G4S Technology Benefits Guide November 1, 2016 – October 31, 2017
I
II
Directory of Resources Plan
Contact
Policy Number
Phone Number
Website
Medical
Blue Cross Blue Shield
71-60706
888-350-2583
www.myhealthtoolkitFL.com
Pharmacy
CVS Caremark
0360
800-930-5196
www.caremark.com
Dental
Delta Dental
16078
800-471-4318
www.deltadentalins.com/G4S
Vision
VSP
12087382
800-877-7195
www.VSP.com
Basic Life and AD&D
Reliance Standard
GL154931
800-351-7500
www.reliancestandard.com
Disability
Reliance Standard
STD164437 LTD126777
800-351-7500
www.reliancestandard.com
EAP
Reliance Standard
855-775-4357
http://rsli.acieap.com
FSA
WageWorks
877-924-3967
www.wageworks.com
Online Enrollment
G4S Benefits Service Center
G4S Technology HR
Human Resources: Angie Nicholson
844-474-6626
https://G4S.benefitsnow.com
402-233-7613
Email:
[email protected]
This brochure is only a brief summary of your benefits and does not constitute a policy. Your certificate booklets will contain the actual detailed provisions of your benefits. All certificate booklets and Summary of Benefits and Coverage (SBC) can be found on the G4S Technology intranet at https://portal.g4stechnologyus.net
III
Table of Contents G4S Benefits Center.........................................................................................................................................I Directory of Resources ................................................................................................................................ .III Table of Contents ..........................................................................................................................................IV Enrollment and Eligibility .............................................................................................................................. 3 Medical Coverage ......................................................................................................................................... 7 Dental Coverage .......................................................................................................................................... 12 Vision Coverage........................................................................................................................................... 13 Group Life and Accidental Death and Dismemberment (AD&D) Insurance .............................................. 14 Supplemental Life and Accidental Death and Dismemberment (AD&D) Insurance ................................... 16 Disability Income Benefits........................................................................................................................... 18 Employee Assistance Program (EAP) .......................................................................................................... 20 Flexible Spending Accounts ........................................................................................................................ 21 Legal Notices ............................................................................................................................................... 22
IV
Enrollment and Eligibility G4S Technology is committed to providing you with a competitive benefits program that gives you and your family a comprehensive level of coverage and protection. Your benefits package includes the following programs:
Medical/Rx Coverage
Dental Coverage
Vision Coverage
Basic Life/AD&D
Supplemental Life
Short Term/Long Term Disability
401(k)
And More...
Benefit Plan Eligibility You are eligible to participate in all benefit programs that G4S Technology offers if you are classified as a full-time employee (30 or more hours per week). If you are classified as a part-time employee, you may become eligible for benefits if you averaged 30 hours or more for the preceding 12-month period from September 1, 2016 - August 31, 2017. Certain plans also permit you to cover your eligible dependents. Your eligible dependents include your:
Legal spouse
Domestic partner (California employees only)
For medical, dental and vision coverage, dependent children to age 26 regardless of marital status, student status, level of support provided, or residency
An employee's "Child" includes a natural child, stepchild, adopted child (or a child placed with the employee for adoption). An employee's child will be an eligible dependent until reaching the limiting age without regard to student status, marital status, financial dependency or residency status with the employee or any other person. When the child reaches the applicable limiting age, coverage will end on the last day of the child's birthday month.
Initial Eligibility Period You are eligible to participate in the G4S Technology Benefits Program on the first day of the month following 30 days of employment.
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Enrollment and Eligibility Making Changes During the Year Enrollment changes outside the Open Enrollment period are not permitted, unless you experience a Qualifying Life Status Event (QLSE) as defined by the Internal Revenue Service (IRS). Examples of Qualifying Life Status Events include:
Marriage, divorce or legal separation,
Birth or adoption of a child,
Death of a spouse or dependent,
A change in employment status for you or your spouse affecting healthcare coverage, such as changing from fulltime to part-time employment (i.e. a reduction in hours) or your spouse ending or starting employment,
COBRA coverage under another health plan is exhausted,
A dependent child satisfies or ceases to satisfy plan requirements (such as age limitations),
Entitlement to, or loss of, Medicare or Medicaid benefits,
A change in place of residence for you, your spouse or your dependent that affects healthcare coverage, or
Termination of other health coverage.
Any changes to your election must be made within 30 days* of the event. If you do not change your coverage within 30 days* of the event, you will have to wait until the next open enrollment period to make a change. * The deadline to change your elections and provide documentation is 60 days for qualifying life events involving Medicare, Medicaid or State Children’s Health Plan.
You must provide information and documentation that is necessary to verify your qualified change in status as required by G4S Technology. Please see the “Required Documentation for Eligible Dependents” section on the next page to see examples of documentation that may be required.
Qualfying Life Status changes can now be updated on the G4S Benefits Service Center at:
https://G4S.benefitsnow.com
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Enrollment and Eligibility Qualifying Life Events Below is a partial list of common Qualifying Life Status Events and how you can update your benefits mid-year:
Medical / Dental / Vision
Voluntary Life Insurance
Marriage
Enroll self, spouse and newly acquired child(ren) in all plans.
May enroll, increase coverage and/or add new spouse and/or child(ren) with evidence of insurability.
Enroll, drop, increase or decrease.
Birth / Adoption / Placement for Adoption
Enroll self and/or child(ren) in all plans.
May enroll, increase coverage and/or add new spouse and/or child(ren) with evidence of insurability.
Enroll or increase coverage.
Divorce/Legal Separation/ Annulment
Enroll self and/or child(ren) in all plans and drop spouse.
May enroll, increase coverage with evidence of insurability and/or add or drop spouse and/or child(ren).
Enroll, drop, increase or decrease.
Significant change in benefits
Enroll self, spouse, and/ or child(ren) in all plans.
May enroll, increase coverage with evidence of insurability and/or add or drop spouse and/or child(ren).
No change allowed.
Qualified Life Status Events
Flexible Spending Accounts (FSA)
Required Documentation for Eligible Dependents You WILL be required to provide verification of dependent eligibility when enrolling. You will be asked to provide supporting documentation for adding your dependents (e.g. marriage certificate when adding spouse, birth certificate when adding a child and domestic partner registration when adding a domestic partner). If you do not provide the required documentation within your designated enrollment window, your dependent will be considered ineligible and unable to enroll in G4S Technology’s benefit program.
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Enrollment and Eligibility When Coverage Ends Coverage for Medical, Dental and Vision for you and your dependents ends on the last day of the month in which your active employment terminates or when you no longer meet the plan’s eligibility requirements. Coverage for your dependents may also terminate at the end of the month when they no longer meet the definition of an eligible dependent. Under certain circumstances, you may be able to continue some benefit coverages for yourself and your dependents through COBRA or the portability/conversion provisions of the plans. Coverage for Life and Disability ends the day your employment ends. If you choose to keep your Life coverage you have the option to port or convert your current coverage to an individual policy. To do so, contact Reliance Standard at (800) 351-7500 Monday through Friday between 8:00am and 7:00pm Eastern Time and provide the contract number GL154931 when calling.
When Coverage Ends Plan
Last Day of Coverage
BCBS $250 Plan PPO Medical BCBS Plan 45 PPO Medical Delta Dental Vision Service Plan (VSP)
End of Month, following Termination Date End of Month, following Termination Date End of Month, following Termination Date End of Month, following Termination Date
Basic Life & AD&D
Date of Termination
Short Term Disability Core Long Term Disability Buy-Up Long Term Disability
Date of Termination Date of Termination Date of Termination
Supplemental Life and/or AD&D
Date of Termination
Flexible Spending Accounts
Date of Termination
COBRA Eligible Yes Yes Yes Yes No, Conversion for Life Only No No No No, Conversion and/or Portability Only Yes
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Medical Coverage Blue Cross Blue Shield PPO – G4S Technology offers 2 PPO (Preferred Provider Organization) which includes an extensive network. All maximums included in these plans are individual maximums for In-Network and Out-of-Network, unless specifically stated otherwise. Calendar Year Deductible – This is the amount you pay each calendar year before benefits are paid. Medicare Fee Schedule* – When receiving services from Out-of-Network providers, the reimbursement is based on the Medicare Fee Schedule. Wellness Credit - The $50 Wellness gift card is back for employees on the BCBS plans! Gift Cards will be sent out twice a year to employees who have completed their wellness visit.
Benefit Highlights Blue Cross Blue Shield $250 PPO In-Network Out-of-Network*
Benefit Calendar Year Deductible Individual Family Calendar Year Out-of-Pocket Maximum - Individual Family Lifetime Maximum
-
Blue Cross Blue Shield Plan 45 PPO In-Network Out-of-Network*
$250 $500
$500 $1,000
$500 $1,200
$2,500 $5,000
$6,500 $13,000
$6,850 $13,700
Unlimited
$5,000 Per Individual N/A Unlimited
Physician Office Visits
$15 Copay
40% after deductible
$20 Copay
50% after deductible
Specialist Visits
$25 Copay
$45 Copay
50% after deductible
TelaDoc/Telemedicine
$10 Copay
40% after deductible N/A
$10 Copay
N/A
Routine Preventive Care Routine Child and Well Baby Care Pre-Natal Office Visits
No Charge
40% (ded. Waived)
No Charge
50% (ded. Waived)
No Charge
40% (ded. Waived)
No Charge
50% (ded. Waived)
No Charge
40% after deductible
No Charge
50% after deductible
10% after deductible
40% after deductible
20% after deductible
50% after deductible
$20 Copay
40% after deductible
$275 Per Day Copay, ded & coins
50% after deductible
Diagnostic X-Rays and Laboratory Inpatient Hospital** Mental Health/Substance Abuse Inpatient** Outpatient Outpatient Hospital Emergency Room Urgent Care (Physician)
10% after deductible $20 Copay 10% after deductible
40% after deductible 40% after deductible 40% after deductible
$200 Copay $50 Copay 40% after deductible
Chiropractic $25 Copay 40% after deductible (limited to 90 visits/calendar CVS Caremark Prescription Drug Coverage- Retail (30 day supply)*** Generic $10 Copay Retail Copay & Brand Formulary $25 Copay Contracted Rate Brand Non-Formulary $40 Copay CVS Caremark Prescription Drug Coverage- Mail Order (90 day supply)*** Generic $20 Copay Retail Copay & Brand Formulary $50 Copay Contracted Rate Brand Non-Formulary $80 Copay
$275 Per Day Copay, ded & coins $175 Copay, ded & coins $175 Copay, ded & coins
50% after deductible 50% after deductible 50% after deductible
$250 Copay, ded & coins $75 Copay 50% after deductible 20% after deductible
50% after deductible
$10 Copay $30 Copay $60 Copay
Retail Copay & Contracted Rate
$25 Copay $75 Copay $150 Copay
Retail Copay & Contracted Rate
**Subject to a 30 day calendar year maximum on Plan 45 ***Members have the option to receive up to a 90-day supply at retail based on the plan mail order copay Specialty drugs are covered at the plan benefit and only through the PBM CVS Caremark The benefit plan information shown in this guide is illustrative only. To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlying insurance documents will govern in all cases.
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WHEN CAN I USE TELADOC?
So many reasons to use Teladoc®! Teladoc gives you 24/7/365 access to a doctor through the convenience of phone or video consults. It's an affordable option for quality medical care.
• When you need care now • If your doctor is unavailable • If you’re considering the ER or urgent care center for a nonemergency issue • On vacation, on a business trip, or away from home • For short-term prescription refills
GET THE CARE YOU NEED Teladoc doctors can treat many medical conditions, including:
Talk to a doctor anytime, anywhere you happen to be
Receive quality care via phone or online video
Prompt treatment, average call back in 16 min
• • • • • • •
Cold & flu symptoms Allergies Bronchitis Skin problems Respiratory infection Sinus problems And more!
SHARE WITH YOUR PCP
A network of doctors that can treat children of any age
Secure, personal and portable electronic health record (EHR)
No limit on consults, so take your time
With your consent, Teladoc is happy to provide information about your Teladoc consult to your primary care physician.
Talk to a doctor anytime for $10 Teladoc.com
1-800-Teladoc (835-2362)
Facebook.com/Teladoc
Teladoc.com/mobile
© 2015 Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are trademarks of Teladoc, Inc. and may not be used without written permission. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services. Teladoc phone consultations are available 24 hours, 7 days a week while video consultations are available during the hours of 7am to 9pm, 7 days a week.
10E-103A 0914
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Medical Coverage Recommended Preventive Health Screenings For Adults
Adult Health – for ages 18 and over Preventive care is very important for adults. By making some good basic health choices, women and men can boost their own health and well-being. Some of these positive choices include: • Eat a healthy diet • Get regular exercise
• Don’t use tobacco products • Limit alcohol use
• Strive for a healthy weight
Adult Recommendations Screenings Physical Exam
Every year or as directed by your doctor.
Body Mass Index (BMI)
Annually.
Blood Pressure (BP)
At least every 2 years.
Colon Cancer Screening
Beginning at age 50 — colonoscopy every 10 years, or flexible sigmoidoscopy every 5 years or fecal blood test annually.
Diabetes Screening
Those with high blood pressure or high cholesterol should be screened. Others, especially those who are overweight or have additional risk factors should consider screening every 3 years.
Heart Screening
Beginning at age 65.
Vision Screening
Every year.
Immunizations
*
Tetanus Diphtheria Pertussis (Td/Tdap)
Get Tdap vaccine once, then a Td booster every 10 years.
Influenza (Flu)
Yearly.
Herpes Zoster (Shingles)
1 dose given at age 60 and over.
Varicella (Chicken Pox)
2 doses if no evidence of immunity.
Pneumococcal (Pneumonia)
1-2 doses for adults ages 19 and over.
Measles, Mumps, Rubella (MMR)
1 or 2 doses for adults ages 18-55 if no evidence of immunity.
Human Papillomavirus (HPV)
3 doses for women ages 19-26 if not already given. 3 doses for men ages 19-21 if not already given.*
Hepatitis A
2 doses for adults age 19 and over.**
Hepatitis B
3 doses for ages 19 and over.**
Recommendations may vary. Discuss the start and frequency of screenings with your doctor, especially if you are at increased risk. For select populations. Discuss with your doctor if this vaccine is right for you.
**
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Recommended Preventive Health Screenings and Vaccines for Children
Children’s Health Put your children on the path to wellness by scheduling regular office visits with a doctor. The doctor will watch your baby’s growth and progress, and should talk with you about eating and sleeping habits, safety and behavior issues. According to the Bright Futures recommendations from the American Academy of Pediatrics, the doctor should: • Check your child’s body mass index percentile regularly beginning at age 2.
• Test vision yearly from ages 3 to 6, then at ages 8, 10, 12 and 15.
• Conduct a yearly wellness exam beginning at age 3.
• Test hearing yearly from ages 4 to 6, then at ages 8 and 10.
• Check blood pressure yearly from age 3 to age 18.
Make sure your child gets the recommended immunizations shown in the charts. Not only do they protect children from sickness, they also lay the basis for good health in the future. It’s never too late to catch up on a missed vaccination. Ask your doctor how to catch up. Routine Children’s Immunization Schedule* Vaccine
Hepatitis B (HepB)
Birth
l
1 month
2 4 6 12 15 18 months months months months months months
l
4-6 years
l
Rotavirus (RV)
l
l
l
Diphtheria Tetanus and Pertussis (DTaP)
l
l
l
Haemophilus Influenzae Type B (Hib)
l
l
l**
l
Pneumococcal Conjugate (PCV)
l
l
l
l
Inactivated Polio Vaccine (IPV)
l
l
Influenza (Flu)
1.5-3 years
**
l†
l
l
l
l Recommended yearly starting at age 6 months with 2 doses given the first year.
Measles, Mumps and Rubella (MMR)
l
l
Varicella (Chicken pox)
l
l
Hepatitis A (HepA)
l First dose: 12-23 months. l Second dose: 6-18 months later.
l One dose n Range of recommended dates ** Number of doses needed varies depending on vaccine used. Ask your doctor. † The fourth dose of DTaP may be given as early as 12 months, as long as at least six months have passed since the third dose.
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Medical Coverage Medical Resources – BCBS Medical Programs Programs to help you learn to live a healthier life
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Dental Coverage Dental Overview The dental coverage offered by G4S Technology is provided through Delta Dental. If you select the Dental PPO plan, you may select and access any dentist you choose – however, if your dentist is not in the Delta Dental network, you may be responsible for a larger outof-pocket cost.
Benefit Summary Benefit
Delta Dental In-Network
Out-Of-Network $50
Individual Deductible Family Deductible
$150
Calendar Plan Year Maximum Benefit
(Applies to Preventive, Basic and Major Services Only)
$1,500
Orthodontia Lifetime Maximum *
$1,500
Periodontal Lifetime Benefits*
$1,000
(per each Enrollee)
Non Surgical TMJ Lifetime Benefits*
$1,000
(per each Enrollee)
Member Responsibility Preventive (exams, x-rays, cleaning, fluoride, sealants) Basic Restorative (fillings, extractions, oral surgery, endodontics, periodontics) Major Restorative (crowns, dentures, bridges and implants) Orthodontia - adults & child(ren)
No Charge
No Charge (up to UCR)
20%
20% of UCR
50%
50% of UCR
50%
50% of UCR
* Out-of-network benefits are based on UCR. UCR is the Reasonable and customary charge based on the type of services and the geographical location where the service was provided. The member may be responsible for balance billing.
charges in excess of UCR in addition to the out-of-network coinsurance
Delta Dental’s Online Dental Resources Delta Dental’s dental website, customized for G4S: www.deltadentalins.com/G4S contains valuable information for you and your family members about dental conditions, checking your personal dental history, finding an in-network dentist or printing an ID Card. Before you are enrolled: You can search for providers for dental without registering as a member. Go to www.deltadentalins.com, and click on either “Dental” under Find a Provider. Follow the instructions for accessing network provider information.
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Vision Coverage Vision Overview The vision coverage offered by G4S Technology is provided through Vision Service Plan (VSP) network.
Benefit Summary VSP Benefits
In-Network
Out-Of-Network
Eye Exams (every 12 months)
$10 copay
Up to $45 allowance
Prescription Glasses
$15 copay
See frame and lenses
Standard Lenses (every 12 months)
Included in Prescription Glasses
Single Bifocal Trifocal
Frames (Every 24 months)
Covered 100% Covered 100% Covered 100%
Up to $45 allowance Up to $65 allowance Up to $85 allowance
Up to $175 allowance wide selection; $195 allowance featured frame brands; 20% savings amount over allowance $95 Costco, Walmart or Sam's Club frame allowance
Up to $70 allowance
Elective Contact Lenses (in lieu of frames) (Every 12 months)
Up to $60 copay for fitting & evaluation ($150 allowance for contacts; copay does not apply)
Up to $105 allowance
Elective (conventional)
Vision Resources
Find the right Vision doctor for you at www.vsp.com or by calling 800-877-7195.
Already have a VSP doctor? Make an appointment and tell them you’re a VSP member.
When you use a VSP provider, No ID card is necessary and there are no claim forms to complete.
Extra discounts and savings
Average 35-40% savings on lens options like progressives and scratch-resistant and anti-reflective coatings. 30% off additional pairs of prescription glasses and/or non-prescription sunglasses purchased on the same day of their covered eye exam. 20% off additional pairs of glasses valid through any VSP Preferred Provider within 12 months of the last covered eye exam. 15% off cost of contact lens exam (fitting and evaluation) available from any VSP doctor within 12 months of your last eye exam. Average 15-20% off the regular price or 5% off the promotional price. Discounts only available from contracted facilities.
13
Group Life and Accidental Death and Dismemberment (AD&D) Insurance Actively at Work If you are on an approved Leave of Absence (FMLA, Personal Medical Leave, Personal Non-Medical Leave, Workers’ Compensation, Military Leave), you are not considered actively at work. If you are not actively at work on the day the coverage is approved, the coverage will be pended until the first day you return to an actively at work, benefit eligible status.
Evidence of Insurability If you are making elections or changes which require Evidence of Insurability, please complete Prudential’s Evidence of Insurability form and submit to Reliance Standard. You and/or your spouse’s requested amount will be effective the first of the month following Prudential’s approval.
Portability/Conversion You can convert your Basic Life at any time if your coverage and have the option to convert or port you Supplemental life at any time coverage is lost for the following reasons:
Termination of employment, including retirement (conversion only for retirement and disability) Become ineligible for benefits due to a reduction in hours, The ported coverage ends, or G4S Technology’s policy is cancelled and coverage is not provided through a successor carrier (total loss of coverage) or replacement coverage is less than what you had in force (lost amounts can be converted).
Coverage for your spouse or child can be converted when coverage is lost due to divorce, reaching the maximum age of coverage for the group plan, reaching the age of majority (child) or the subscriber’s employment is terminated. You and/or your dependents may convert up to the in force amount lost and coverage amount cannot be increased. Evidence of Insurability is not required. To do so you must complete an application and apply for these options within 31 days of your coverage termination. To obtain an application, please contact Reliance Standard at (800) 351-7500 Monday through Friday between 8:00am and 7:00pm Eastern Time and provide the contract number GL154931
Update your Beneficiary! Please remember to keep your beneficiary designations up to date. This will guarantee that your loved ones will be protected. Please contact your HR Representative as soon as possible if you would like to update or check on your beneficiaries.
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Group Basic Life and Accidental Death and Dismemberment (AD&D) Insurance Life and AD&D Benefits G4S Technology provides Basic Life and AD&D coverage at no cost to you. You are automatically enrolled for basic Life and AD&D insurance on the first day of the month following the date you complete 30 days of continuous service and you are actively at work.
Eligibility Benefit Amount Benefit Reductions
AD&D Coverage
Conversion Living Benefits Option
Active, full-time employee working at least 30 hours per week on a regularly scheduled basis 2x annual salary up to $500,000 Reduced by 35% at age 70 Reduced by 50% at age 75 All coverage cancelled at retirement AD&D provides benefits due to certain injuries or death from an accident. The covered injuries or death can occur up to 365 days after the accident. The insurance pays: 100% for loss of life, two limbs, sign of both eyes, one limb and the sight of one eye, or speech and hearing in both ears, or quadriplegia 75% for paraplegia or triplegia (paralysis of three limbs) 50% for loss of one limb, sight of one eye, or speech or hearing in both ears or hemiplegia. 25% for loss of thumb and index finger of the same hand or uniplegia. Total benefit will not be more than 100% of the amount of coverage you purchase. You have the option of converting your group life coverage to your own individual policy when your coverage under the group plan ends. If you are diagnosed as terminally ill with a 12 month life expectancy, you may be eligible to receive payment of a portion of your Life Insurance. The remaining amount of your Life Insurance would be paid to your beneficiary when you die.
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Supplemental Life and Accidental Death and Dismemberment (AD&D) Insurance You may also purchase additional Life and/or AD&D protection for yourself and your dependents. You pay the full cost of these benefits. Eligibility
Active, full-time employee working at least 30 hours per week on a regularly scheduled basis. You must elect employee voluntary Life and AD&D for yourself in order for your dependents to be eligible for voluntary Life and AD&D coverage.
Child Eligibility
Age 19 or 26 if a full-time student
Life Benefit Amount
Employee: 1X to 5X annual salary for Life Spouse: Increments of $10,000 (you must elect voluntary Life for yourself) Child(ren): Increments of $1,000 (you must elect voluntary Life for yourself)
AD&D Benefit Amount
Employee: Increments of $25,000 Spouse: Increments of $10,000 (you must elect voluntary AD&D for yourself) Child(ren): Increments of $1,000 (you must elect voluntary AD&D for yourself)
Maximum Benefit Amount – Life
Employee: Lesser of 5x your annual earnings or $1,000,000 basic and supplemental life combined. Spouse: $250,000 (coverage cannot exceed 50% of amount of your combined basic/supplemental life coverage) Child(ren): $10,000
Maximum Benefit Amount – AD&D
Employee: $500,000 Spouse: $250,000 Child(ren): $25,000
Guaranteed Issue (Life)
Employee: New hires and if currently enrolled in Voluntary Life, you may increase coverage at annual enrollment by the lesser of 1 x salary or $100,000, subject to the non-medical maximum (5 x salary or $600,000) Spouse: offered in increments of $10,000 up to a maximum of $250,000, Evidence of Insurability Required Child(ren): $10,000
Benefit Reductions (Life and AD&D)
Reduced by 35% at age 70 Reduced by 50% at age 75
Conversion/Portability
You have the option of converting or porting your group life coverage to your own individual policy when your coverage under the group plan ends.
Living Benefits Option
If you are diagnosed as terminally ill with a less than 12 month life expectancy, you may be eligible to receive payment of a portion of your Life Insurance. The remaining amount of your Life Insurance would be paid to your beneficiary when you die.
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Supplemental Life and Accidental Death and Dismemberment (AD&D) Insurance Supplemental Life - Cost Per $1000 Age <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+
Voluntary Products Monthly Employee Spouse $0.059 $0.059 $0.059 $0.059 $0.059 $0.059 $0.077 $0.077 $0.122 $0.122 $0.212 $0.212 $0.356 $0.356 $0.578 $0.578 $0.750 $0.750 $1.309 $1.309 $3.421 $3.421 $3.421 $3.421 $7.653 $7.653
Bi Weekly Employee Spouse $0.027 $0.027 $0.027 $0.027 $0.027 $0.027 $0.036 $0.036 $0.056 $0.056 $0.098 $0.098 $0.164 $0.164 $0.267 $0.267 $0.346 $0.346 $0.604 $0.604 $1.579 $1.579 $1.579 $1.579 $3.532 $3.532
Semi Monthly Employee Spouse $0.030 $0.030 $0.030 $0.030 $0.030 $0.030 $0.039 $0.039 $0.061 $0.061 $0.106 $0.106 $0.178 $0.178 $0.289 $0.289 $0.375 $0.375 $0.655 $0.655 $1.711 $1.711 $1.711 $1.711 $3.827 $3.827
Child Life Child AD&D
$0.076 $0.024
N/A N/A
$0.035 $0.011
N/A N/A
$0.038 $0.012
N/A N/A
Voluntary AD&D
$0.024
$0.024
$0.011
$0.011
$0.012
$0.012
Example 1: Male employee age 35, annual earnings: $60,000 Elects 3x annual earnings in addition to the 2x annual earnings from basic life insurance 3x annual earnings = $180,000 Multiple by $0.056 and Divide by 1,000 = $10.08 (This is your per pay period cost) Total amount of Life Insurance = $300,000 or 5x annual earnings. The maximum life benefit is $1,000,000 combined supplemental and basic life benefit.
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Disability Income Benefits Short Term Disability G4S Technology provides Short Term Disability benefits at no cost to you, to protect you and your family in the event of serious illness or injury. Weekly STD benefit
66 2/3% of your weekly earnings
Maximum benefit
$2,000 per week
Elimination period
Duration
The elimination period is the length of time of continuous disability which must be satisfied before you are eligible to receive benefits. If your disability is the result of an injury that occurs while you are covered under the plan, your elimination period is 7 days. If your disability is due to sickness, your elimination period is 7 days. If, because of your disability, you are hospital confined as an inpatient, benefits begin immediately. Up to 26 weeks (including the elimination period)
Your STD benefits may be reduced by the amount of other income replacement benefits you receive from the same disability, such as benefits from state-mandated disability plans, etc. However the minimum weekly benefit is $25.
Long Term Disability (Core) G4S Technology provides core Long Term Disability benefits at no cost to you, to protect you and your family in the event of serious illness or injury. Employees also have the option to buy up Long Term Disability from 60% to 66.67% in coverage. Monthly LTD Benefit
60% of your monthly earnings
Maximum Benefit
$15,000 per month
Elimination Period
Duration
The Elimination Period is the length of time of continuous disability which must be satisfied before you are eligible to receive benefits. LTD benefits would begin after 180 consecutive days of disability, if you are disabled. Your duration of benefits is based on your age when the disability occurs. Your LTD benefits are payable for the period during which you continue to meet the definition of disability. If your disability occurs before age 60, benefits will be payable until age 65. If your disability occurs at or after age 60, benefits would be paid according to a benefit duration schedule.
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Disability Income Benefits Long Term Disability (Buy-up) G4S Technology provides buy-up Long Term Disability benefits giving employees the option to buy additional LTD coverage. This additional coverage increases the financial protection for you and your family in the event of serious illness or injury. If you elect to participate in the Buy-up LTD plan after your initial eligibility date you will need to submit an Evidence of Insurability (EOI) form to Reliance Standard for approval. Your enhanced benefit will go into effect the first of the month following approval. Monthly LTD Benefit
66 2/3% of your monthly earnings (combined with core LTD)
Maximum Benefit
$15,000 per month
Elimination Period
Duration
The Elimination Period is the length of time of continuous disability which must be satisfied before you are eligible to receive benefits. LTD benefits would begin after 180 consecutive days of disability, if you are disabled. Your duration of benefits is based on your age when the disability occurs. Your LTD benefits are payable for the period during which you continue to meet the definition of disability. If your disability occurs before age 60, benefits will be payable until age 65. If your disability occurs at or after age 60, benefits would be paid according to a benefit duration schedule.
Example: Annual Earnings: $60,000 Monthly Earnings (divide by 12) = $5,000 Divide Monthly Earnings (by $100) = $5,000/$100 = $50 Multiply $50 x by the LTD rate (.358) = $50 x $.358 Monthly Cost of Insurance = $17.79
The premium for the buy-up LTD plan is paid with post-tax dollars, meaning your disability benefits will not be taxed. While receiving LTD benefits you will not be required to pay LTD premiums.
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Employee Assistance Program (EAP) Your work-life balance Employee Assistance Program – provided by Reliance Standard – can help you find solutions for the everyday challenges of work and home life as well as for more serious issues involving emotional and physical well-being. G4S Technology offers this benefit at no cost to you. The service is available to you and your family members twenty-four hours a day, 365 days a year, and provides resources to help you find solutions to everyday issues such as:
Childcare and/or eldercare referrals, Personal relationship information, Health information and online tools, Legal consultations with licensed attorneys,
Program Access • All Covered Employees and Family Members Eligible, Regardless of Location or Relationship
Financial planning assistance, Stress management, and Career development.
Legal and Financial Services • Unlimited Phone Consultation for Any Financial Issue
• 24/7, 365 Days-a-year Dedicated Toll-Free Line, Always Live Answer
• Unlimited In-Office or Phone Consultation for Any Legal Issue, 25% Discount for Services Beyond Initial Consultation
• Website, Mobile App, IM, Text, Chat, Email and Video Chat Access to Services
• Online Legal and Financial Resource Center Including Document Preparation
Work-Life Benefits and Resources Assessment and Referral Services
• Unlimited Phone Assessment and Referral for Any Work-Life Need
• Unlimited Telephonic Assessment and Referral
• Unlimited Child, Elder, and Pet Care Referrals and Resources
• Global Network of 52,000+ Licensed Providers
• Unlimited Education, Personal Services, and Health and Wellness Referrals and Resources
• 24/7 Access to Clinicians for Urgent Matters
• Unlimited Veteran Resources and Support Including Veteran Resource Website • Online Resources and Tools for 100+ Work-Life Topics
Additional Questions?
Contact ACI Specialty Benefits toll-free at
855-RSL-HELP (855-775-4357)
[email protected]
Flexible Spending Accounts Flexible Spending Accounts (FSAs & DFSA's) allow you to set aside a portion of your salary that is not subject to federal income, Social Security and, in most cases, state and local taxes. You can then use this money to pay for eligible Healthcare and Dependent Care expenses. In effect, FSAs reduce your taxable income and the amount of income taxes you pay each pay period. It is important to plan for upcoming Healthcare and/or Dependent Care expenses carefully when determining how much to contribute to your FSA(s). IF YOU DON'T USE IT YOU LOSE IT. The accounts are voluntary. You decide if you want to participate and how much you want to contribute to the Healthcare and/or Dependent Care FSA. You must enroll in the FSA when you are first eligible, or when there is a qualifying life event, or during the annual open enrollment period.
Healthcare Flexible Spending Account You may contribute up to $2,550 for the calendar year to the Healthcare FSA to pay for these types of eligible expenses that you and your eligible dependents incur during the plan year. The Healthcare FSA is a supplement to your health benefits and is not intended as a replacement to the health plan. The FSA will pay qualified out-of-pocket healthcare expenses not covered by insurance such as:
Health plan copays, coinsurance, and deductibles, Prescription copays, Out-of-pocket dentist, orthodontic, or other provider fees, Lasik surgery and eyeglasses, and Balances due from eligible providers.
ADP offers Health FSA members a flex card that functions just like a debit card. When you use the card you are spending only the pre-tax dollars from your Health Spending Account. NOTE: If you want participate in these plans, you must re-enroll EACH YEAR in order to continue participating. Enrollment is never automatic from one year to the next.
Dependent Care Flexible Spending Account You may contribute up to $5,000 each plan year to the Dependent Care FSA. If you are married and you and your spouse file separate tax returns, the maximum amount you may contribute is $2,500 each plan year. If your spouse’s employer offers a Dependent Care FSA, you and your spouse can contribute a combined maximum of $5,000 to your accounts each plan year. You can use your Dependent Care Account to pay for eligible expenses during the year such as:
Day care provided by individuals inside or outside of your home, Day care at a licensed nursery school, day camp (not sleep-away camp) or day care center, Day care for an elderly dependent, and A housekeeper who cares for your eligible dependents.
If you participate in the Dependent Care FSA, you will need to provide the taxpayer identification number (or Social Security number) of the caregiver. An eligible dependent means: Your child under age 13; or a mentally or physically disabled spouse, parent or other relative who spends at least eight hours a day in your home. In addition, you must claim the person as a dependent on your federal income tax return. For a more detailed list of eligible healthcare expenses, refer to IRS Publication 502. IRS Publication 503 contains a detailed list of dependent care expenses. Both can be obtained from the IRS at 800-829-3676 or www.irs.ustreas.gov .
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Legal Notices Newborns' and Mothers' Health Protection Act unchanged since 1996 (Hospital Stay in Connection with Childbirth) 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 insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Women’s Health and Cancer Rights Act (WHCRA) (Post-Mastectomy Reconstructive Surgery) In the case of a participant or beneficiary who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with the mastectomy, the Plan will provide coverage for reconstruction of the breast on which the mastectomy has been performed; surgery and reconstruction on the other breast to produce a symmetrical appearance; and prostheses and treatment for physical complications of all stages of mastectomy, including lymphedemas; in a manner determined in consultation with the attending physician and the patient. The coverage may be subject to annual deductibles and coinsurance provisions as may be deemed appropriate and as are consistent with those established for other benefits under the Plan. This notice is provided to you for informational purposes. No action is required on your part. Please keep this information with your other group health plan documents. If you have any questions regarding this notice, please contact Member Services at the number found on your Medical ID Card.
MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE Important Notice from G4S Technology Products About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with G4S Technology and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. G4S Technology has determined that the prescription drug coverage offered by the BCBS health plans are, on average for all plam participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
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What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current G4S Technology coverage will not be affected. Refer to the medical plan explanation of coverage for an explanation of the prescription drug coverage plan provisions/options that apply to Medicare eligible individuals when they become eligible for Medicare. See pages 7-9 of the CMS Disclosure of Creditable Coverage to Medicare Part D Eligible Individuals Guidance (available at http://www.cms.hhs.gov/CreditableCoverage/), which outlines the prescription drug plan provisions/options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D. If you do decide to join a Medicare drug plan and drop your current G4S Technology coverage, be aware that you and your dependents will be able to get this coverage back.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with G4S Technology and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.
For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through G4S Technology changes. You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:
Visit www.medicare.gov
Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Effective Date:
11/01/2016
Name of Entity/Sender:
G4S Technology
Contact--Position/Office:
Human Resources
Address:
1200 Landmark Center, Suite 1300 Omaha, NE 68102
Phone Number:
402-233-7613
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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 1877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2016. Contact your State for more information on eligibility –
ALABAMA – Medicaid
GEORGIA – Medicaid
Website: http://myalhipp.com/
Website: http://dch.georgia.gov/medicaid
Phone: 1-855-692-5447
- Click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507
ALASKA – Medicaid
INDIANA – Medicaid
Website:
Healthy Indiana Plan for low-income adults 19-64
http://health.hss.state.ak.us/dpa/programs/medicaid/
Website: http://www.hip.in.gov
Phone (Outside of Anchorage): 1-888-318-8890
Phone: 1-877-438-4479
Phone (Anchorage): 907-269-6529
All other Medicaid Website: http://www.indianamedicaid.com Phone 1-800-403-0864
COLORADO – Medicaid
IOWA – Medicaid
Medicaid Website: http://www.colorado.gov/hcpf
Website: http://www.dhs.state.ia.us/hipp/
Medicaid Customer Contact Center: 1-800-221-3943
Phone: 1-888-346-9562
FLORIDA – Medicaid
KANSAS – Medicaid
Website: http://flmedicaidtplrecovery.com/hipp/
Website: http://www.kdheks.gov/hcf/
Phone: 1-877-357-3268
Phone: 1-785-296-3512
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KENTUCKY – Medicaid
NEW HAMPSHIRE – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 1-800-635-2570
Phone: 603-271-5218
LOUISIANA – Medicaid Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447
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
MAINE – Medicaid Website: http://www.maine.gov/dhhs/ofi/publicassistance/index.html Phone: 1-800-442-6003
NEW YORK – Medicaid Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831
TTY: Maine relay 711
MASSACHUSETTS – Medicaid and CHIP
NORTH CAROLINA – Medicaid
Website: http://www.mass.gov/MassHealth
Website: http://www.ncdhhs.gov/dma
Phone: 1-800-462-1120
Phone: 919-855-4100
MINNESOTA – Medicaid Website: http://mn.gov/dhs/ma/ Phone: 1-800-657-3739
MISSOURI – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005
MONTANA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084
NEBRASKA – Medicaid Website: http://dhhs.ne.gov/Children_Family_Services/AccessNebras ka/Pages/accessnebraska_index.aspx
NORTH DAKOTA – Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825
OKLAHOMA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742
OREGON – Medicaid Website: http://www.oregonhealthykids.gov http://www.hijossaludablesoregon.gov Phone: 1-800-699-9075
PENNSYLVANIA – Medicaid Website: http://www.dhs.pa.gov/hipp Phone: 1-800-692-7462
Phone: 1-855-632-7633
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NEVADA – Medicaid
RHODE ISLAND – Medicaid
Medicaid Website: http://dwss.nv.gov/
Website: http://www.eohhs.ri.gov/
Medicaid Phone: 1-800-992-0900
Phone: 401-462-5300
SOUTH CAROLINA – Medicaid
VIRGINIA – Medicaid and CHIP
Website: http://www.scdhhs.gov
Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm
Phone: 1-888-549-0820
Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282
SOUTH DAKOTA - Medicaid
WASHINGTON – Medicaid
Website: http://dss.sd.gov
Website: http://www.hca.wa.gov/medicaid/premiumpymt/pages/index. aspx
Phone: 1-888-828-0059
Phone: 1-800-562-3022 ext. 15473
TEXAS – Medicaid
WEST VIRGINIA – Medicaid
Website: http://gethipptexas.com/
Website: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages /default.aspx
Phone: 1-800-440-0493
Phone: 1-877-598-5820, HMS Third Party Liability
UTAH – Medicaid and CHIP
WISCONSIN – Medicaid and CHIP
Website:
Website:
Medicaid: http://health.utah.gov/medicaid
https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf
CHIP: http://health.utah.gov/chip
Phone: 1-800-362-3002
Phone: 1-877-543-7669
VERMONT– Medicaid
WYOMING – Medicaid
Website: http://www.greenmountaincare.org/
Website: https://wyequalitycare.acs-inc.com/
Phone: 1-800-250-8427
Phone: 307-777-7531
To see if any other states have added a premium assistance program since January 31, 2016, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/ebsa 1-866-444-EBSA (3272)
U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565
OMB Control Number 1210-0137 (expires 10/31/2016)
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