or mobile app visits The best part about this is that it is free to all plan members Call (800) 835-2362 or online at www.teladoc.com General Medical $0/visit • Board-certified doctors are available 24/7/365 by web, phone, or app • Treat flu, allergies, sinus infection, rash, sore throat, and more Behavioral Health • Schedule a video or phone appointment seven days a week • Support for anxiety, eating disorders, depression, family issues, and more Psychiatrist $0/session Psychiatrist $0/session Psychologist, licensed clinical social worker, counselor or therapist $0/session (initial visit) (ongoing visit) 1-800-TELADOC (835-2362)AVAILABLE RESOURCES Mycastlighthealth.com - Castlight is your personalized healthcare assistant Find an in-network doctor, free-standing facilities, urgent care, emergency rooms, access your HRA balances, see what is covered by your plan, understand how much services will cost, and view previous claims Myameriben.com - View your Explanation of Benefits (EOB), find an in-network provider and much more Leapfroggroup.org - Learn how the hospital of your choice rates with regard to safety and quality Mobile Apps - Many of our vendors offer a mobile app Search the App Store or Google Play to take advantage of technology right at your fingertips MEDICAL PLAN COMPARISON Premier Plan Type of service In-Network Benefit Coinsurance(1) Annual Out-of-Pocket Maximum (OPM)/ Coinsurance(1) Primary Care Office Visit(2) Specialist Office Visit(2) Mental Health Office Visit* Urgent Care Emergency Room Visits In-Network Benefit unlimited Lifetime maximum Annual Deductible Out-of-Network Benefit Advantage Plan Out-of-Network Benefit unlimited $500 Individual $1250 Family $1,250 Individual $2,500 Family $1,500 Individual $3,000 Family $4500 Individual $9000 Family You pay 20% You pay 50% You pay 20% You pay 50% $2,500 Individual $7,500 Family $4,050 Individual $12,150 Family $3,500 Individual $8000 Family $9,000 Individual $18,000 Family EPHC - $25 co-pay, deductible waived; All others - $35 after deductible Tier I - $40 co-pay, deductible waived; All others - $60 after deductible $25 co-pay, deductible waived You pay 50% after deductible EPHC - $30 co-pay, deductible waived; All others - $40 after deductible Tier I - $60 co-pay, deductible waived; All others - $70 after deductible $30 co-pay, deductible waived You pay 50% after deductible You pay 50% after deductible You pay 50% after deductible $50 co-pay, deductible You pay 50% after waived; coinsurance for deductible diagnostic & surgical services $250 co-pay, then you pay 20% for diagnostic and surgical services, deductible waived If admitted to the hospital, ER co-pay waived You pay 50% after deductible You pay 50% after deductible You pay 20%, deductible You pay 50%, deductible waived; coinsurance for waived diagnostic & surgical services You pay 20% after deductible Diagnostic Services You pay 20% after deductible You pay 50% after deductible You pay 20% after deductible You pay 50% after deductible Inpatient Mental Health You pay 20% after deductible You pay 50% after deductible You pay 20% after deductible You pay 50% after deductible Utilize an UCHealth Facility - you pay 15% after deductible All hospital services and all other facilities - You pay 20% after deductible Freestanding Facility - you pay 10% after deductible; All other facilities - you pay 20% after deductible You pay 50% after deductible Utilize an UCHealth Facility - you pay 15% after deductible All hospital services and all other facilities - You pay 20% after deductible Freestanding Facility - you pay 10% after deductible; All other facilities - you pay 20% after deductible You pay 50% after deductible Freestanding Facility - you pay 10% after deductible; All other facilities - you pay 20% after deductible You pay 50% after deductible Freestanding Facility - you pay 10% after deductible; All other facilities - you pay 20% after deductible You pay 50% after deductible You pay $0 You pay 50%; deductible waived You pay $0 You pay 50%; deductible waived Inpatient Hospital Services Advanced Imaging (MRI/CT/PET) Outpatient/Ambulatory Surgery Preventive Care Alternative Medicine Notes: You pay 50% after deductible You pay 50% after deductible Plan Pays 50% of each claim up to an annual family maximum of $1000, deductible waived Nutritionists & Dieticians – maximum of visits per year per each, 50% coinsurance, deductible waived (1) The OPM and coinsurance are accounted for separately for in-network and out-of-network services (2) Co-pay applies to office visit only Deductible and co-insurance apply for diagnostic and surgical services performed in the office setting This table is not intended to include all benefit details It is an outline of coverage available and is not intended to be a legal contract If a discrepancy exists between this document and the official Plan Documents, the Plan Documents govern CITY EMPLOYEE MEDICAL CLINIC The City Employee Medical Clinic (CEMC) is available to employees enrolled in both Advantage and Premier medical plans The CEMC partners with UCCS staff Nurse Practitioners to provide a multitude of services to meet your health care needs They offer on-site lab services and same day appointments for acute and urgent care concerns, similar services to what you would see at a primary care provider      Evaluation & treatment of injuries  Referrals to specialists, including diagnostics $15 co-pay Preventive Care is FREE Acute Care Services (Ages & Up) Diagnosis & treatment of acute illness Lane Center for Academic Health Sciences Building 4863 North Nevada Avenue 2nd Floor Colorado Springs, CO 80918 T: (719) 385-5841 F: (719) 385-5842 Hours: Monday, Tuesday, Thursday, Friday 7:30 a.m to 4:30 p.m Wednesday 9:00 a.m to 6:00 p.m Free parking in designated area Preventive Services • • • • Annual Physical Exams (ages and up) School & Sports Physicals Women’s Health Immunizations On-Site Lab Services • • • By Appointment $15 co-pay $0 Preventive Care Lab Service Chronic Care Services Diagnosis, treatment, and management of chronic conditions such as: • • • • High Blood Pressure Asthma Diabetes High Cholesterol Other Services • • • • • Health Coaching Smoking Cessation Weight Management Well Women And More… NON-GRANDFATHER STATUS The Medical Plan is a “non-grandfathered” health care plan under the Patient Protection and Affordable Care Act (“Health Care Reform”) Being a non-grandfathered plan means the plan must comply with certain consumer protections, as outlined under Health Care Reform, which have been incorporated within this document Questions regarding these Health Care Reform provisions can be directed to the HR Solutions Center or you may contact the U.S Department of Health and Human Services at healthcare.gov NOTICES IMPORTANT REMINDER TO PROVIDE THE PLAN WITH THE TAXPAYER IDENTIFICATION NUMBER (TIN) OR SOCIAL SECURITY NUMBER (SSN) Employers are required by law to collect the taxpayer identification number (TIN) or social security number (SSN) of each medical plan participant and provide that number on reports that will be provided to the IRS each year Employers are required to make at least two consecutive attempts to gather missing TINs/SSNs If a dependent does not yet have a social security number, you can go to this website to complete a form to request a SSN: http://www.socialsecurity.gov/online/ss-5.pdf Applying for a social security number is FREE The SSN will also be used to help fulfill mandatory reporting requirements to the Centers for Medicare and Medicaid (CMS) for the purposes of permitting Medicare to coordinate benefits for individuals enrolled in both an employer-sponsored medical plan and Medicare If you have not yet provided the social security number (or other TIN) for each of your dependents that you have enrolled in the health plan, please contact the HR Solutions Center at (719) 385-5125 PRIVACY NOTICE REMINDER The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires health plans to comply with privacy rules These rules are intended to protect your personal health information from being inappropriately used and disclosed The rules also give you additional rights concerning control of your own healthcare information This Plan’s HIPAA Privacy Notice explains how the group health plan uses and discloses your personal health information You are provided a copy of this Notice when you enroll in the Plan You can get another copy of this Notice from the HR Solutions Center A full copy of the Privacy Notice is also available in this benefit guide AVAILABILITY OF SUMMARY OF BENEFIT AND COVERAGE (SBC) DOCUMENTS The health benefits available to you represent a significant component of your compensation package They also provide important protection for you and your family in the case of illness or injury In accordance with law, our plan provides you with a Summary of Benefits and Coverage or SBC as a way to help you understand and compare medical plan benefits The SBC summarizes and compares important information including, what is covered, what you need to pay for various benefits, what is not covered, and where to get answers to questions SBC documents are updated when there is a change to the benefits information displayed on an SBC To get a free copy of the most current Summary of Benefits and Coverage (SBC) documents for our medical plan options, and the Uniform Glossary that defines many terms in the SBC, go to https://coloradosprings.gov/human-resources/page/employee-benefits-guide or for a paper copy, contact the HR Solutions Center at (719) 385-5125 32 THE WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998 ANNUAL NOTIFICATION The United States Congress passed the Women's Health and Cancer Rights Act of 1998 This act affects both group and individual health plans that provide medical/surgical coverage for a mastectomy This act requires these health plans to provide coverage for reconstructive surgery and related services that may follow a mastectomy You or your dependents may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA) For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient for: • • • • All stages of reconstructive surgery of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; and Prostheses; and Physical complications for all stages of mastectomy, including lymphedemas These benefits will be provided subject to the same deductibles, copayment and coinsurance applicable to other medical and surgical benefits provided under the various medical plans offered by the City of Colorado Springs Please refer to the Medical Benefits Plan for further benefit coverage information If you have any questions about the Plan provisions, please call AmeriBen Solutions, the claims administrator, at (800) 786-7930 HIPAA SPECIAL ENROLLMENT NOTICE IMPORTANT: After the open enrollment period is completed, (or, if you are a new hire, after your initial enrollment election period is over), generally you will not be allowed to change your benefit elections or add/delete dependents until next years’ open enrollment, unless you have a Special Enrollment Event or a Mid-year Permitted Election Change Event as outlined below: • Special Enrollment Event: Loss of Other Coverage Event: 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 toward 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 towards the other coverage) Marriage, Birth, Adoption Event: 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 Medicaid/CHIP Event: You and your eligible dependents may also enroll in this plan if you (or your dependents): • have coverage through Medicaid or a State Children’s Health Insurance Program (CHIP) and you (or your dependents) lose eligibility for that coverage However, you must request enrollment within 60 days after the Medicaid or CHIP coverage ends 33 • become eligible for a premium assistance program through Medicaid or CHIP However, you must request enrollment within 60 days after you (or your dependents) are determined to be eligible for such assistance To request special enrollment or obtain more information, contact the HR Solutions Center at (719) 385-5125 NOTICE OF NEWBORN & MOTHERS HEALTH PROTECTION ACT Under Federal law, group health plans and health insurance issuers offering group health insurance coverage generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48-hours following a vaginal delivery, or less than 96-hours following a delivery by cesarean section However, the plan or issuer may pay for a shorter stay if the attending physician or health care practitioner, after consultation with the mother, discharges the mother or newborn earlier Also, under federal law, plans may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay In addition, the Plan may not, under federal law, require that a Physician or other Health Care Practitioner obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours) However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain precertification If you have questions about this Notice, contact the HR Solutions Center at (719) 385-5125 NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION Please carefully review this notice It describes how medical information about you may be used and disclosed and how you can get access to this information The City of Colorado Springs self-funded group health plan including medical, dental, vision, FSA benefits (hereafter referred to as the “Plan”), is required by law to take reasonable steps to maintain the privacy of your personally identifiable health information (called Protected Health Information or PHI) and to inform you about the Plan’s legal duties and privacy practices with respect to Protected Health Information PHI use and disclosure by the Plan is regulated by the Federal law, Health Insurance Portability and Accountability Act, commonly called HIPAA You may find these rules in Section 45 of the Code of Federal Regulations, Parts 160 and 164 This Notice attempts to summarize key points in the regulation The regulations will supersede this Notice if there is any discrepancy between the information in this Notice and the regulations The Plan will abide by the terms of the Notice currently in effect The Plan reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all PHI it maintains The Plan’s duties with respect to health information about you The Plan is required by law to maintain the privacy of your health information and to provide you with this notice of the Plan’s legal duties and privacy practices with respect to your health information If you participate in an insured plan option, you will receive a notice directly from the Insurer It’s important to note that these rules apply to the Plan, not City of Colorado Springs as an employer — that’s the way the HIPAA rules work Different policies may apply to other City of Colorado Springs programs or to data unrelated to the Plan How the Plan may use or disclose your health information The privacy rules generally allow the use and disclosure of your health information without your permission (known as an authorization) for purposes of health care treatment, payment activities, and health care operations Here are some examples of what that might entail: 34 • Treatment includes providing, coordinating, or managing health care by one or more health care providers or doctors Treatment can also include coordination or management of care between a provider and a third party, and consultation and referrals between providers For example, the Plan may share your health information with physicians who are treating you • Payment includes activities by this Plan, other plans, or providers to obtain premiums, make coverage determinations, and provide reimbursement for health care This can include determining eligibility, reviewing services for medical necessity or appropriateness, engaging in utilization management activities, claims management, and billing; as well as performing “behind the scenes” plan functions, such as risk adjustment, collection, or reinsurance For example, the Plan may share information about your coverage or the expenses you have incurred with another health plan to coordinate payment of benefits • Health care operations include activities by this Plan (and, in limited circumstances, by other plans or providers), such as wellness and risk assessment programs, quality assessment and improvement activities, customer service, and internal grievance resolution Health care operations also include evaluating vendors; engaging in credentialing, training, and accreditation activities; performing underwriting or premium rating; arranging for medical review and audit activities; and conducting business planning and development For example, the Plan may use information about your claims to audit the third parties that approve payment for Plan benefits The amount of health information used, disclosed or requested will be limited and, when needed, restricted to the minimum necessary to accomplish the intended purposes, as defined under the HIPAA rules If the Plan uses or discloses PHI for underwriting purposes, the Plan will not use or disclose PHI that is your genetic information for such purposes How the Plan may share your health information with the City of Colorado Springs Here’s how additional information may be shared between the Plan and the City of Colorado Springs, as allowed under the HIPAA rules: • • • The Plan, or its insurer, may disclose “summary health information” to City of Colorado Springs, if requested, for purposes of obtaining premium bids to provide coverage under the Plan or for modifying, amending, or terminating the Plan Summary health information is information that summarizes participants’ claims information, from which names and other identifying information have been removed The Plan, or its insurer, may disclose to the City of Colorado Springs information on whether an individual is participating in the Plan or has enrolled or disenrolled in an insurance option offered by the Plan In addition, you should know that the City of Colorado Springs cannot and will not use health information obtained from the Plan for any employment-related actions However, health information collected by the City of Colorado Springs from other sources — for example, under the Family and Medical Leave Act, Americans with Disabilities Act, or workers’ compensation programs — is not protected under HIPAA (although this type of information may be protected under other federal or state laws) Other permitted uses or disclosures of your health information In certain cases, your health information can be disclosed without authorization to a family member, close friend, or other person you identify who is involved in your care or payment for your care Information about your location, general condition, or death may be provided to a 35 similar person (or to a public or private entity authorized to assist in disaster relief efforts) You’ll generally be given the chance to agree or object to these disclosures (although exceptions may be made — for example, if you’re not present or if you’re incapacitated) In addition, your health information may be disclosed without authorization to your legal representative The Plan also is also permitted to use or disclose your health information without your written authorization for the following activities: 1) Required by law Disclosures otherwise required by law 36 2) Workers’ compensation Disclosures to workers’ compensation or similar legal programs that provide benefits for work-related injuries or illness without regard to fault, as authorized by and necessary to comply with the laws 3) Proof of Immunization Disclosures to a school about an individual who is a student or prospective student of the school if the protected health information is limited to proof of immunization 4) Necessary to prevent serious threat to health or safety Disclosures made in the good-faith belief that releasing your health information is necessary to prevent or lessen a serious and imminent threat to public or personal health or safety, if made to someone reasonably able to prevent or lessen the threat (or to the target of the threat); includes disclosures to help law enforcement officials identify or apprehend an individual who has admitted participation in a violent crime that the Plan reasonably believes may have caused serious physical harm to a victim, or where it appears the individual has escaped from prison or from lawful custody 5) Public health activities Disclosures authorized by law to persons who may be at risk of contracting or spreading a disease or condition; disclosures to public health authorities to prevent or control disease or report child abuse or neglect; and disclosures to the Food and Drug Administration to collect or report adverse events or product defects 6) Victims of abuse, neglect, or domestic violence Disclosures to government authorities, including social services or protected services agencies authorized by law to receive reports of abuse, neglect, or domestic violence, as required by law or if you agree or the Plan believes that disclosure is necessary to prevent serious harm to you or potential victims (you’ll be notified of the Plan’s disclosure if informing you won’t put you at further risk) 7) Judicial and administrative proceedings Disclosures in response to a court or administrative order, subpoena, discovery request, or other lawful process (the Plan may be required to notify you of the request or receive satisfactory assurance from the party seeking your health information that efforts were made to notify you or to obtain a qualified protective order concerning the information) 8) Law enforcement purposes Disclosures to law enforcement officials required by law or legal process, or to identify a suspect, fugitive, witness, or missing person; disclosures about a crime victim if you agree or if disclosure is necessary for immediate law enforcement activity; disclosures about a death that may have resulted from criminal conduct; and disclosures to provide evidence of criminal conduct on the Plan’s premises 9) Decedents Disclosures to a coroner or medical examiner to identify the deceased or determine cause of death; and to funeral directors to carry out their duties 10) Organ, eye, or tissue donation Disclosures to organ procurement organizations or other entities to facilitate organ, eye, or tissue donation and transplantation after death 11) Research purposes Disclosures subject to approval by institutional or private privacy review boards, subject to certain assurances and representations by researchers about the necessity of using your health information and the treatment of the information during a research project 12) Health oversight activities Disclosures to health agencies for activities authorized by law (audits, inspections, investigations, or licensing actions) for oversight of the health care system, government benefits programs for which health information is relevant to beneficiary eligibility, and compliance with regulatory programs or civil rights laws 13) Specialized government functions Disclosures about individuals who are Armed Forces personnel or foreign military personnel under appropriate military command; disclosures to authorized federal officials for national security or intelligence activities; and disclosures to correctional facilities or custodial law enforcement officials about inmates 14) HHS investigations Disclosures of your health information to the Department of Health and Human Services to investigate or determine the Plan’s compliance with the HIPAA privacy rule Any other Plan uses and disclosures not described in this Notice will be made only if you provide the Plan with written authorization, subject to your right to revoke your authorization, and information used and disclosed will be made in compliance with the minimum necessary standards of the regulation Although the Plan does not routinely obtain psychotherapy notes, generally, an authorization will be required by the Plan before the Plan will use or disclose psychotherapy notes about you However, the Plan may use and disclose such notes when needed by the Plan to defend itself against litigation filed by you The Plan generally will require an authorization form for uses and disclosure of your PHI for marketing purposes (meaning a communication that encourages you to purchase or use a product or service) if the Plan receives direct or indirect financial remuneration (payment) from the entity whose product or service is being marketed The Plan generally will require an authorization form for the sale of Protected Health Information if the Plan receives direct or indirect financial remuneration (payment) from the entity to which the PHI is sold The Plan does not intend to engage in fundraising activities The Plan will notify you if it becomes aware that there has been a loss of your health information in a manner that could compromise the privacy of your health information Your individual rights You have the following rights with respect to your health information the Plan maintains These rights are subject to certain limitations, as discussed below This section of the notice describes how you may exercise each individual right See the table at the end of this notice for information on how to submit requests Right to request restrictions on certain uses and disclosures of your health information and the Plan’s right to refuse You have the right to ask the Plan to restrict the use and disclosure of your health information for treatment, payment, or health care operations, except for uses or disclosures required by law You have the right to ask the Plan to restrict the use and disclosure of your health information to family members, close friends, or other persons you identify as being involved in your care or payment for your care You also have the right to ask the Plan to restrict use and disclosure of health information to notify those persons of your location, general condition, or death — or to coordinate those efforts with entities assisting in disaster relief efforts If you want to exercise this right, your request to the Plan must be in writing 37 The Plan is not required to agree to a requested restriction If the Plan does agree, a restriction may later be terminated by your written request, by agreement between you and the Plan (including an oral agreement), or unilaterally by the Plan for health information created or received after you’re notified that the Plan has removed the restrictions The Plan may also disclose health information about you if you need emergency treatment, even if the Plan has agreed to a restriction An entity covered by these HIPAA rules (such as your health care provider) or its business associate must comply with your request that health information regarding a specific health care item or service not be disclosed to the Plan for purposes of payment or health care operations if you have paid out of pocket and in full for the item or service Right to receive confidential communications of your health information If you think that disclosure of your health information by the usual means could endanger you in some way, the Plan will accommodate reasonable requests to receive communications of health information from the Plan by alternative means or at alternative locations If you want to exercise this right, your request to the Plan must be in writing and you must include a statement that disclosure of all or part of the information could endanger you Right to inspect and copy your health information With certain exceptions, you have the right to inspect or obtain a copy of your health information in a “designated record set.” This may include medical and billing records maintained for a health care provider; enrollment, payment, claims adjudication, and case or medical management record systems maintained by a plan; or a group of records the Plan uses to make decisions about individuals However, you not have a right to inspect or obtain copies of psychotherapy notes or information compiled for civil, criminal, or administrative proceedings The Plan may deny your right to access, although in certain circumstances, you may request a review of the denial If you want to exercise this right, your request to the Plan must be in writing Within 30 days of receipt of your request (60 days if the health information is not accessible on site), the Plan will provide you with one of these responses: • The access or copies you requested • A written denial that explains why your request was denied and any rights you may have to have the denial reviewed or file a complaint • A written statement that the time period for reviewing your request will be extended for no more than 30 more days, along with the reasons for the delay and the date by which the Plan expects to address your request You may also request your health information be sent to another entity or person, so long as that request is clear, conspicuous and specific The Plan may provide you with a summary or explanation of the information instead of access to or copies of your health information, if you agree in advance and pay any applicable fees The Plan also may charge reasonable fees for copies or postage If the Plan doesn’t maintain the health information but knows where it is maintained, you will be informed where to direct your request If the Plan keeps your records in an electronic format, you may request an electronic copy of your health information in a form and format readily producible by the Plan You may also request that such electronic health information be sent to another entity or person, so long as that request is clear, conspicuous, and specific Any charge that is assessed to you for these copies must be reasonable and based on the Plan’s cost Right to amend your health information that is inaccurate or incomplete With certain exceptions, you have a right to request that the Plan amend your health information in a designated record set The Plan may deny your request for a number of reasons For example, your request may be denied if the health information is accurate and complete, was not created by the Plan (unless the person or entity that created the information is no longer available), is not part of the designated record set, or is not available for inspection (e.g., psychotherapy notes or information compiled for civil, criminal, or administrative proceedings) If you want to exercise this right, your request to the Plan must be in writing, and you must include a statement to support the requested amendment Within 60 days of receipt of your request, the Plan will take one of these actions: • Make the amendment as requested • Provide a written denial that explains why your request was denied and any rights you may have to disagree or file a complaint • Provide a written statement that the time period for reviewing your request will be extended for no more than 30 more days, along with the reasons for the delay and the date by which the Plan expects to address your request Right to receive an accounting of disclosures of your health information You have the right to a list of certain disclosures of your health information the Plan has made This is often referred to as an “accounting of disclosures.” You generally may receive this accounting if the disclosure is required by law, in connection with public health activities, or in similar situations listed in the table earlier in this notice, unless otherwise indicated below You may receive information on disclosures of your health information for up to six years before the date of your request You not have a right to receive an accounting of any disclosures made in any of these circumstances: • For treatment, payment, or health care operations • To you about your own health information • Incidental to other permitted or required disclosures • Where authorization was provided • To family members or friends involved in your care (where disclosure is permitted without authorization) • For national security or intelligence purposes or to correctional institutions or law enforcement officials in certain circumstances • As part of a “limited data set” (health information that excludes certain identifying information) In addition, your right to an accounting of disclosures to a health oversight agency or law enforcement official may be suspended at the request of the agency or official If you want to exercise this right, your request to the Plan must be in writing Within 60 days of the request, the Plan will provide you with the list of disclosures or a written statement that the time period for providing this list will be extended for no more than 30 more days, along with the reasons for the delay and the date by which the Plan expects to address your request You may make one request in any 12-month period at no cost to you, but the Plan may charge a fee for subsequent requests You’ll be notified of the fee in advance and have the opportunity to change or revoke your request Breach Notification If a breach of your unsecured protected health information occurs, the Plan will notify you 39 Right to obtain a paper copy of this notice from the Plan upon request You have the right to obtain a paper copy of this privacy notice upon request Even individuals who agreed to receive this notice electronically may request a paper copy at any time Changes to the information in this notice The Plan must abide by the terms of the privacy notice currently in effect This notice takes effect on September 23, 2013 However, the Plan reserves the right to change the terms of its privacy policies, as described in this notice, at any time and to make new provisions effective for all health information that the Plan maintains This includes health information that was previously created or received, not just health information created or received after the policy is changed If changes are made to the Plan’s privacy policies described in this notice, you will be provided with a revised privacy notice emailed to you or mailed to your home address Complaints If you believe your privacy rights have been violated or your Plan has not followed its legal obligations under HIPAA, you may complain to the Plan and to the Secretary of Health and Human Services You won’t be retaliated against for filing a complaint To file a complaint, you may send a written complaint to the Plan’s Privacy Officer, 30 South Nevada Avenue, Suite 301, Colorado Springs, CO 80903; or you may file a complaint with the Secretary of the Department of Health Human Services, Huber H Humphrey Building, 2000 Independence Avenue SW., Washington, DC 20201 Contact For more information on the Plan’s privacy policies or your rights under HIPAA, contact Privacy Officer, 30 South Nevada Avenue, Suite 301, Colorado Springs, CO 80903 PATIENT PROTECTION RIGHTS OF THE AFFORDABLE CARE ACT Designation of a Primary Care Provider (PCP): The medical plans offered by the City of Colorado Springs not require you to select a primary care physician (PCP) You have the ability to visit any in-network (or non-network) health care provider; however, payment by the Plan may be less for the use of a non-network provider Direct Access to OB/GYN Providers: You not need prior authorization (pre-approval) from the Plan, the Claims Administrator, or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological (OB/GYN) care from a health care professional in the network who specializes in obstetrics and/or gynecology The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or for procedures for making referrals For a list of participating health care professionals who specialize in obstetrics and/or gynecology, visit www.mycastlighthealth.com NOTICES REGARDING THE “REACH YOUR PEAK” EMPLOYEE WELLNESS PROGRAM The City of Colorado Springs REACH YOUR PEAK is a voluntary wellness program available to all employees enrolled in the medical plan and is designed to promote health or prevent disease The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others 40 If you choose to participate in the wellness program you may choose to complete a voluntary Well-Being Assessment (WBA), an online series of questions targeting your health and lifestyle habits, these questions can help you identify factors which can contribute to disease risk and/or protect you from risk You may also choose to complete a biometric screening, which will include a blood test for cholesterol (HDL, LDL and risk ratio), triglycerides and blood glucose You are not required to complete the WBA or to participate in the blood test or other medical examinations, such as waist circumference, body weight and blood pressure, which will be taken during the biometric screening Employees who choose to participate in the wellness program will receive an incentive of $300 for participating in the wellness program’s activities, such as completing the WBA, participating in the biometric health screening, health coaching sessions, wellness activities and challenges Employees will be eligible to receive a $300 financial incentive award by participating in any combination of these wellness program activities to accumulate 300 points If you are unable to participate in any of the wellness program activities, you may be entitled to a reasonable accommodation or an alternative standard You may request a reasonable accommodation or an alternative standard by contacting HealthYou at (719) 314-3535 or support@myhealthyou.com PROTECTIONS FROM DISCLOSURE OF MEDICAL INFORMATION We are required by law to maintain the privacy and security of your personally identifiable health information Although the wellness program and the City of Colorado Springs may use aggregate information it collects to design a program based on identified health risks in the workplace, the City’s group health plan and the REACH YOUR PEAK Employee Wellness Program will never disclose any of your personal information either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements The only individual(s) who will receive your personally identifiable health information are your health coach and the City’s Health Promotion/Disease Management vendors in order to provide you with services under the wellness program In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making any employment decision Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you immediately You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate 41 If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact HealthYou at (719) 314-3535 or support@myhealthyou.com PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace For more information, visit www.healthcare.gov If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272) If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums The following list of states is current as of July 31, 2019 Contact your State for more information on eligibility – ALABAMA – Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447 ALASKA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/de fault.aspx ARKANSAS – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447) 42 FLORIDA – Medicaid Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268 GEORGIA – Medicaid Website: https://medicaid.georgia.gov/healthinsurance-premium-payment-program-hipp Phone: 678-564-1162 ext 2131 INDIANA – Medicaid Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1-800-403-0864 COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/childhealth-plan-plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711 IOWA – Medicaid Website: http://dhs.iowa.gov/Hawki Phone: 1-800-257-8563 KANSAS – Medicaid NEW HAMPSHIRE – Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512 Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800852-3345, ext 5218 KENTUCKY – Medicaid Website: https://chfs.ky.gov Phone: 1-800-635-2570 NEW JERSEY – Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 NEW YORK – Medicaid Website: https://www.health.ny.gov/health_care/medica id/ Phone: 1-800-541-2831 NORTH CAROLINA – Medicaid Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100 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/publicassistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711 MASSACHUSETTS – Medicaid and CHIP Website: http://www.mass.gov/eohhs/gov/departments/ masshealth/ Phone: 1-800-862-4840 MINNESOTA – Medicaid Website: https://mn.gov/dhs/people-weserve/seniors/health-care/health-careprograms/programs-and-services/otherinsurance.jsp Phone: 1-800-657-3739 NORTH DAKOTA – Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/m edicaid/ Phone: 1-844-854-4825 OKLAHOMA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 43 MISSOURI – Medicaid Website: http://www.dss.mo.gov/mhd/participants/page s/hipp.htm Phone: 573-751-2005 MONTANA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcareProgra ms/HIPP Phone: 1-800-694-3084 NEBRASKA – Medicaid Website: http://www.ACCESSNebraska.ne.gov Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-1178 NEVADA – Medicaid Medicaid Website: https://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900 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 and CHIP Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669 VERMONT– Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427 VIRGINIA – Medicaid and CHIP Medicaid Website: http://www.coverva.org/programs_premium_a ssistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_a ssistance.cfm CHIP Phone: 1-855-242-8282 44 OREGON – Medicaid Website: http://healthcare.oregon.gov/Pages/index.asp x http://www.oregonhealthcare.gov/indexes.html Phone: 1-800-699-9075 PENNSYLVANIA – Medicaid Website: http://www.dhs.pa.gov/provider/medicalassista nce/healthinsurancepremiumpaymenthippprog ram/index.htm Phone: 1-800-692-7462 RHODE ISLAND – Medicaid and CHIP Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347, or 401-462-0311 (Direct RIte Share Line) SOUTH CAROLINA – Medicaid Website: https://www.scdhhs.gov Phone: 1-888-549-0820 WASHINGTON – Medicaid Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022 ext 15473 WEST VIRGINIA – Medicaid Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855699-8447) WISCONSIN – Medicaid and CHIP 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 To see if any other states have added a premium assistance program since July 31, 2019, or for more information on special enrollment rights, contact either: U.S Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272) U.S Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext 61565 Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number See 44 U.S.C 3507 Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number See 44 U.S.C 3512 The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137 45 Benefit Plan Medical Insurance Group Number: 000COG834 Premier Plan Advantage Plan VENDOR DIRECTORY Vendor Name Ameriben Enhanced Customer Service Designated Customer Care Ameriben Concierge Consumer Support Benefit Coverage, Questions, Claims Explanation of benefits, and Medical ID Cards Ameriben Medical Management Disease Management, Case Management, and Prior Authorization Anthem - Provider Network Access Castlight Provider Search, Cost and Quality Comparisons, and Health Related Resources City Employee Medical Clinic Medical Services City Employee Pharmacy Pharmacy Dental Insurance Vision Insurance Employee Assistance Program (EAP) Life Insurance Disability Insurance Long Term Care (LTC) Spending Accounts FSA HRA Retirement MaxorPlus Pharmacy Benefit Manager, In-Network Retail Pharmacies, and Pharmacy ID Cards Teladoc Medical Services Delta Dental Hi Option Plan #1512 Standard Option Plan #1844 Vision Service Plan (VSP) Plan #12061804 Profile EAP: Centura Health UserName: City The Hartford Policy #804057 Cigna Short Term Disability (STD) Policy #LK7822 Long Term Disability (LTD) Policy #LK7823 UNUM Life Insurance Company of America Policy #220508 (Elections prior to 2008) Policy #127251 (Elections 2008 and forward) ASIFlex FSA for Health Care & Dependent Care HRA for Active Employees Enrolled on the Advantage Plan Public Employees Retirement Association (PERA) Fire & Police Protective Assoc (FPPA) ICMA-RC Services, LLC Don Eschbach Wellness Addiction & Recovery Coaching 46 HealthYou Face It Together Contact Information (866) 955-1482 www.myameriben.com (855) 778-9052 www.myameriben.com www.anthem.com (800) 684-0624 www.mycastlighthealth.com (719) 385-5841 Fax: (719) 385-5842 (719) 385-2261 Auto Refill Line: (800) 573-6214 www.cityemployeepharmacy.com (800) 687-0707 www.maxor.com (800) 687-0707 www.teladoc.com (800) 610-0201 www.deltadentalco.com (800) 877-7195 www.vsp.com (800) 645-6571 www.profileeap.org (888) 563-1124 www.thehartford.com (800) 362-4462 Claims: (800) 781-2006 www.cigna.com (800) 227-4165 www.unum.com (800) 659-3035 Fax: (877) 879-9093 www.asiflex.com (800) 759-7372 www.copera.org (800) 332-3772 www.fppaco.org (866) 749-5174 deschbach@icmarc.org (719) 314-3535 www.cosreachyourpeak.com (855) 539-9375 www.wefaceittogether.org care@wefaceittogether.org