2024 Employee Benefit Guide - Salaried - Yeled 11.3.23

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HSA EPO LIBERTY PLAN

EPO LIBERTY LOW PLAN

BENEFIT

IN-NETWORK ONLY

Annual Deductible (Calendar Year)

Individual: $3;000 Family: $6,000* *If you have a family contract, the entire family Deductible must be satisfied before coverage under this Plan is available.

Individual: $2,500 Family: $5,000

Out-of-Pocket Maximum (Calendar Year)

Individual: $6,350 Family: $12,700

Coinsurance

You pay 50% Oxford pays 50%

You pay 40% Oxford pays 60%

Preventive Care Adult Preventive Care Infant and Pediatric Preventive Care

No Charge No Charge

Outpatient Care Primary care physician office visits Specialist office visits Virtual Visits Outpatient Surgery - hospital/freestanding facility Laboratory - Preferred Lab Network Laboratory - Non-Preferred Lab Network Radiology - hospital/freestanding facility Complex Radiology hospital/freestanding facility (MRIs, MRAs, CT Scans, Pet Scans)

Deductible & 50% Coinsurance Deductible & 50% Coinsurance No Charge (Not subject to deductible)

$30 copay $50 copay No Charge Deductible and 40% coinsurance No Charge Deductible and 50% Coinsurance Deductible and 40% Coinsurance Deductible and 40% coinsurance

Deductible & 50% Coinsurance Deductible & 50% Coinsurance Deductible & 50% Coinsurance Deductible & 50% Coinsurance Deductible & 50% Coinsurance

Inpatient Hospital Physicians and Surgeons Services Semi-Private Room and Board All Drugs and Medications Emergency Care Ambulance when medically necessary At hospital emergency room Urgent Care Maternity Care Prenatal and Post-natal care Hospital services for mother and child Mental Health/Substance Abuse Inpatient Outpatient Prescription Drugs Annual Deductible Retail Pharmacy Copay (30 day supply) Tier-1/Tier-2/Tier-3 Mail Order Copay (90 day supply) Tier-1/Tier-2/Tier-3

Deductible & 50% Coinsurance Deductible & 50% Coinsurance Deductible & 50% Coinsurance

Deductible and 40% coinsurance Deductible and 40% coinsurance Deductible and 40% coinsurance

Deductible & 50% Coinsurance Deductible & 50% Coinsurance Deductible & 50% Coinsurance

No Charge Deductible and 40% coinsurance $50 copay

No Charge Deductible & 50% Coinsurance

No Charge Deductible and 40% coinsurance

Deductible & 50% Coinsurance Deductible & 50% Coinsurance

Deductible and 40% coinsurance $50/$30 copay

Subject to the plan deductible, then copays apply

$50 per person (waived for Tier 1 drugs)

$15/$35/$75

$37.50/$87.50/$187.50

Dependent Age Limit: To age 26; benefits terminate at the end of the month in which the dependent turns 26

PRE-TAX SEMI MONTHLY CONTRIBUTIONS

0 TO 2 YEARS

2+ YEARS**

0 TO 2 YEARS

2+ YEARS**

Employee

$128.95

$441.93

Employee & Spouse*

$392.64

$203.09

$1,049.90

$860.35

Employee & Child(ren)*

$372.33

$203.09

$920.05

$750.81

Family*

$747.23

$452.27

$1,701.84

$1,406.88

For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

EPO LIBERTY HIGH PLAN

PPO LIBERTY IN-NETWORK & OUT-OF-NETWORK PLAN

BENEFIT

IN-NETWORK ONLY

IN-NETWORK

OUT-OF-NETWORK

Annual Deductible (Calendar Year)

Individual: None Family: None

Individual: $1,000 Family: $2,000

Individual: $2,000 Family: $4,000

Out-of-Pocket Maximum (Calendar Year)

Individual: $2,500 Family: $5,000

Individual: $5,000 Family: $10,000

Coinsurance

You pay 0% Oxford pays 100%

You pay 30% Oxford pays 70%

Preventive Care Adult Preventive Care Infant and Pediatric Preventive Care

No Charge No Charge

Not Covered Deductible & 30% Coinsurance

$30 copay $50 copay No Charge $250 copay No Charge $60 copay No Charge No Charge

$30 copay $50 copay No Charge No Charge after deductible No Charge 50% after deductible No Charge No Charge after deductible

Deductible & 30% Coinsurance Deductible & 30% Coinsurance In-Network Only Deductible & 30% Coinsurance

In-Network Only In-Network Only

Deductible & 30% Coinsurance Deductible & 30% Coinsurance

No Charge $500 copay per admission No Charge

No Charge after deductible No Charge after deductible No Charge after deductible

Deductible & 30% Coinsurance Deductible & 30% Coinsurance Deductible & 30% Coinsurance

No Charge $300 copay (waived if admitted) $50 copay

No Charge after deductible $300 copay $50 copay

Deductible & 30% Coinsurance $300 copay Deductible & 30% Coinsurance

No Charge $500 copay per admission

No Charge No Charge after deductible

Deductible & 30% Coinsurance Deductible & 30% Coinsurance

$500 copay per admission $50 /$30 copay

$50/$30 copay No Charge after deductible

Deductible & 30% Coinsurance Deductible & 30% Coinsurance

$50 per person (waived for Tier 1 drugs) $15/$35/$75

None

Not Applicable

$7/$20/$50

Not Covered

$37.50/$87.50/$187.50

Not Covered

$17.50/$50/$125

Dependent Age Limit: To age 26; benefits terminate at the end of the month in which the dependent turns 26

PRE-TAX SEMI MONTHLY CONTRIBUTIONS

0 TO 2 YEARS

2+ YEARS

0 TO 2 YEARS

2+ YEARS

Employee

$780.75

$1,060.01

Employee & Spouse*

$1,761.43

$1,571.88

$2,347.88

$2,158.33

Employee & Child(ren)*

$1,512.99

$1,343.75

$2,001.70

$1,832.46

Family*

$2,735.24

$2,440.28

$3,586.99

$3,292.03

For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

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For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

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For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

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For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

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PREFERRED PROVIDER ORGANIZATION DENTAL HIGH PLAN (PPO 30)

PREFERRED PROVIDER ORGANIZATION DENTAL LOW PLAN (PPO 20)

BENEFIT

IN-NETWORK

OUT-OF-NETWORK*

IN-NETWORK

OUT-OF-NETWORK**

Annual Deductible (Calendar Year)

Individual:

$50

Individual:

$50

Individual:

$50

Individual:

$50

Family:

$150

Family:

$150

Family:

$150

Family:

$150

Benefit Annual Maximum (Calendar Year) Orthodontia Lifetime Maximum

Individual: Individual:

$2,000 $1,000

Individual: Individual:

$2,000 $1,000

Individual:

$1,000

Individual:

$1,000

Not covered

Preventive Services & Diagnostic Services Prophylaxis (Cleaning) Fluoride Treatment (Preventive) Sealants Space Maintainers Periodic Oral Evaluation Radiographs Lab and other Diagnostic Tests Basic Services Restorations (Amalgams or Composite) Emergency Treatment/General Services Simple Extractions Oral Surgery (incl. Surgical Extractions

Plan pays 100% No deductible

Plan pays 100% (U&C)* No deductible

Plan pays 100% No deductible

Plan pays 100% (MAC)** No deductible

Plan pays 80% After deductible

Plan pays 80% (U&C)* After deductible

Plan pays 100% After deductible

Plan pays 100% (MAC)** After deductible

Periodontics Endodontics

Major Services Inlays/Onlays/Crowns Dentures and Removeable Prosthetics Fixed Partial Dentures (Bridges)

Plan pays 50% After deductible

Plan pays 50% (U&C)* After deductible

Plan pays 60% After deductible

Plan pays 60% (MAC)** After deductible

Orthodontic Services Dependent Children to age 19 only

Plan pays 50% No deductible

Plan pays 50% (U&C)* No deductible

Not Covered

Dependent Age Limit: To age 26; benefits terminate at the end of the month in which the dependent turns 26

PRE-TAX SEMI-MONTHLY CONTRIBUTIONS

Employee

$41.66

$15.22

Employee & 1 (either a spouse or child)

$62.32

$10.78

Family

$93.31

$33.70

For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

EXCLUSIVE NETWORK DENTAL PLAN DENTAL DHMO (SNY02)

BENEFIT

IN NETWORK ONLY

Annual Deductible

Not Applicable

Annual Benefit Maximum

Not Applicable

Preventive Services Oral Exams Full Mouth, Panoramic and Bitewing X-rays Cleanings Emergency Care to Relieve Pain Flouride Application Basic Services Fillings Oral Surgery, Simple Extractions Periodontics Root Canal/Therapy Surgical Extraction of Impacted Teeth Relines, Rebases and Adjustments Repairs — Bridges, Crowns and Inlays Repairs — Dentures

See DMO Schedule

Major Services Crowns Dentures Bridges

See DMO Schedule

Orthodontic Services Adults and Children

Subject to Copay

Dependent Age Limit: To age 26; benefits terminate at the end of the month in which the dependent turns 26

PRE-TAX SEMI-MONTHLY CONTRIBUTIONS

Employee

$4.72

Employee & Spouse

$5.68

Employee & Child(ren)

$10.39

Family

$17.44

For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

VISION CARE PLAN - INSIGHT NETWORK

OUT-OF-NETWORK REIMBURSEMENT

BENEFIT

IN-NETWORK

FREQUENCY

Eye Examination

Up to $40

Every 12 months

$20 Copay

Retinal Imaging

Up to $39 reimbursement

Not covered

Every 12 months

Lenses Single Vision Lined Bifocal Lined Trifocal Lenticular

$25 Copay $25 Copay $25 Copay $25 Copay $90 Copay

Up to $30 Up to $50 Up to $70 Up to $70 Up to $50 Up to $50 Up to $50 Up to $50 Up to $50

Standard Progressive Premium Progressive

Every 12 months

Tier 1 Tier 2 Tier 3 Tier 4

$110 Copay $120 Copay $135 Copay $90 Copay 80% of charge less $120 allowance

Contact Lenses Medically Necessary

$0 Copay Paid In Full

Up to $300

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Conventional

$0 Copay $150 allowance, 15% off balance over $150 $0 Copay $150 allowance 100% of balance over $150

Up to $150

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Every 12 months

Disposable

Up to $150

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Contact Lens Fit and Follow-up Standard Contact Lens Premium Contact Lens

Up to $40 reimbursement 10% off retail

Not Covered Not Covered

Frames

$0 copay $150 allowance 20% off balance over $150

Up to $105

Every 24 months

Dependent Age Limit: To age 26; benefits terminate at the end of the month in which the dependent turns 26

PRE-TAX MONTHLY CONTRIBUTIONS

Employee

$6.61

Family

$16.87

Contributions are deducted on a monthly basis on the second paycheck of every month

For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

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For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

PRE-TAX BENEFIT

EXAMPLES OF ELIGIBLE EXPENSES

CONTRIBUTION LIMITS

ACCESS TO FUNDS

ACCOUNT TYPE

• Medical Plan Deductibles • Prescription Drugs • OTC Medications • Vision Exams/Glasses/ Contacts

Enrollees will receive a Beniversal Mastercard that can be used to pay for eligible expenses. Employees have immediate access to the entire contribution amount from the 1st day of the benefit year, before contributions have been made Enrollees will receive a Beniversal Mastercard that can be used to pay for eligible expenses. Employees have immediate access to the entire contribution amount from the 1st day of the benefit year, before contributions have been made You will be able to submit claims up to your year-to-date accumulated amount in your account (You will only be reimbursed based on your accumulated contribution amounts)

Maximum contribution is $3,200 for the 2024 plan year Any amounts of $610 or less remaining at the end of the plan year (December 31, 2024) will automatically roll over to the following plan year Maximum contribution is $3,200 for the 2024 plan year for Dental and Vision Expenses only Any amounts of $610 or less remaining at the end of the plan year (December 31, 2024) will automatically roll over to the following plan year

HEALTH CARE FSA

• Save 20% - 40% on your health care expenses • Save on eligible purchases not covered by insurance • Reduce your taxable income

• Laser Eye Surgery • Menstrual products

Only Dental and Vision Expenses are eligible for reimbursement • Dental and Orthodontia • Vision Exams/Eyeglasses/Contacts • Laser Eye Surgery

LIMITED PURPOSE FSA (for employees who participate in the High Deductible Health Plan)

• Daycare • Day Camp • Eldercare • Before and After School Care • MetroCard • LIRR, MetroNorth or other Train Tickets • Rideshares

There is no minimum contribution per year

• Save 20% - 40% on childcare or eldercare expenses

DEPENDENT CARE FSA

Maximum contribution is $5,000 for the 2024 plan year

Between $10 and $315 per month

An employee with a $125 monthly expense saves an estimated $650 annually Employees with higher commuting expenses could save as much as $1,500* annually for both mass transit and parking

Funds in the Commuter Accounts will continue to roll over. You can start and stop deductions throughout the year

MASS TRANSIT

Enrollees will receive a Beniversal Mastercard that can be used to pay for eligible expenses

Between $10 and $315 per month

• Qualified Parking Expenses near work, train or rideshare

Funds in the Commuter Accounts will continue to roll over. You can start and stop deductions throughout the year

PARKING

You may be required to provide substantiation, complete the processing of your claim and check your balance(s). Your contribution are deducted on a bi-weekly basis.

For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

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For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

BENEFIT

Who’s Eligible?

All regular full-time employees working at least 20 hours per week

Life Benefit Amount

Flat $10,000

AD&D Benefit Amount

Flat $10,000

Reduces to 65% of original amount at age 70 Reduces to 50% of original amount at age 75

Reduction of Benefits Schedule*

Accelerated Life Benefit

50% of benefit amount

Seatbelt(s) Benefit

10% of benefit amount

5% of benefit amount

Air Bag Benefit

Available

Portability

Available

Conversion

*Note: Automatic reduction of benefit occurs at end of year after attained age

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For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

BENEFIT

EMPLOYEE

SPOUSE

DEPENDENT CHILDREN

Benefit Amount

Up to 5 times your annual salary in increments of $10,000

Increments of $5,000

Increments of $2,000

Minimum Benefit Amount

$10,000

$5,000

$2,000

Maximum Benefit Amount

Less than or equal to 100% of the Employee benefit amount, not to exceed $10,000

Less than or equal to 100% of the Employee benefit amount, not to exceed $250,000

$500,000

Benefit for child(ren) from birth to 6 months $1,000

Guaranteed Coverage Amount*

$150,000

$25,000

$10,000

Reduction of Benefits Schedule

65% of original benefit at age 70 50% of original benefit at age 75

65% of original benefit when employee turns age 70 50% of original benefit when employee turns age 75

No Reduction

*Guaranteed coverage means the maximum amount of coverage available to new hires without medical information required. If you are a current active, full-time employee looking to enroll, Evidence of Insurability will be required for any elected amounts. VOLUNTARY LIFE INSURANCE MONTHLY RATES

EMPLOYEE RATES

SPOUSE RATES

CHILD(REN) RATE

RATE PER $10,000 OF BENEFIT

RATE PER $5,000 OF BENEFIT

RATE PER $2,000 OF BENEFIT

AGE

Birth to age 19 (26 if full-time student)

Under 25

$0.500

50-54

$3.680

Under 25

$0.330

50-54

$2.425

$0.773

25-29

$0.600

55-59

$5.660

25-29

$0.375

55-59

$3.720

30-34

$0.800

60-64

$8.840

30-34

$0.475

60-64

$6.355

35-39

$1.010

65-69

$15.330

35-39

$0.695

65-69

$10.860

40-44

$1.450

70-74

$27.350

40-44

$0.995

70-74

$19.345

45-49

$2.320

75+

$53.610

45-49

$1.555

75+

$38.745

Employee

$______,000

÷ $10,000 = $_____

X $____________

= $____________

$______,000

÷ $5,000 = $_____

X $____________

Spouse

= $____________

$______,000

÷ $2,000 = $_____

X $____________

Child

= $____________

Total Cost

For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

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For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

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BENEFIT

ACCIDENT INSURANCE

$50,000

Employee Accidental Death

$400

Ground Ambulance

$150

Emergency Room

$165 (Per day)

Hospital Confinement

$165 (Per day)

Intensive Care Unit Confinement

$1,500

Major Surgery

$250

Minor Surgery

$750

Singular Prosthetic Limb

$1,500

Multiple Prosthetic Limbs

$300

Eye Injury

See Schedule of benefits for full list of covered benefits

ACCIDENT INSURANCE MONTHLY RATES

Employee

Spouse

Dependent(s)

Family

$11.38

$18.34

$21.22

$28.18

For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

VOLUNTARY LONG TERM DISABILITY

BENEFIT

Benefit Percentage

60% of pre-disability earnings

2 years own occupation, any occupation thereafter to age 65

Definition of Disability

Maximum Monthly Benefit

$3,000

Elimination Period

90 days

Maximum Benefit Duration

Social Security Retirement Age

Pre-existing Conditions Limitations*

6/12*

MAXIMUM MONTHLY BENEFIT

$______,000

÷ $10,000 = $_____

X 60%_________

= $____________

Your annual earnings

Divide by 12 to get your monthly earnings

X by 60% (Maximum covered income)

Maximum monthly benefit available (up to $3,000)

COST PER PAYCHECK CALCULATOR

$______,000

÷ $100 = $_____

X $_________

= $__________÷ 12

=$________________

Your annual earnings

Divide by 100

X by your rate

Total cost per paycheck

VOLUNTARY LONG TERM DISABILITY MONTHLY RATE PER $100 OF BENEFIT

AGE

RATE

AGE

RATE

AGE

RATE

15 - 24

$0.21

45 - 49

$1.18

70+

$2.76

25 - 29

$0.30

50 - 54

$1.57

30 - 34

$0.49

55 - 59

$1.89

35 - 39

$0.69

60 - 64

$1.85

40 - 44

$0.86

65 - 69

$2.17

For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

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CATEGORY 1

CATEGORY 2

CATEGORY 3

Heart Attack

Benign Brain Tumor

Cancer

Stroke

Carcinoma in situ - pays 25% of your coverage amount. (Carcinoma in situ is defined as cancer that involves only cells in the tissue in which it began and that has not spread to nearby tissues

Major Organ Failure

Coronary Artery Disease

End Stage Renal (kidney) Failure

Skin Cancer - pays $250 benefit per person per lifetime. Not part of the 100% payout.

Blood tests

Chest X-rays

Stress tests

Colonoscopies

Mammograms

Other tests listed in your policy

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For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

PLAN HIGHLIGHTS

Hospital Admission

$1,500 per insured per calendar year

Daily Hospital Confinement

$165 per day; to a maximum of 60 days per calendar year

Portability

Included

Family Coverage Options

Employee, Spouse or Domestic Partner and Child Employee must have coverage in order for spouse and child to participate Employee/Spouse At initial enrollment or when first eligible, health questions are not required for the employee or spouse Pre-Existing Conditions are not covered under the plan. This means any covered person having a sickness or physical condition for which medical advice or treatment was recommended by a physician or received from a physician within 6 months before the coverage effective date. After this policy has been in force for 12 months, Unum will pay benefits for any loss as a result of a pre-existing condition not excluded by name or specific description if the covered loss began 12 months after the effective date of the policy.

Evidence of Insurability (Health Questions)

Pre-existing Condition Limitation

MONTHLY PREMIUMS

Employee + Spouse

Employee + Child(ren)

Age Band

Employee

Family

17 - 49

$17.80

$35.65

$26.15

$44.00

50 - 59

$23.19

$47.67

$31.54

$56.02

60 - 64

$32.46

$67.00

$40.81

$75.35

65+

$48.93

$101.39

$57.28

$109.74

For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

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For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

PACKAGE TYPE

TYPE OF EMPLOYEE

MEMBERSHIP PLAN

INITIATION

DUES

NOTES

Full Time 24+ hrs.

PIF (Paid in Full upfront)

$400

No refund

Full Time 24+ hrs.

PIF 3+ Family Members

200

No refund

Full Time 24+ hrs.

EFT (External Funds Transfer - CC on account)

$50

Monthly $29.99

CC on file

Full Time 24+ hrs.

FT 3+Family Members - 1 EFT account**

$50

Monthly $19.99

CC on file

Full Time 24+ hrs.

MTM (Month by Month)

$50

No freeze

Full Time 24+ hrs.

Pay As You Go* - trial visit

$25

Limit of 2

Part Time 15 - 23 hrs.

PIF

$550

No refund

PIF 2 nd Family Member

Part Time 15 - 23 hrs.

$450

No refund

Part Time 15 - 23 hrs.

PIF 3+ Family Members

$200

No refund

Part Time 15 - 23 hrs.

EFT

$50

Monthly $49.99

CC on file

Part Time 15 - 23 hrs.

EFT 3+Family Members - 1 EFT account**

$50

Monthly $19.99

CC on file

Part Time 15 - 23 hrs.

MTM

$99

No freeze

Part Time 15 - 23 hrs.

Pay As You Go - trial visit

$25

Limit of 2

0-14 hrs.

PIF

Annually $699

No refund

PIF 2 nd Family Member

0-14 hrs.

Annually $599

No refund

0-14 hrs.

PIF 3+ Family Members

$200

No refund

0-14 hrs.

EFT Standard

$75

Monthly $64.99

CC on file

EFT 2 nd Family Member

0-14 hrs.

$50

Monthly $59.99

CC on file

0-14 hrs.

EFT 3+ Family Members - 1 EFT account

$50

Monthly $19.99

CC on file

0-14 hrs.

MTM

$99

No freeze

0-14 hrs.

Pay As You Go - trial visit

$25

Limit of 2

*Please contact the Fitness Center at 718.686.3701 should you have any further questions.

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DAY OF THE WEEK

MEN**

WOMEN**

Sunday

5:15pm - 12am

8am - 2pm

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Monday

6:30am - 10am

11am - 2:30pm & 5pm - 9pm

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Tuesday

5:15pm - 12am

6:30am - 1pm

Wednesday

6:30am - 10am

11am - 2:30pm & 5pm -11:30pm

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Thursday

5:15pm - 12am

6:30am - 2:30pm

Friday

6:30am - 10am

10:30am - 1pm

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**Pool closes 1/2 hour before shift ends. **Fitness room closes 5 minutes before shift ends. ALL PATRONS MUST EXIT FITNESS CENTER BY CLOSING TIME PROMPTLY.

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NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT OF 1996 (NEWBORN’S ACT) Group health plans and health insurance issuers generally may not, under federal law, 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 cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). THE WOMEN’S HEALTH A ND CANCER RIGHTS ACT OF 1998 (WHCRA, ALSO KNOWN AS JANET’S LAW) Under WHCRA, group health plans, insurance companies and health maintenance organizations (HMOs) offering mastectomy coverage must also provide coverage for reconstructive surgery in a manner determined in consultation with the attending physician and the patient. Coverage includes reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and treatment of physical complications at all stages of the mastectomy, including lymph edemas. Call your Plan Administrator for more information. QUALIFIED MEDICAL CHILD SUPPORT ORDER (QMCSO) QMCSO is a medical child support order issued under State law that creates or recognizes the existence of an “alternate recipient’s” right to receive benefits for which a participant or beneficiary is eligible under a group health plan. An “alternate recipient” is any child of a participant (including a child adopted by or placed for adoption with a participant in a group health plan) who is recognized under a medical child support order as having a right to enrollment under a group health plan with respect to such participant. Upon receipt, the administrator of a group health plan is required to determine, within a reasonable period of time, whether a medical child support order is qualified, and to administer benefits in accordance with the applicable terms of each order that is qualified. In the event you are served with a notice to provide medical coverage for a dependent child as the result of a legal determination, you may obtain information from your employer on the rules for seeking to enact such coverage. These rules are provided at no cost to you and may be requested from your employer at any time. SPECIAL ENROLLMENT RIGHTS (HIPAA) If you have previously declined enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 30 days after

your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. COVERAGE EXTENSION RIGHTS UNDER THE UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA) If you leave your job to perform military service, you have the right to elect to continue your existing employer-based health plan coverage for you and your dependents (including spouse) for up to 24 months while in the military. Even if you do not elect to continue coverage during your military service, you have the right to be reinstated in your employer’s health plan when you are reemployed, generally without any waiting periods or exclusions for pre-existing conditions except for service-connected injuries or illnesses. MICHELLE’S LAW Michelle’s Law permits seriously ill or injured college students to continue coverage under a group health plan when they must leave school on a full-time basis due to their injury or illness and would otherwise lose coverage. The continuation of coverage applies to a dependent child’s leave of absence from (or other change in enrollment) a postsecondary educational institution (college or university) because of a serious illness or injury, while covered under a health plan. This would otherwise cause the child to lose dependent status under the terms of the plan. Coverage will be continued until: 1. One year from the start of the medically necessary leave of absence, or 2. The date on which the coverage would otherwise terminate under the terms of the health plan; whichever is earlier. MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008 This act expands the mental health parity requirements in the Employee Retirement Income Security Act, the Internal Revenue Code and the Public Health Services Act by imposing new mandates on group health plans that provide both medical and surgical benefits and mental health or substance abuse disorder benefits. Among the new requirements, such plans (or the health insurance coverage offered in connection with such plans) must ensure that: The financial requirements applicable to mental health or substance abuse disorder benefits are no more restrictive that the predominant financial requirements applied to substantially all medical and surgical benefits covered by the plan (or coverage), and there are no separate cost sharing requirements that are applicable only with respect to mental health or substance abuse disorder benefits. GENETIC INFORMATION NON-DISCRIMINATION ACT (GINA) GINA broadly prohibits covered employers from discriminating against an employee, individual, or member because of the employee’s “genetic

information,” which is broadly defined in GINA to mean (1) genetic tests of the individual, (2) genetic tests of family members of the individual, and (3) the manifestation of a disease or disorder in family members of such individual. GINA also prohibits employers from requesting, requiring, or purchasing an employee’s genetic information. This prohibition does not extend to information that is requested or required to comply with the certification requirements of family and medical leave laws, or to information inadvertently obtained through lawful inquiries under, for example, the Americans with Disabilities Act, provided the employer does not use the information in any discriminatory manner. In the event a covered employer lawfully (or inadvertently) acquires genetic information, the information must be kept in a separate file and treated as a confidential medical record, and may be disclosed to third parties only in very limited situations. The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires employers who provide medical coverage to their employees to offer such coverage to employees and covered family members on a temporary basis when there has been a change in circumstances that would otherwise result in a loss of such coverage [26 USC §4980B ] This benefit, known as “continuation coverage,” applies if, for example, dependent children become independent, spouses get divorced, or employees leave the employer. CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA) CHILDREN'S HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT (CHIPRA) Effective April 1, 2009 employees and dependents who are eligible for coverage, but who have not enrolled, have the right to elect coverage during the plan year under two circumstances: • The employee’s or dependent’s state Medicaid or CHIP (Children's Health Insurance Program) coverage terminates because the individual cease to be eligible. • The employee or dependent becomes eligible for a CHIP premium assistance subsidy under state Medicaid or CHIP (Children's Health Insurance Program). Employees must request this special enrollment within 60 days of the loss of coverage and/or within 60 days of when eligibility is determined for the premium subsidy. PREMIUM ASSISTANCE UNDER MEDICAID AND CHILDREN’S HEALTH IN SURANCE 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, 2023.

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: https://health.alaska.gov/ dpa/Pages/default.aspx

ARKANSAS – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

CALIFORNIA – Medicaid Health Insurance Premium Payment (HIPP) Program Website:

http://dhcs.ca.gov/hipp Phone: 916-445-8322 Fax: 916-440-5676 Email: hipp@dhcs.ca.gov

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://hcpf.colorado.gov/child-health-plan -plus CHP+ Customer Service: 1-800-359-1991/State Relay 711 Health Insurance Buy-In Program (HIBI): https:// www.mycohibi.com/ HIBI Customer Service: 1-855-692-6442 FLORIDA – Medicaid Website: https:// www.flmedicaidtplrecovery.com/ flmedicaidtplrecovery.com/hipp/index.html Phone: 1-877-357-3268 GEORGIA – Medicaid GA HIPP Website: https://medicaid.georgia.gov/ health-insurance-premium-payment-program-hipp 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: https://www.in.gov/medicaid/ Phone: 1-800-457-4584 IOWA – Medicaid and CHIP (Hawki) Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563 HIPP Website: https://dhs.iowa.gov/ime/ KENTUCKY – Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/ Pages/kihipp.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: https://kidshealth.ky.gov/Pages/ index.aspx Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov/ agencies/dms LOUISIANA – Medicaid Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP) Phone: 678-564-1162, Press 1 GA CHIPRA Website: https:// medicaid.georgia.gov/programs/third-party liability/childrens-health-insurance-program reauthorization-act-2009-chipra Phone: 678-564-1162, Press 2 members/medicaid-a-to-z/hipp HIPP Phone: 1-888-346-9562 KANSAS – Medicaid Website: https://www.kancare.ks.gov/ Phone: 1-800-792-4884 HIPP Phone: 1-800-967-4660

Enrollment Website: https:// www.mymaineconnection.gov/benefits/s/? language=en_US

Phone: 919-855-4100

CHIP Toll-free phone: 1-855-MyWVHIPP (1-855 699-8447)

NORTH DAKOTA – Medicaid Website: https://www.hhs.nd.gov/healthcare Phone: 1-844-854-4825 OKLAHOMA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 OREGON – Medicaid Website: http://healthcare.oregon.gov/Pages/ index.aspx Phone: 1-800-699-9075 PENNSYLVANIA – Medicaid and CHIP Website: https://www.dhs.pa.gov/Services/ Assistance/Pages/HIPP-Program.aspx Phone: 1-800-692-7462 CHIP Website: Children's Health Insurance Program (CHIP) (pa.gov) CHIP Phone: 1-800-986-KIDS (5437)

Phone: 1-800-442-6003 TTY: Maine relay 711

WISCONSIN – Medicaid and CHIP Website: https://www.dhs.wisconsin.gov/badgercareplus/ p-10095.htm Phone: 1-800-362-3002 WYOMING – Medicaid Website: https://health.wyo.gov/healthcarefin/ medicaid/programs-and-eligibility/ Phone: 1-800-251-1269 To see if any other states have added a premium assistance program since July 31, 2023, 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.

Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications forms

Phone: 1-800-977-6740 TTY: Maine relay 711

MASSACHUSETTS – Medicaid and CHIP Website: https://www.mass.gov/masshealth/pa Phone: 1-800-862-4840 TTY: 711 Email: masspremassistance@accenture.com MINNESOTA – Medicaid Website: https://mn.gov/dhs/people-we-serve/ children-and-families/health-care/health-care programs/programs-and-services/other insurance.jsp Phone: 1-800-657-3739

RHODE ISLAND – Medicaid and CHIP Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line) SOUTH CAROLINA – Medicaid Website: https://www.scdhhs.gov Phone: 1-888-549-0820

MISSOURI – Medicaid Website: http://www.dss.mo.gov/mhd/ participants/pages/hipp.htm Phone: 573-751-2005 MONTANA – Medicaid Website: http://dphhs.mt.gov/ MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084 Email: HHSHIPPProgram@mt.gov

SOUTH DAKOTA - Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059

NEBRASKA – Medicaid Website: http://www.ACCESSNebraska.ne.gov

TEXAS – Medicaid Website: Health Insurance Premium Payment (HIPP) Program | Texas Health and Human Services 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: Health Insurance Premium Payment (HIPP) Program | Department of Vermont Health Access Phone: 1-800-250-8427 VIRGINIA – Medicaid and CHIP Website: https://coverva.dmas.virginia.gov/learn/ premium-assistance/famis-select https://coverva.dmas.virginia.gov/learn/premium assistance/health-insurance-premium-payment hipp-programs Medicaid/CHIP Phone: 1-800-432-5924 WASHINGTON – Medicaid Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022 Website: https:// dhhr.wv.gov/bms/

Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178

NEVADA – Medicaid Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900

NEW HAMPSHIRE – Medicaid Website: https://www.dhhs.nh.gov/programs services/medicaid/health-insurance-premium program Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852 3345, ext. 5218 NEW JERSEY – Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/ index.html CHIP Phone: 1-800-701-0710

NEW YORK – Medicaid Website: https://www.health.ny.gov/

OMB Control Number 1210-0137 (expires 1/31/2026 )

health_care/medicaid/ Phone: 1-800-541-2831

WEST VIRGINIA – Medicaid and CHIP http://mywvhipp.com/ Medicaid Phone: 304-558-1700

MAINE – Medicaid

NORTH CAROLINA – Medicaid Website: https://medicaid.ncdhhs.gov/

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