HELPING YOU UNDERSTAND
Your Benefit Choices
2022
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| BENEFITS GUIDE
CONTENTS
3
WELCOME PAGE
4
MY MOBILE WALLET CARD
5
GROUP INSURANCE ELIGIBILITY
6
HEALTH INSURANCE INFORMATION
7
MEDICAL INSURANCE
8
DENTAL INSURANCE
9
VISION INSURANCE
10
FLEXIBLE SPENDING ACCOUNTS (FSA)
12
BASIC LIFE AND AD&D INSURANCE
13
SUPPLEMENTAL LIFE INSURANCE
14
DISABILTY BENEFITS
15
WELLNESS CLINIC
16
RETIREMENT PLAN
17
WELLBEATS
18
REQUIRED NOTICES & IMPORTANT INFORMATION
29
PROVIDER CONTACT INFORMATION
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WELCOME
BENEFITS MENU
BENEFITS OFFERED
Your Benefit Period
January 1, 2022 – December 31, 2022
For Full-Time Employees Only
Fairfield County sponsors the Fairfield County Welfare Benefit Plan under plan
number 501 and hereby provides notice of the plan changes which are effective on
1/1/2022. Please refer to the section below for an overview of benefit offerings. If
you have any questions about these changes in benefits, please contact Rochelle
Menningen at 740-652-7898 or
Rochelle.menningen@fairfieldcountyohio.gov or
Cheryl Reeves at 740-652-7898 or
Cheryl.reeves@fairfieldcountyohio.gov.
EFFECTIVE JANUARY 1, 2022 Overview of Benefit Offerings:
Medical/RX: Provided through United Healthcare with no plan
changes.
• $300 Single/$600 Family Deductible then 85% Coinsurance
Dental: Provided through Delta Dental with no plan
changes.
• PPO $0 Single/Family Deductible
• Premier $25/Person Deductible
Vision: Provided through VSP with no plan changes.
Basic Life/AD&D: NEW CARRIER: Symetra. Employer paid
benefit.
Voluntary Life/AD&D: NEW CARRIER: Symetra. Benefit for
Employee, Spouse and Children.
Short-Term Disability: NEW CARRIER: Symetra.
Long-Term Disability: NEW CARRIER: Symetra.
MY HEALTH
Medical | United Healthcare
Dental | Delta Dental
Vision | VSP
MY LIFE
Life and AD&D | Symetra
Voluntary Life and AD&D | Symetra
Disability | Symetra
MY EXTRAS
EAP | Optum
Wellness Clinic | Fairfield County
Virtual Visits | United Healthcare
Retirement Plan | OPERS
Fitness | Wellbeats
1. Do you plan to enroll an eligible dependent(s)?
If so, make sure to have their social security numbers and birthdates available. You
cannot enroll your dependent(s) without this information.
2. Have you recently been married/divorced or had a baby?
If so, remember to add or remove any dependent(s) and/or update your beneficiary
designation.
3. Did any of your covered children reach their 26th birthday this
year?
If so, they may no longer be eligible for benefits, unless they meet specific criteria.
Helpful Tips To Consider
Before You Enroll
IMPORTANT REMINDER:
Your open enrollment period
begins on October 18, 2021
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MOBILE WALLET
ONLINE ACCESS
My Mobile Wallet Card is the easy way to find your benefits contact information.
• Benefits information
• Group numbers
• Phone numbers
• Email addresses
• Websites
• And more!
Bookmark My Mobile Wallet on your phone for quick and easy access on the go!
Scan the QR code with
the camera on your
phone or visit
https://mymobilewallet
card.com/fairfieldco/ to
get started!
The first time you visit My Mobile Wallet Card on your phone, a
pop-up will appear with bookmarking instructions. This will
allow you to add the wallet card to your home screen.
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ELIGIBILITY
RULES | REQUIREMENTS
Qualifying Life
Events
If you have a Qualifying Life Event and want to
request a mid-year change, you must notify
Human Resources and complete your election
changes within 30 days following the event. Be
prepared to provide documentation to support
the Qualifying Life Event.
Common life events include; Marriage, Divorce,
New Dependent, Loss/gain of available
coverage by you or any of your dependents.
*A full list of qualifying events can be found
in the ‘Required Notices’ section of this
benefits guide.
IMPORTANT
You cannot make changes to these
elections during the year unless you
experience a qualified family status
change, which must be reported to
Human Resources within 30 days of
the event.
If you separate from employment,
COBRA continuation of coverage may
be available as applicable by law.
COBRA continuation details can be
found in the notices section of this
employee benefit guide.
EMPLOYEE ELIGIBILITY
You are eligible to participate if you are
full-time and work a minimum of 30 hours
per week. Your coverage will be effective
on the 1st of the month following 30 days
from your date of hire.
DEPENDENT ELIGIBILITY
You may also enroll eligible dependents for
benefits coverage. A ‘dependent’ is
defined as the legal spouse and/or
‘dependent child(ren)’ of the plan
participant or the spouse.
The term ‘child’ refers to any
of the following:
A natural (biological) child;
A stepchild;
A legally adopted child;
A foster child;
A child for whom legal guardianship
has been awarded to the participant or
the participant’s spouse/domestic
partner; or
Disabled dependents may be eligible if
requirements set by the plan are met.
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COMMON INSURANCE TERMS
A PREMIUM is the amount you pay for
insurance, using pre-tax or post-tax dollars.
A COPAYMENT (COPAY) is a fixed amount you
pay to receive services. Your co-payment(s) will
count towards your out-of-pocket maximum but
not your deductible. (e.g., $30 for every visit to
the doctor), while your insurance company pays
the rest.
A DEDUCTIBLE is the amount of money you are
responsible for paying each year before the plan
begins to pay for covered services, with the
exception of preventive care services, which are
covered at 100% In-Network.
COINSURANCE This is your share of the
expense of covered services after your deductible
has been paid when the company plan is paying
a percentage. The coinsurance rate is usually a
percentage.
OUT-OF-POCKET (OOP) MAXIMUM is the most
you pay per Plan Year for health care expenses
and applies to deductibles, flat-dollar copays and
coinsurance for all covered services – including
cost-sharing amounts for prescription drugs.
Once this limit is met, the plan will cover all in-
network services at 100% until the end of the plan
year.
OUT-OF-NETWORK charges in the above plans
are subject to reasonable and customary
limitations, which means you are responsible for
any charges that exceed the carrier’s contracted
amount (often referred to as balance billing). In
addition, charges will be paid at the non-network
deductible and coinsurance.
How do I find an In-Network Provider?
In-Network providers can be found at
https://www.uhc.com/find-a-doctor. You may log in to
your account by selecting “Plan through your
employer” or you may do a general search by
selecting “Start your search”.
Did You Know?
Preventive Services are covered at
100% In-Network and copays &
deductibles do not apply.
You pay less out of pocket if you receive
care from an In-Network provider.
HEALTH
MEDICAL | PRESCRIPTION DRUGS
PPO | In-Network & Out-of-Network Benefits Available
The PPO option offers the freedom to see any provider when you
need care. When you use providers from within the PPO network,
you receive benefits at the discounted network cost. Most
expenses, such as office visits, emergency room and prescription
drugs are covered by a copay. Other expenses are subject to a
deductible and coinsurance.
Preventive Services | Covered at 100%
All plans recognize routine preventive services at 100%, no
coinsurance, no deductible as long as the claim is submitted as
“routine or preventive” and the services performed fall within the
approved list of preventive services. For a complete and updated
listing, please go online and search uspstf-a-and-b
recommendations or visit
https://www.uspreventiveservicestaskforce.org.
During your wellness visit, proactively let your physician know the
reason for the appointment is for a wellness visit and that your
physician needs to submit and code the visit as routine,
preventive in nature. If your visit is submitted with a diagnosis, the
wellness visit will not
be paid at 100%, but instead, will be subject
to deductible and coinsurance. Below are a few examples of
services that can be recognized as preventive:
• Routine Wellness Exams, including well baby & child routine
exams
• Cholesterol and lipid level screening
• Pelvic exam, pap test and screening mammograms
• Colorectal cancer screening, colonoscopies, sigmoidoscopies
(age limit applies)
• Vaccines & immunizations: Hepatitis A & B, Influenza,
Pneumonia, Shingles
• Contraceptives (specific list applies) & Diabetes screenings
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Primary Care Physician (PCP)
For routine, primary/preventive care, or non-urgent treatment, we recommend going to your doctor’s office for medical care. Your
doctor knows you and your health history and has access to your medical records. You may also pay the least amount out-of-
pocket when you receive care in your doctor’s office.
Urgent Care Centers vs. Freestanding Emergency Rooms
Freestanding emergency rooms look a lot like the urgent care centers you are likely used to, but the costs and services are
drastically different. In general, consider an urgent care center as an extension of your PCP, while freestanding emergency
rooms should be used for health conditions that require a high level of care. Research the options in your area and determine
which ones are covered by your insurance plan's network; note that balance billing may apply. Choosing an urgent care center
for everyday health concerns could save you hundreds of dollars.
Your Care
Options and
When to Use
Them.
United Healthcare Choice Plus Plan
PLAN BENEFITS In Network Out of Network
DEDUCTIBLE
Single $300 $650
Family $600 $1,300
COINSURANCE (applies after deductible is met) & OUT-OF-POCKET MAX
Plan Pays 85% 70%
Single OOP Maximum $2,250 $3,750
Family OOP Maximum $4,500 $7,500
MEMBER COPAYMENT(S)
Primary Care (PCP) - Office Visit $15 copay 30% after deductible
Virtual Visit
Amwell, Doctors on Demand & Teladoc
$0 copay $0 copay
Specialist - Office Visit
Premium Program Provider: $15
Network Provider: $30
30% after deductible
Preventive Care No charge 30% after deductible
Inpatient & Outpatient Hospital Services 15% after deductible 30% after deductible
Urgent Care Facility $20 copay 30% after deductible
Emergency Room Visit $200 copay $200 copay
PRESCRIPTION DRUGS RETAIL – 30 DAYS MAIL ORDER – 90 DAYS
Tier 1 – Generic $4 copay $10 copay
Tier 2 – Brand Preferred $25 copay $50 copay
Tier 3 – Brand Non-Preferred $50 copay $100 copay
Tier 4 – Specialty $150 copay $300 copay
EMPLOYEE CONTRIBUTIONS – PER PAY
Single $56.77
Family $135.26
MEDICAL
UNITED HEALTHCARE
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COMMON TERMS
PRE-TREATMENT ESTIMATE
If your dental care is extensive and
you want to plan ahead for the
cost, you can ask your dentist to
submit a pre-treatment estimate.
While it is not a guarantee of
payment, a pre-treatment estimate
can help you predict your out-of-
pocket costs.
DUAL COVERAGE
You might have benefits from more
than one dental plan, which is
called dual coverage. In this
situation, the total amount paid by
both plans can’t exceed 100% of
your dental expenses. And in some
cases, depending on the specifics
of the plans, your coverage may
not total 100%.
LIMITATIONS AND
EXCLUSIONS
Dental plans are intended to cover
part of your dental expenses, so
coverage may not extend to your
every dental need. A typical plan
has limitations such as the number
of times you can receive a cleaning
each year. In addition, some
procedures may be not be covered
under your plan, which is referred
to as an exclusion.
How do I find an In-
Network Provider?
Go to
https://www.deltadental.com/us
/en/member/find-a-dentist.html
to find a dentist in network.
PPO Network
Premier Network Out-of-Network
PLAN FEATURES
Benefit Period
Calendar Year
DEDUCTIBLE
Single/Family
$0 / $0 $25 per person $25 per person
When does it apply?
When receiving Basic or Major services
(Does not apply for Preventive services)
COVERED SERVICES
CLASS I: Preventive
Services
Routine oral exams and
cleanings, x-rays & fluoride
treatments
Covered at 100%
Covered at 90%
With possible
balance billing
Covered at 90%
With possible
balance billing
CLASS II: Basic Services
Sealants, fillings, crown
repair, root canals,
periodontics & extractions
Covered at 80%
Covered at 70%
With possible
balance billing
Covered at 70%
With possible
balance billing
CLASS III: Major Services
Crowns, bridges, implants &
dentures
Covered at 80%
Covered at 60%
With possible
balance billing
Covered at 60%
With possible
balance billing
CLASS IV: Orthodontia
Up to age 19
Covered at 75%
ANNUAL MAXIMUM
Maximum Benefit
Allowed per Benefit Period
$1,500 / person $1,000 / person
$1,000 / person
Ortho Maximum Benefit
$1,500 / person $1,400 / person $1,400 / person
EMPLOYEE CONTRIBUTIONS – PER PAY
Single
$2.41
Family
$5.76
DENTAL
DELTA DENTAL
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In addition to eye disease, a routine eye exam can help
detect signs of serious health conditions like diabetes
and high cholesterol. This is important, since you won’t
always notice the symptoms yourself and since some of
these diseases cause early and irreversible damage.
Need to locate a
participating
In-Network provider?
Visit www.vsp.com/find-eye-doctors
Search by location, doctor name, or
office name.
Did you know your eyes
can tell an eye care
provider a lot about you?
VISION
VSP
IN-NETWORK
VSP Choice Network PROVIDER
OUT-OF-NETWORK
PROVIDER
PLAN FEATURES
Vision Exam
$10 copay Up to $50
COVERED SERVICES – LENSES / FRAMES
Prescription Glasses (Materials)
$20 copay (see below)
Single Lenses
Included with Prescription Glasses Up to $50
Bifocals
Included with Prescription Glasses Up to $75
Trifocals Included with Prescription Glasses Up to $100
Progressive $0 copay Up to $74
Frames
$150 retail allowance,
plus 20% over the allowance
Up to $70
COVERED SERVICES
Contact Lenses
$140 allowance Up to $105
Contact Lens Evaluation Fitting
Up to $60 No discounts
BENEFIT FREQUENCY
Exams
Once every 12 Months Once every 12 Months
Lenses
Once every 12 Months Once every 12 Months
Frames Once every 24 Months Once every 24 Months
Contacts
Once every 12 Months
(contacts in lieu of frames/lenses)
Once every 12 Months
EMPLOYEE CONTRIBUTIONS – PER PAY
Single
$0.58
Family
$1.39
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Flexible Spending Accounts (FSA) allow you to reduce your taxable income
by setting aside pre-tax dollars from each paycheck to pay for eligible out-of-
pocket health care and dependent care expenses* for yourself, your spouse
and your dependent children.
In order to participate in the FSA, you must enroll each year. Your annual
contribution stays in effect during the entire year (January 1st through
December 31st). The only time you can change your election is during the
enrollment period or if you experience a change-in-status event. Also, you
must elect this benefit within 30 days of your hire date or first date of benefits
eligibility.
HEALTH CARE & LIMITED PURPOSE FSA
MAXIMUM ANNUAL CONTRIBUTION | $2,750
All eligible health care expenses – such as deductibles, medical and
prescription copays, dental expenses, and vision expenses – can be
reimbursed from your general purpose FSA account.
With the Health Care FSA or Limited Purpose FSA, you can spend up to the
full amount of your annual election as soon as your account has been set
up.
LIMITED PURPOSE FSA | ADDITIONAL REQUIREMENTS
If you open or contribute to a Health Saving Account (HSA), you may only enroll in
a Limited Purpose FSA.
If you enroll in a HDHP (High Deductible Health Plan) and elect a Health FSA, you
will automatically be enrolled in the Limited Purpose FSA.
A limited purpose FSA will reimburse you for dental and vision expenses, but you
cannot claim the same expense on both the FSA and HSA Accounts.
DEPENDENT CARE FSA
The Dependent Care FSA allows you to pay for eligible dependent care
expenses with tax-free dollars so that you and your spouse can work or
attend school FT.
Unlike the Health Care FSA, funds in a Dependent Care FSA are only
available once they have been deposited into your account and you cannot
use the funds ahead of time.
You may set aside up to $5,000 annually in pre-tax dollars, or $2,500 if
you are married and file taxes separately from your spouse.
If you participate in a Dependent Care FSA, you cannot apply the same
expenses for a dependent care tax credit when you file your income
taxes.
*ELIGIBLE DEPENDENT CARE
EXPENSES INCLUDE:
1.‘Care’ for your dependent child who is under
the age of 13 that you can claim as a
dependent on your federal tax return;
2.‘Care’ for your dependent child who resides
with you and who is physically or mentally
incapable of caring for themselves; or
3.‘Care’ for your spouse, parent or
grandparent who is physically or mentally
incapable of caring for themselves and
spends at least eight hours a day in your
home.
‘Care’ is defined as: In-home baby-sitting
services (not by an individual you claim as a
dependent); care of a preschool child by a
licensed nursery or day care provider; before
and after-school care; summer day camp
(provided it is not overnight); and in-home
dependent day care.
“USE IT” OR “LOSE IT”
Unused FSA funds do not roll over
from year to year. If you don’t use
the funds in your account by
December 31, 2022, you’ll lose
them.
Claims for reimbursement must be
submitted by March 31st of the
following year.
____________________________
NOTE: FSA elections do not
automatically continue from year to
year. You must actively enroll each
year.
IMPORTANT FSA RULES
ELIGIBLE EXPENSES
A full list of qualified FSA expenses can be found in IRS Publication
502 at
www.irs.gov.
You can learn more about FSA qualified expenses and also make
purchases by visiting the FSA Store at www.fsastore.com.
FLEXIBLE SPENDING ACCOUNT
FSA | TAX SAVING VEHICLE
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Without FSA With FSA
Gross Income $30,000 $30,000
FSA Contributions $0 -$2,650
TAXABLE INCOME $30,000 $27,350
Estimated Taxes
Federal
$3,090* -$2,817*
State
$1,104** $1,106**
FICA
$2,295 $2,092
AFTER TAX EARNINGS $23,511 $21,435
Eligible Out-Of-Pocket
Expenses
$2,650 $0
AVAILABLE/SPENDABLE
INCOME
$20,861 $21,435
ELIGIBLE HEALTH
FSA EXPENSES*
Acupuncture
Alcoholism treatment
Artificial teeth/dentures
Blood pressure monitors
Braces
Braille-books & magazines
Breast pumps & lactation supplies
Chiropractors
Co-insurance, co-pay & deductibles
Cost of operations & related treatments
Crutches
Diabetic supplies
Drug addiction treatment
Eye exams, eye glasses, contacts
Hearing devices & batteries
Hospital services
Operations
Pregnancy tests
Radial keratotomy & lasik eye surgery
Smoking cessation programs
Speech therapy
Surgical fees
Vaccines
Walkers & wheelchairs
X-rays and more.
*A full list of qualified expenses can be
found in IRS Publication 502 at www.irs.gov.
Visit the FSA Store at www.FSAstore.com, where
you can purchase FSA-eligible products without a
prescription online.
Although you do not need to file for reimbursement
when using your FSA debit card, you may be
required to submit documentation, so be sure to
save your receipts.
If you use a personal form of payment to pay
for eligible expenses out-of-pocket, you can
submit an FSA claim form along with your
original receipts for reimbursement.
IMPORTANT: PAYING FOR ELIGIBLE
SERVICES & EXPENSES
HERE’S HOW IT WORKS
An employee earning $30,000 elects to place $1,000 into a Health Care
FSA. The payroll deduction is $110.42 based on a 24-pay period schedule.
As a result, the insurance premiums and health care expenses are paid with
tax-free dollars, giving the employee a tax savings of $574.
This example is for illustrative purposes only. Every situation varies and it is
recommended you consult a tax advisor for all tax advice.
*Varies, assumes 10.30%;
**Varies, assumes 3.68%
That’s a savings of $574 for the year!
Health Care Reform legislation requires that certain over-the-
counter (OTC) items require a “prescription” in order to be
considered an eligible Health Care FSA expense. You will
only need to obtain a “one-time prescription” for the 2022 plan
year.
You can continue to purchase your regular prescription
medications with your debit card. However, the debit card
may not be used as payment for an OTC item, even when
accompanied by a prescription.
OVER-THE-COUNTER (OTC)
MEDICATION REMINDER
FLEXIBLE SPENDING ACCOUNT
FSA | TAX SAVING VEHICLE
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BASIC LIFE INSURANCE
Life insurance is an important part of your financial security. Life
insurance helps protect your family from financial risk and sudden
loss of income in the event of your death. AD&D insurance is equal
to your Life benefit in the event of your death being a result of an
accident and may also pay benefits for certain injuries sustained.
Company Paid Benefit - Provided to you at no cost
Coverage Amount Flat $50,000 Benefit
Accidental Death and
Dismemberment
(AD&D)
Amount equal to your Life benefit
ADDITIONAL PLAN PROVISIONS
Portability
If your employment ends or you retire,
you may be eligible to continue your
term insurance at group rates.
Conversion
When coverage ends under the plan, you can
convert to an individual permanent life policy
without evidence of insurability.
Accelerated Death
Benefit
90% of Basic Life amount
WHAT WILL MY BENEFICIARY RECEIVE?
In The Event That Death Occurs:
– Your Basic Life insurance is paid to your beneficiary.
– If death occurs from an accident: 100% of the AD&D benefit would be payable to
your beneficiary(ies) in addition to your Basic Life insurance.
BENEFICIARY(IES)
It’s very important to designate
beneficiaries. Taking a few minutes to
designate your beneficiaries now will
help ensure that your assets will be
distributed according to your
direction.
A Beneficiary is the person you
designate to receive your life
insurance benefits in the event of
your death. It is important that your
beneficiary designation is clear so
there is no question as to your
intentions.
It is also important that you name a
Primary and Contingent
Beneficiary. A contingent beneficiary
will receive the benefits of your life
insurance if the primary beneficiary
cannot. You can change beneficiaries
at any time.
You should review your beneficiary
elections on a regular basis to
ensure they are updated as life
changes. Even if you are single, your
beneficiary can use your Life
Insurance to pay off your debts, such
as: credit cards, mortgages, and
other expenses.
*You designate your beneficiary(ies)
when enrolling for your benefits.
BASIC LIFE
COVERAGE OVERVIEW
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PLAN OPTIONS
Cost of Coverage
Premiums are based on age-rated tables and paid by the employee every pay period through
a payroll deduction. These premiums are post-tax and benefits payable are tax-free.
Coverage Options
Employee Coverage
Choose in $10,000
increments up to $300,000
Spouse Coverage
Choose in $10,000 increments
up to the lesser of 100% of the
amount you elect for yourself or
$150,000
*Coverage terminates at age 70
Dependent Coverage
Choose in $5,000 increments
up to $10,000
*Coverage from birth to age
26
Do I have to take a health
exam to get coverage?
If you and your dependents enroll in coverage at your initial eligibility date,
you may apply for up to the Guaranteed Issue amounts without medical questions.
Guaranteed Issue
Employee
$200,000
Spouse
$50,000
Dependent
$10,000
PLAN PROVISIONS
Cost Calculation Age Rated Benefit (Spouse Life based on employee's age)
Portability
If your employment ends or you retire, you may be eligible to continue your term insurance at
group rates.
Conversion
When coverage ends under the plan, you can convert to an individual permanent life policy
without evidence of insurability.
SUPPLEMENTAL LIFE INSURANCE
*Guaranteed Issue (GI) and Evidence of Insurability (EOI)
During the upcoming scheduled Open Enrollment for 1/1/2022, coverage can be elected
without submitting EOI, subject to the Guaranteed Issue limit. Employees that were
previously denied coverage are not eligible.
During subsequent annual enrollments, coverage can be increased up to 5 increment
levels without submitting EOI, subject to the Guaranteed Issue limit. Employees that were
previously denied coverage are not eligible.
Employees have the opportunity to enroll in Supplemental Life insurance. If you choose to enroll in employee
coverage, this will be in addition to your employer provided Basic Life coverage. Coverage is also available for
your spouse and/or child dependents.
SUPPLEMENTAL LIFE
COVERAGE OPTIONS FOR YOU & THE FAMILY
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LONG-TERM DISABILITY (LTD)
Serious illnesses or accidents can come out of nowhere.
They can interrupt your life, and your ability to work for
months – even years.
Long Term Disability provides financial protection for you by
paying a portion of your income, so you have financial
support to manage your disability and your household.
SHORT-TERM DISABILITY (STD)
Everyday illnesses or injuries can interfere with
your ability to work. Even a few weeks away
from work can make it difficult to manage
household costs.
Short Term Disability coverage provides financial
protection for you by paying a portion of your
income, so you can focus on getting better and
worry less about keeping up with your bills.
DISABILITY
SHORT-TERM | LONG-TERM
PLAN FEATURES SHORT-TERM DISABILITY (STD)
LONG-TERM DISABILITY (LTD)
Cost of Coverage
Voluntary Benefit
Employee is responsible for 100% of the cost
Voluntary Benefit
Employee is responsible for 100% of the cost
Elimination Period
This is the number of
days that must pass
between your first day of
a covered disability & the
day you can begin to
receive your disability
benefits.
Benefits begin on the 15th day of an
accident or an illness (including
pregnancy).
Your elimination period is 180 days.
Benefit Duration
The maximum number of
weeks you can receive
benefits while you are sick
or disabled.
Payments may last up to 24 weeks
You must be sick or disabled for the duration
of the waiting period before you can receive a
benefit payment.
Payments will last for as long as you are disabled,
or until you reach Retirement Age (age 65),
whichever is sooner
You must be sick or disabled for the duration of the
elimination period before you can receive a benefit
payment.
Coverage Amount
Covers 60% of your weekly income,
up to a maximum benefit of $1,500 per week.
Covers 60% of your monthly income,
up to a maximum benefit of $10,000 per month.
What's covered?
A variety of conditions and injuries.
Typical claims would include pregnancy,
injuries and joint, back and digestive
disorders.
A variety of conditions and injuries.
Typical claims would include cancer, back disorders,
injuries and poison, cardiovascular, joint disorders.
Definition of Earnings
Base Salary
(excludes commissions and bonuses)
Base Salary
(excludes commissions and bonuses)
ADDITIONAL PLAN PROVISIONS
Benefit Payment
Frequency
Weekly benefit may be reduced or offset by
other sources of income.
Monthly benefit may be reduced or offset by other
sources of income.
Waiver of Premium Not included.
If you're disabled and receiving benefit payments,
you cost may be waived until you return to work.
Pre-Existing Condition
Limitation
None.
You have a pre-existing condition if you have received:
medical treatment, consultation, care or services
including diagnostic measures for the condition, or took
prescribed drugs or medicines for it in the 3 months just
prior to your effective date of coverage; and the
disability begins in the first 12 months after your
effective date of coverage.
Certain exclusions and any pre-existing condition limitations may apply.
Please refer to the Provider’s detailed benefit summary for details.
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WELLNESS CLINIC
Fairfield County & First Medical Occupational Health
Lower Level of First Medical Urgent Care
1199 River Valley Blvd.
Lancaster, Ohio 43130
Phone 740-689-4404
Clinic Hours:
Monday, Wednesday &Friday: 9am –
4:30pm
Tuesday & Thursday: 10am-5:30pm
Minor Illnesses
• Allergy symptoms
• Earaches
• Flu-like symptoms
• Gout
• Indigestion
• Mononucleosis
• Mouth conditions/pain
• Nausea/vomiting/diarrhea
• Pink eye & styes
• Sinus infections/congestion
• Sore throat
• Upper respiratory infections
• Urinary tract infections
• Yeast infections
In-Clinic Lab Tests
• Strep test
• Glucose
• Mono test
• Urine dip stick
• Pregnancy test
Vaccines/Injections
• Allergy (must bring serum)
• Birth control (must bring medication)
Minor Injuries
• Bug bites & stings
• Tick bites
• Cholesterol screenings
• Minor burns
• Minor cuts/blisters/wounds
• Splinter removal – superficial
• Sprains, strains, joint pains
• Suture & staple removal
Wellness/Physicals
• Physicals – basic wellness only
• Routine/school/sport/work permit/camp
• Ear wax removal
• Pregnancy tests
• Smoking cessation assessment &
follow-up visits
• Weight loss assessment & follow-up
visits
Skin Conditions
• Acne
• Athlete’s foot
• Chicken pox
• Cold, canker, mouth sores
• Dermatitis, rashes, skin irritations
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OPERS RETIREMENT PLAN
BENEFIT OVERVIEW
PLAN OVERVIEW
Member Contribution
Employer Contribution
TRADITIONAL PENSION PLAN
Contributions
10%
14%
OPERS manages investments
Lifetime retirement payments are based on a formula that includes your length of service and salary history
Survivor and disability benefits
Access to healthcare
MEMBER-DIRECTED PLAN
Contributions 10% 7.5%
Member manages investments
Employer contributions into Retiree Medical Account 4%
Mitigating Rate: 2%*
Lifetime retirement payments are based on your vested account balance and age at retirement
Vested account balance is available in the case of death or disability
COMBINED PLAN
Contributions 10% 12%
Member manages member contributions
OPERS manages employer contributions
Mitigating Rate: 2%*
Lifetime retirement payments are based on a formula that includes the length of service and salary history, plus your
vested account balance and age at retirement.
Survivor and disability benefits
Access to healthcare
*If OPERS determines the number and demographic characteristics of members who have elected to participate in the
Member-Directed or Combined Plan results in a negative financial impact on the Traditional Pension Plan, a portion of
the employer contribution may be withheld and credited to the Traditional Pension Plan. This is called the mitigating
rate.
Investments
Two methods for new members to manage
investments in the Member-Directed and Combined
plans:
• OPERS Target Date Funds: simple, easy,
automatically adjust quarterly
• OPERS Core Funds: six funds ranging from
lower-risk, income-oriented options to higher-risk,
growth-oriented options
More Information
To access the Plan Comparison Calculator, log
on to
www.opers.org. For additional details
about the OPERS Retirement Plan, call 866-
673-7748.
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WELLBEATS FITNESS
ON DEMAND FITNESS OVERVIEW
Wellbeats Offerings
600+ classes including yoga, HIIT, strength
training, cycling, running/walking, mindfulness,
office breaks, recovery
Nutrition education and recipes
Kid-friendly activities and pre/post-natal classes
Easy-to-use navigation and interface
Recommended classes according to your
personal preferences
Coached by a team of certified, supportive
instructors
Stay accountable with goal-based challenges
Track your progress with personal statistics
No equipment options available
To learn how to use Wellbeats, watch the
5-minute Navigation Tour Videos at
www.wellbeats.com/faqs
Wellbeats Login Information
Username: your work e-mail address
Password: be on the lookout for an email
from Wellbeats (
support@wellbeats.com)
which includes your temporary password
Begin using
Wellbeats on
November 1
st
, 2021
Stream Wellbeats
Anywhere
Visit www.wellbeats.com or
download the app
Stream fitness videos at
home or on-the-go!
REQUIRED
NOTICES
& FEDERAL MANDATES
REQUIRED
NOTICES
Federal regulations require employers to provide
certain notifications and disclosures to all eligible
employees. This section of your benefit guide is
dedicated to those disclosures for 1/1/2022-
12/31/2022. If you have any questions or concerns
please contact your plan administrator as follows:
Human Resources
740-652-7898
FAMILY MEDICAL LEAVE ACT (FMLA)
The Family and Medical Leave Act (FMLA) of 1993 was designed to provide
eligible employees with up to 12 workweeks per year of job-protected leave
to address critical personal and family matters. It is the policy of your
employer and its U.S. subsidiaries to provide eligible employees with a leave
of absence in accordance with the provisions of FMLA.
You are eligible for an FMLA leave of absence under this policy if you
meet the following requirements:
You have completed at least 12 months of employment (need not be
consecutive, but employment prior to a continuous break in service of
seven or more years may not be counted).
You have worked at least 1,250 hours during the 12-month period
immediately preceding the commencement of the requested leave.
You are employed at a work site where 50 or more employees are
employed by the Company within 75 miles of that work site (“eligible
employees”).
To the extent permitted by law, leave taken pursuant to FMLA will run
concurrently with Workers’ Compensation, Short Term Disability, and all
other Company leave policies.
The “break in service cap” doesn’t apply if it:
is attributable to fulfillment of National Guard or Reserve military service
obligations; or
is addressed in a written agreement, including a collective bargaining
agreement, that expresses the employer’s intent to rehire the employee
after the break in service, such as a break to pursue education or raise
children.
Procedure for Applying for FMLA Leave
If you desire and require an FMLA leave of absence under this policy, you
must notify your manager and your Human Resources Department and call
your FMLA Administrator at least 30 calendar days in advance of the start of
the leave when the need for such leave is reasonably foreseeable (as in the
case of a birth, the placement for adoption of a son or daughter, or a planned
medical treatment for a serious health condition).
However, if the date of the birth, placement, or planned medical treatment
requires leave to begin in less than 30 calendar days, you must provide such
notice to the aforementioned parties as soon as it is both possible and
practicable. Failure to provide timely notice may result in a delay or denial of
FMLA leave.
IRS CODE SECTION 125
Premiums for medical, dental, vision insurance, and/or certain supplemental plans
and contributions to FSA accounts (Health Care and Dependent Care FSAs) are
deducted through a Cafeteria Plan established under Section 125 of the Internal
Revenue Code (IRC) and are pre-tax to the extent permitted. Under Section 125,
changes to an employee's pre-tax benefits can be made ONLY during the Open
Enrollment period unless the employee or qualified dependents experience a
qualifying event and the request to make a change is made within 30 days of the
qualifying event.
Under certain circumstances, employees may be allowed to make changes to benefit
elections during the plan year, if the event affects the employee, spouse, or
dependent’s coverage eligibility. An “eligible” qualifying event is determined by the
Internal Revenue Service (IRS) Code, Section 125. Any requested changes must be
consistent with and on account of the qualifying event.
Examples Of Qualifying Events:
Legal marital status (for example, marriage, divorce, legal separation,
annulment);
Number of eligible dependents (for example, birth, death, adoption, placement
for adoption);
Employment status (for example, strike or lockout, termination, commencement,
leave of absence, including those protected under the FMLA);
Work schedule (for example, full-time, part-time);
Death of a spouse or child;
Change in your child’s eligibility for benefits (reaching the age limit);
Change in your address or location that may affect the coverage for which you
are eligible;
Significant change in coverage or cost in your, your spouse’s or child’s benefit
plans;
A covered dependent’s status (that is, a family member becomes eligible or
ineligible for benefits under the Plan);
Becoming eligible for Medicare or Medicaid; or
Your coverage or the coverage of your Spouse or other eligible dependent under
a Medicaid plan or state Children’s Health Insurance Program (“CHIP”) is
terminated as a result of loss of eligibility and you request coverage under this
Plan no later than 60 days after the date the Medicaid or CHIP coverage
terminates; or
You, your spouse or other eligible dependent become eligible for a premium
assistance subsidy in this Plan under a Medicaid plan or state CHIP (including
any waiver or demonstration project) and you request coverage under this Plan
no later than 60 days after the date you are determined to be eligible for such
assistance.
Qualifying Events, which ARE NOT available for a Health Care FSA program, if
applicable:
Coverage by your spouse or other covered dependent permitted under the
spouse’s or covered dependent’s employer’s benefit plan due to a Change
Event;
The availability of benefit options or coverage under any of the Benefit Programs
under the Plan (for example, an HMO is added to or deleted from the Medical
Program);
An election made by your spouse or other covered dependent during an open
enrollment period under your spouse’s or other covered dependent’s employer’s
benefit plan that relates to a period that is different from the Plan Year for this
Plan (for example, your spouse’s open enrollment period is in July and your
spouse changes coverage); or
The cost of coverage during the Plan Year, but only if it is a significant increase
or decrease.
Available for Dependent Care FSA Only, If applicable:
Your dependent care provider or cost of dependent care (a significant increase
or decrease).
Additional Change Events For Health Care Options:
In addition to the above Change Events, you may also change elections for the
Medical, Dental, Vision and Health Care FSA Programs if:
You, your spouse, or other covered dependent become eligible for continuation
coverage under COBRA or USERRA;
A judgment, decree, or order resulting from a divorce, legal separation,
annulment, or change in legal custody (including a Qualified Medical Child
Support Order), is entered by a court of competent jurisdiction that requires
accident or health coverage for your child;
You, your spouse, or other covered dependent become enrolled under Part A,
Part B, or Part D of Medicare or under Medicaid (other than coverage solely with
respect to the distribution of pediatric vaccines); or
You, your spouse, or other covered dependent become eligible for a Special
Enrollment Period.
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| BENEFITS GUIDE
HEALTH COVERAGE REMINDER
The Patient Protection and Affordable Care Act (PPACA) requires most
individuals to have minimum essential health coverage or pay a penalty. You
may obtain coverage through your employer or through the Marketplace.
Depending on your income and the coverage offered by your employer,
you may be able to obtain lower cost private insurance in the Marketplace.
If you buy insurance through the Marketplace, you may lose any
employer contribution to your health benefits.
Visit www.healthcare.gov for Marketplace information.
WOMEN’S HEALTH & CANCER RIGHTS ACT
(WHCRA)
In October 1998, Congress enacted the Women’s Health and Cancer Rights
Act of 1998. This notice explains some important provisions of the Act.
If you have had or are going to have a mastectomy, you may be entitled to
certain benefits under the Women’s Health and Cancer Rights Act of 1998
(WHCRA). For individuals receiving mastectomy-related benefits, coverage will
be provided in a manner determined in consultation with the attending
physician and the patient, for:
All stages of 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 of the mastectomy,
including lymphedema.
Health plans must determine the manner of coverage in consultation with the
attending physician and the patient. Coverage for breast reconstruction and
related services may be subject to deductibles and coinsurance amounts that
are consistent with those that apply to other benefits under the plan.
SPECIAL ENROLLMENT NOTICE
This notice is being provided to ensure that you understand your right to apply
for group health insurance coverage. You should read this notice even if you
plan to waive coverage at this time.
Loss of Other Coverage or Becoming Eligible for Medicaid or a state
Children’s Health Insurance Program (CHIP)
If you are declining coverage for yourself or your dependents because of other
health insurance or group health plan coverage, you may be able to later enroll
yourself and your dependents in this plan if you or your dependents lose
eligibility for that other coverage (or if the employer stops contributing toward
your or your dependents’ other coverage). However, you must enroll within 31
days after your or your dependents’ other coverage ends (or after the
employer that sponsors that coverage stops contributing toward the other
coverage).
If you or your dependents lose eligibility under a Medicaid plan or CHIP, or if
you or your dependents become eligible for a subsidy under Medicaid or CHIP,
you may be able to enroll yourself and your dependents in this plan. You must
provide notification within 60 days after you or your dependent is terminated
from or determined to be eligible for such assistance.
Marriage, Birth or Adoption
If you have a new dependent as a result of a marriage, birth, adoption, or
placement for adoption, you may be able to enroll yourself and your
dependents. However, you must enroll within 31 days after the marriage, birth,
or placement for adoption.
For More Information or Assistance
To request special enrollment or obtain more information, contact Human
Resource Department
MICHELLE’S LAW NOTICE
The health plan may extend medical coverage for dependent children if they
lose eligibility for coverage because of a medically necessary leave of
absence from school. Coverage may continue for up to a year, unless your
child’s eligibility would end earlier for another reason.
Extended coverage is available if a child’s leave of absence from school — or
change in school enrollment status (for example, switching from full-time to
part-time status) — starts while the child has a serious illness or injury, is
medically necessary, and otherwise causes eligibility for student coverage
under the plan to end. Written certification from the child’s physician stating
that the child suffers from a serious illness or injury and the leave of absence
is medically necessary may be required.
If your child will lose eligibility for coverage because of a medically necessary
leave of absence from school and you want his or her coverage to be
extended, contact your Human Resource Department as soon as the need for
the leave is recognized. In addition, contact your child’s health plan to see if
any state laws requiring extended coverage may apply to his or her benefits.
THE GENETIC INFORMATION NON-
DISCRIMINATION ACT (GINA)
Genetic Information Non-Discrimination Act (GINA) prohibits discrimination by
health insurers and employers based on individuals' genetic information.
Genetic information includes the results of genetic tests to determine whether
someone is at increased risk of acquiring a condition in the future, as well as
an individual's family medical history. GINA imposes the following restrictions
prohibits the use of genetic information in making employment decisions;
restricts the acquisition of genetic information by employers and others;
imposes strict confidentiality requirements; and prohibits retaliation against
individuals who oppose actions made unlawful by GINA or who participate in
proceedings to vindicate rights under the law or aid others in doing so.
NOTICE OF ELIGIBILITY FOR HEALTH PLANS
RELATED TO MILITARY LEAVE
If you take a military leave, the Uniformed Services Employment and
Reemployment Rights Act (USERRA) provides the following rights:
If you take a leave from your job to perform military service, you have the
right to elect to continue your existing employer-based health plan
coverage at your cost for you and your dependents for up to 24 months
during your military service; or
If you don’t elect to continue coverage during your military service, you
have the right to be reinstated in the Plan when you are reemployed within
the time period specified by USERRA, without any additional waiting
period or exclusions (e.g., pre-existing condition exclusions) except for
service-connected illnesses or injuries.
The Plan Administrator can provide you with information about how to elect
Continuation Coverage Under USERRA.
NEWBORNS’ AND MOTHERS’ HEALTH
PROTECTION ACT NOTICE
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).
REQUIRED NOTICES
CREDITABLE COVERAGE (PART D MEDICARE)
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MEDICARE PART D CREDITABLE COVERAGE NOTICE
Your Prescription Drug Coverage and Medicare
REQUIRED NOTICES
Important Notice from Fairfield County 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 Fairfield County 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. Fairfield County has determined that the prescription drug coverage
offered by the plan is, on average for all plan participants, expected
to pay out as much as standard Medicare prescription drug coverage
pays and is therefore considered Creditable Coverage. Because your
existing coverage is Creditable Coverage, you can keep this
coverage and not pay a higher premium (a penalty) if you later
decide to join a Medicare drug plan.
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 Fairfield County coverage will not be affected. If you do decide to
join a Medicare drug plan and drop your current Fairfield County
coverage, be aware that you and your dependents may not 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 Fairfield County 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.
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.
For More Information About This Notice Or Your Current Prescription
Drug Coverage contact the Human Resources Department.
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
Fairfield County changes. You also may request a copy of this notice at
any time.
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 1-800-325-0778).
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).
CMS Form 10182-CC Updated April 1, 2011 According to the Paperwork Reduction Act of 1995,
no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-0990. The
time required to complete this information collection is estimated to average 8 hours per response
initially, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning
the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.
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| BENEFITS GUIDE
What Is COBRA Continuation Coverage?
COBRA continuation coverage is a continuation of Plan coverage when it would
otherwise end because of a life event. This is also called a “qualifying event.”
Specific qualifying events are listed later in this notice. After a qualifying
event, COBRA continuation coverage must be offered to each person who is
a “qualified beneficiary.” You, your spouse, and your dependent children
could become qualified beneficiaries if coverage under the Plan is lost
because of the qualifying event. Under the Plan, qualified beneficiaries who
elect COBRA continuation coverage must pay for COBRA continuation
coverage.
If you’re an employee, you’ll become a qualified beneficiary if you lose your
coverage under the Plan because of the following qualifying events:
Your hours of employment are reduced, or
Your employment ends for any reason other than your gross misconduct.
If you’re the spouse of an employee, you’ll become a qualified
beneficiary if you lose your coverage under the Plan because of the
following qualifying events:
Your spouse dies
Your spouse’s hours of employment are reduced;
Your spouse’s employment ends for any reason other than his or her
gross misconduct;
Your spouse becomes entitled to Medicare benefits (under Part A, Part
B, or both); or
You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose
coverage under the Plan because of the following qualifying events:
The parent-employee dies;
The parent-employee’s hours of employment are reduced;
The parent-employee’s employment ends for any reason other than his
or her gross misconduct;
The parent-employee becomes entitled to Medicare benefits (Part A,
Part B, or both);
The parents become divorced or legally separated; or
The child stops being eligible for coverage under the Plans as a
“dependent child.”
When Is COBRA Continuation Coverage Available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries
only after the Plan Administrator has been notified that a qualifying event has
occurred. The employer must notify the Plan Administrator of the following
qualifying events:
The end of employment or reduction of hours of employment;
Death of the employee;
The employee’s becoming entitled to Medicare benefits (under Part A,
Part B, or both).
For all other qualifying events (divorce or legal separation of the employee
and spouse or a dependent child’s losing eligibility for coverage as a
dependent child), you must notify the Plan Administrator within 60 days after
the qualifying event occurs.
How Is COBRA Continuation Coverage Provided?
Once the Plan Administrator receives notice that a qualifying event has
occurred, COBRA continuation coverage will be offered to each of the
qualified beneficiaries. Each qualified beneficiary will have an independent
right to elect COBRA continuation coverage. Covered employees may elect
COBRA continuation coverage on behalf of their spouses, and parents may
elect COBRA continuation coverage on behalf of their children.
COBRA continuation coverage is a temporary continuation of coverage that
generally lasts for 18 months due to employment termination or reduction of
hours of work. Certain qualifying events, or a second qualifying event during
the initial period of coverage, may permit a beneficiary to receive a maximum
of 36 months of coverage.
There are also ways in which this 18-month period of COBRA continuation
coverage can be extended:
COBRA COVERAGE
Federal law requires Fairfield County to offer employees and their families
the opportunity for a temporary extension of health coverage (called
“continuation coverage”) at group rates in certain instances where coverage
under the plan would otherwise end.
To Qualify For COBRA Coverage:
Employees – As an employee of Fairfield County covered by our health
plans, you have the right to elect this continuation coverage if you lose your
group health coverage because of a reduction in your hours of employment
or the termination of your employment (for reasons other than gross
misconduct on your part).
Spouses – As the spouse of an employee covered by our health plans, you
have the right to choose continuation coverage for yourself if you lose group
health coverage under our health plans, for any of the following reasons:
The death of your spouse who was a Fairfield County employee;
A termination of your spouse’s employment (for reasons other than
gross misconduct);
A reduction in your spouse’s hours of employment;
Divorce or legal separation from your spouse; or
Your spouse becomes entitled to Medicare.
Dependent Children
Dependent children of Fairfield County employees covered by our health
plans, have the right to continuation coverage if group health coverage under
our plans, is lost for any of the following reasons:
The death of a parent who was a Fairfield County employee;
The termination of a parent’s employment (for reasons other than gross
misconduct) or reduction in a parent’s hours of employment with
Fairfield County;
Parents’ divorce or legal separation;
A parent who is an employee of Fairfield County becomes entitled to
Medicare; or
The dependent ceases to be a “dependent child” under the terms of our
health plans.
Please note that it is the employee’s responsibility to notify the Human
Resources/Benefits Department of any communication regarding loss of
coverage and communication regarding such between the employee and the
insurance carrier. Please note that employees must also provide notice of
other events (e.g., divorce) to the Human Resources Department.
Continuation of Coverage Rights Under COBRA
The right to COBRA continuation coverage was created by a federal law, the
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA
continuation coverage can become available to you and other members of
your family when group health coverage would otherwise end. For more
information about your rights and obligations under the Plan and under
federal law, you should review the Plan’s Summary Plan Description or
contact the Plan Administrator.
You may have other options available to you when you lose group
health coverage.
For example, you may be eligible to buy an individual plan through the Health
Insurance Marketplace. By enrolling in coverage through the Marketplace,
you may qualify for lower costs on your monthly premiums and lower out-of-
pocket costs. Additionally, you may qualify for a 30-day special enrollment
period for another group health plan for which you are eligible (such as a
spouse’s plan), even if that plan generally doesn’t accept late enrollees.
REQUIRED NOTICES
COBRA
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COBRA COVERAGE (cont.)
Disability Extension Of 18-month Period Of COBRA Continuation Coverage
If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you
and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would
have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA
continuation coverage.
Second Qualifying Event Extension Of 18-month Period Of Continuation Coverage
If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can
get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event.
This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies;
becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the
Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under
the Plan had the first qualifying event not occurred.
Are There Other Coverage Options Besides COBRA Continuation Coverage?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace,
Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may
cost less than COBRA continuation coverage. You can learn more about many of these options at
www.healthcare.gov.
If you have questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For
more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act,
and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security
Administration (EBSA) in your area or visit www. dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s
website.)
For more information about the Marketplace, visit
www.healthcare.gov.
**Keep Your Plan Administrator Informed Of Address Changes**
To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your
records, of any notices you send to the Plan Administrator.
REQUIRED NOTICES
COBRA
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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 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).
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:
Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
ARKANSAS – Medicaid
Website: http://myarhipp.com/
Phone: 1-855-MyARHIPP (855-692-7447)
CALIFORNIA – Medicaid
Website: https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx
Phone: 1-800-541-5555
COLORADO – Health First Colorado (Colorado’s Medicaid Program) &
Child Health Plan Plus (CHP+)
Health First Colorado Website: https://www.healthfirstcolorado.com/
Health First Colorado Member Contact Center:
1-800-221-3943/ State Relay 711
CHP+:
https://www.colorado.gov/pacific/hcpf/child-health-plan-plus
CHP+ Customer Service: 1-800-359-1991/ State Relay 711
FLORIDA – Medicaid
Website:
http://flmedicaidtplrecovery.com/hipp/
Phone: 1-877-357-3268
GEORGIA – Medicaid
Website: https://medicaid.georgia.gov/health-insurance-premium-payment-
program-hipp
Phone: 678-564-1162 ext 2131
INDIANA – Medicaid
Healthy Indiana Plan for low-income adults 19-64
Website:
http://www.in.gov/fssa/hip/
Phone: 1-877-438-4479
All other Medicaid
Website:
http://www.indianamedicaid.com
Phone 1-800-403-0864
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
KANSAS – Medicaid
Website: http://www.kdheks.gov/hcf/default.htm
Phone: 1-800-792-4884
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:
KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx
Phone: 1-877-524-4718
Kentucky Medicaid Website:
https://chfs.ky.gov
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)
MAINE – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html
Phone: 1-800-442-6003
TTY: Maine relay 711
MASSACHUSETTS – Medicaid and CHIP
Website: http://www.mass.gov/eohhs/gov/departments/masshealth/
Phone: 1-800-862-4840
MINNESOTA – Medicaid
Website:
https://mn.gov/dhs/people-we-serve/children-and-families/health-care/health-
care-programs/programs-and-services/medical-assistance.jsp [Under
ELIGIBILITY tab, see “what if I have other health insurance?”]
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://www.ACCESSNebraska.ne.gov
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
REQUIRED NOTICES
CHIP
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| BENEFITS GUIDE
To see if any other states have added a premium assistance program since January 31, 2020,
or for more information on special enrollment rights, contact either:
U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/ebsa
P: 866.444.EBSA (3272)
U.S. Department and Human Services Center for
Medicare & Medicaid Services
www.cms.hhs.gov
P: 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
[email protected] and reference the OMB Control Number 1210-0137.
OMB Control Number 1210-0137 (expires 1/31/2023)
NEW HAMPSHIRE – Medicaid
Website: https://www.dhhs.nh.gov/oii/hipp.htm
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/health_care/medicaid/
Phone: 1-800-541-2831
NORTH CAROLINA – Medicaid
Website: https://medicaid.ncdhhs.gov/
Phone: 919-855-4100
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://healthcare.oregon.gov/Pages/index.aspx
http://www.oregonhealthcare.gov/index-es.html
Phone: 1-800-699-9075
PENNSYLVANIA – Medicaid
Website:
https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HIPP-
Program.aspx
Phone: 1-800-692-7462
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
SOUTH DAKOTA - Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
TEXAS – Medicaid
Website: http://gethipptexas.com/
Phone: 1-800-440-0493
UTAH – Medicaid and CHIP
Medicaid Website: https://medicaid.utah.gov/
CHIP Website: http://health.utah.gov/chip
Phone: 1-877-543-7669
VERMONT– Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
VIRGINIA – Medicaid and CHIP
Website: https://www.coverva.org/hipp/
Medicaid Phone: 1-800-432-5924
CHIP Phone: 1-855-242-8282
WASHINGTON – Medicaid
Website: https://www.hca.wa.gov/
Phone: 1-800-562-3022
WEST VIRGINIA – Medicaid
Website: http://mywvhipp.com/
Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
WISCONSIN – Medicaid and CHIP
Website:
https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf
Phone: 1-800-362-3002
WYOMING – Medicaid
Website: https://wyequalitycare.acs-inc.com/
Phone: 307-777-7531
REQUIRED NOTICES
CHIP
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| BENEFITS GUIDE
NOTICE OF HIPAA PRIVACY PRACTICES
The privacy regulations of the Health Insurance Portability and Accountability Act
(HIPAA) became effective April 14,2003. These federal regulations require covered
entities, such as health plans, to provide plan participants with a notice of privacy
practices describing the health-related information that is collected, how it is used, and
the ways in which the regulations permit it to be disclosed. These privacy notices also
provide information on a participant’s right to access, review and, if necessary, to have
this information amended.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
“We,” “us”, and “Plan” refer to all the health benefit plans and programs presented
herein. “Plan Sponsor” refers to your employer. ‘’You” or “yours” refers to individual
participants in the Plans.
PHI is information that may identify you and that relates to past, present, or future health
care services provided to you, payment for health care services provided to you, or your
physical or mental health or condition.
Your employer Plan is required by law to take reasonable steps to ensure the
privacy of your personally identifiable health information and to inform you about:
1. The Plan’s uses and disclosures of Protected Health Information (PHI);
2. Your privacy rights with respect to your PHI;
3. The Plan’s duties with respect to your PHI;
4. Your right to file a complaint with the Plan and to the Secretary of the U.S.
Department of Health and Human Services; and
5. The person or office to contact for further information about the Plan’s privacy
practices.
The term “Protected Health Information” (PHI) includes all individually identifiable health
information transmitted or maintained by the Plan, regardless of form (oral, written,
electronic).
We are required by the Health Insurance Portability and Accountability Act
(HIPAA) to:
1. Maintain the privacy of your PHI;
2. Provide you with certain rights with respect to your PHI;
3. Provide you with this Notice of our legal duties and privacy practices regarding
your PHI; and
4. Abide by the terms of this Notice as it may be updated from time to time.
We protect your PHI from inappropriate use or disclosure. Our employees and those of
our Business Associates are required to protect the confidentiality of PHI. They may look
at your PHI only when there is an appropriate reason to do so, such as to determine
coordination of benefits or services. We will not disclose your PHI to anyone for
marketing purposes.
USES AND DISCLOSURES OF PHI
Primary Uses and Disclosures of PHI: The main reasons for which we may use and
may disclose your PHI are in order to administer our health benefit programs effectively
and to evaluate and process requests for coverage and claims for benefits.
The following describes these and other uses and disclosures together with some
examples:
Treatment*: Treatment refers to the provision and coordination of health care by a
doctor, hospital or other health care provider. We may disclose your PHI to health care
providers to provide you with treatment. For example, we might respond to an inquiry
from a hospital about your eligibility for a particular surgical procedure.
Payment*:Payment refers to our activities in collecting premiums and paying claims for
health care services you receive. We may use your PHI or disclose it to others for these
purposes. For example, if you had insurance coverage from a spouse’s employer, we
might disclose your PHI to the other insurer to determine coordination of benefits or
services. Payment also refers to the activities of a health care provider in obtaining
reimbursement for services. We may disclose your PHI to a provider for this purpose.
Health Care Operations Purposes*
1. We may use your PHI or disclose it to others for quality assessment and improvement
activities.
2. We may use your PHI or disclose it to others for activities relating to improving health or
reducing health care costs, development of health care procedures, case management,
and care coordination.
3. We may use your PHI or disclose it to others for the purpose of informing you or a
health care provider about treatment alternatives.
4. We may use your PHI or disclose it to others for the purpose of reviewing the
competence, qualifications, or performance of health care providers, or conducting
training programs.
5. We may use your PHI or disclose it to others for accreditation, certification,
licensing, or credentialing activities.
6. We may use your PHI or disclose it to others in the process of contracting for
health benefits or insurance covering health care costs.
7. We may use your PHI or disclose it to others for purposes of reviewing your medical
treatment, obtaining legal services, performing audits or obtaining auditing services, and
detecting fraud and abuse.
8. We may use your PHI or disclose it to others in our business management,
planning, and administrative activities. As an example, we might use your PHI in
the process of analyzing data about treatment of certain conditions to develop a
list of preferred medications.
Business Associates: We contract with various individuals and entities (Business
Associates) to perform functions on behalf of the Plans or to provide certain services. To
perform these functions, our Business Associates may receive, create, maintain, use, or
disclose PHI, but only after we require the Business Associates to agree in writing to
contract terms designed to safeguard your PHI.
Plan Sponsor: We and our Business Associates may also disclose PHI to the Plan
Sponsor without your written authorization in connection with payment, treatment, or
health care operations purposes or pursuant to a written request signed by you. Such
disclosures may only be made to the individuals authorized to receive such information.
If PHI is disclosed to the Plan Sponsor for these purposes, the Plan Sponsor agrees not
to use or disclose your health information other than as permitted or required by the
Plan documents and by law.
Other Covered Entities: your employer (including the insured plans) together are
called an “organized health care arrangement. ”The Plans may share PHI with each
other for the health care operations purposes of the organized health care arrangement.
*The amount of health information used, disclosed, or requested will be limited and, when
needed, restricted to the minimum necessary to accomplish the intended purpose, as defined
under the HIPAA rules.
OTHER POSSIBLE USES AND DISCLOSURES OF PHI
In addition to using and disclosing your PHI for treatment, payment, and health care
operations purposes, we may (and are permitted) to use or disclose it in the following
circumstances:
To Persons Involved in Care and for Notification Purposes: We may disclose PHI to a
family member, relative, close personal friend, or any other person identified by you, provided
that the PHI is directly relevant to that person’s involvement with your care or payment
related to your care. In addition, we may use or disclose PHI to notify a member of your
family, your personal representative, or another person responsible for your care of your
location, your general condition, or your death.
In Regard to Abuse, Neglect, or Domestic Violence: In certain circumstances, we may
disclose your PHI to a government authority that is authorized to receive reports of cases of
abuse, neglect, or domestic violence.
To Coroners, Medical Examiners, and Funeral Directors: We may disclose PHI to
coroners and medical examiners for the purpose of identifying a deceased person,
determining a cause of death, or other purposes authorized by law. We may disclose PHI to
funeral directors to enable them to carry out their duties.
For Public Health Activities: We may disclose PHI to public authorities for the purpose of
preventing or controlling disease, injury, or disability. Under some circumstances, when
authorized by law, we may disclose PHI to an individual who is at risk of contracting or
spreading a contagious disease or condition. We also may disclose PHI to appropriate
parties for the purpose of activities related to the quality, safety, or the effectiveness of
products regulated by the U.S. Food and Drug Administration.
To Avert a Threat to Health or Safety: We may, under certain circumstances, disclose PHI
to avert a serious threat to the health or safety of a person or the general public.
Organ and Tissue Donations: We may, under certain circumstances, disclose PHI for
purposes of organ, eye, or other medical transplants or tissue donation purposes.
REQUIRED NOTICES
NOTICE OF PRIVACY PRACTICES
27
| BENEFITS GUIDE
Right to Inspect, Copy, and Amend Your PHI
As long as we maintain records containing your PHI, you have a right to
inspect and copy such information. These rights are subject to certain
limitations and exceptions. For example, if the requested information contains
psychotherapy notes or may endanger someone, it may not be available. You
may request a review of any denial to access. If the Plan keeps your
records in an electronic format, you may request an electronic copy of your
health information in a form and format readily producible by the Plan. If you
believe your PHI held and created by us is incorrect or incomplete, you may
request that we amend your PHI. You will be required to provide the reason
the amendment is necessary. Requests for access to your PHI or
amendment of your records should be in writing and directed to the Health
Information Privacy Officer identified at the end of this Notice.
Right to a List of Disclosures
You have a right to an accounting of certain disclosures of your PHI by us.
The accounting will not include those items which are not required to be
provided such as disclosures made at your request or disclosures made for
treatment, payment, or health care operations. A request for a list of
disclosures should be directed to the Health Information Privacy Officer
identified at the end of this Notice.
Right to Request Confidential Communications
We will accommodate a reasonable request by you to receive
communications from us by alternative means or at an alternative location if
you believe that disclosure of your PHI could pose a danger to you. For
example, you may request that we only contact you by mail or at work.
Requests for confidential communications should be in writing and directed to
the Health Information Privacy Officer identified at the end of this Notice.
Right to be Notified of a Breach
You have the right to be notified in the event that we (or a Business
Associate) discover a breach of unsecured PHI.
Right to Receive Paper Copy
You have the right to receive a paper copy of this Notice from the Plan upon
request even if you have previously agreed to receive copies of this Notice
electronically. Requests for a paper copy should be in writing and directed to
the Health Information Privacy Officer identified at the end of this Notice.
CHANGES TO THIS NOTICE
We reserve the right to change the terms of this Notice and to make the new
Notice provisions effective for all PHI we maintain. If we change this Notice,
you will receive a new Notice. Active employees will receive the Notice by
distribution in the workplace; inactive employees (including retirees) will
receive the Notice by mail.
Complaints: If you believe that your privacy rights have been violated, you may complain
to us in writing at the location described below under “Health Information Privacy Officer’’
or with the office for Civil Rights of the Department of Health and Human Services, Hubert
H. Humphrey Building, 200 Independence Avenue SW, Washington, DC 20201. You will
not be retaliated against for filing a complaint.
Health Information Privacy Officer: You may exercise the rights described in this
Notice by contacting the office identified below, which will provide you with additional
information.
To Comply with Workers’ Compensation Laws: We may disclose your PHI to
the extent necessary to comply with laws relating to Workers’ Compensation or
other similar programs.
For Law Enforcement and National Security Purposes: In certain
circumstances, we may disclose PHI to appropriate officials for law enforcement
purposes; for example, if it is required by law or legal process. In addition, we
may disclose your PHI if you are or were armed forces personnel or to authorized
federal officials for conducting national security and intelligence activities.
In Connection with Legal Proceedings: In certain cases, we may disclose PHI
in connection with the legal proceedings of courts or governmental agencies. For
example, we may disclose your PHI in response to a subpoena for such
information but only after certain conditions required by HIPAA are met.
For Health Oversight Activities: We may disclose PHI to a governmental
agency authorized by law to oversee the health care system, compliance with
civil rights laws, or government benefit. Health oversight activities include audits,
inspections, investigations, or legal proceedings.
Military Personnel: If you are in the armed forces, we may disclose your PHI for
activities that military authorities consider necessary to the accomplishment of a
mission.
Inmates: If you are incarcerated, we may disclose your PHI to appropriate
authorities who tell us they need it for your health care, your safety, the health or
safety of other persons, or general administrative purposes.
Research: Under certain circumstances, we may disclose PHI for research
purposes.
Health Information: We may contact you with information about
treatment alternatives and other health-related benefits and services.
As Required by Law: We may disclose your PHI when required to do so by
federal, state, or local law.
REQUIRED DISCLOSURES OF PHI
The following is a description of disclosures we are required by law to
make:
Disclosures to the Secretary of the U.S. Department of Health & Human
Services
: We are required to disclose your PHI to the Secretary of the U.S.
Department of Health and Human Services when the Secretary is investigating or
determining compliance with HIPAA.
Disclosure to You: We are required to disclose to you most of your PHI. We
will also disclose your PHI to an individual whom you have designated as your
personal representative. However, before we can disclose your PHI to such
person, you must submit a written notice of his/her designation along with
documents supporting his/her qualification (such as a power of attorney). In
limited situations HIPAA permits us to elect not to treat the person as your
personal representative if we have reasonable belief that it could endanger
you.
OTHER USES AND DISCLOSURES OF YOUR PHI WITH AUTHORIZATION
Other uses and disclosures of your PHI that are not described above will be made
only with your written authorization. You may revoke an authorization at any time
by providing written notice to us. We will honor a request to revoke as of the day it
is received and to the extent that we have not already used or disclosed your PHI
in reliance on the authorization. To obtain an Authorization for Release of
Information, call the Human Resources Department. You may revoke an
authorization by contacting the Health Information Privacy Officer identified at the
end of this Notice.
YOUR RIGHTS
Right to Request Restrictions on Uses and Disclosure
You may ask us to restrict uses and disclosures of your PHI for treatment,
payment, or health care operations purposes, or to restrict disclosures to family
members, relatives, friends, or other persons identified by you who are involved
in your care or payment for your care, or to restrict disclosures for notification
purposes. However, we are not generally required to comply with your request for
restrictions except in those situations where the requested restriction relates to the
disclosure to the Plan for purposes of carrying out payment or health care
operations (and not for treatment), and the PHI pertains solely to a health care
item or service that was paid out of pocket in full. You may exercise this right by
contacting the Health Information Privacy Officer identified at the end of this Notice
who will provide you with additional information including what information is
required to make a restriction request.
REQUIRED NOTICES
NOTICE OF PRIVACY PRACTICES
28
| BENEFITS GUIDE
Dependent Verification Services (DVS) – Service used to verify
dependent proof of relationship when adding dependents to benefit
plans.
Beneficiary – A person designated by you, the participant of a benefit
plan, to receive the benefits of the plan in the event of the participant’s
death.
• Primary Beneficiary – A person who is designated to receive the
benefits of a benefit plan in the event of the participant’s death
• Contingent Beneficiary – A person who is designated to receive the
benefits of a benefit plan in the event of the Primary Beneficiary’s
death
Charges – The term “charges” means the actual billed charges. It also
means an amount negotiated by a provider, directly or indirectly, if that
amount is different from the actual billed charges.
Coinsurance – The percentage of charges for covered expenses that
an insured person is required to pay under the plan (separate from
copayments)
Deductible – The amount of money you must pay each year to cover
eligible expenses before your insurance policy starts paying.
Dependents – Dependents are your:
• Lawful spouse through a marriage that is lawfully
recognized.
• Dependent child (married or unmarried) under the age of 26 including
stepchildren and legally adopted children.
Proof of relationship documentation will be required in order to add
dependents to your plan(s). Employees will receive request for
documentation.
Emergency Services – Medical, psychiatric, surgical, hospital, and
related health care services and testing, including ambulance service,
that are required to treat a sudden, unexpected onset of a bodily injury
or serious sickness that could reasonably be expected by a prudent
layperson to result in serious medical complications, loss of life, or
permanent impairment to bodily functions in the absence of immediate
medical attention. Examples of emergency situations include
uncontrolled bleeding, seizures or loss of consciousness, shortness of
breath, chest pains or severe squeezing sensations in the chest,
suspected overdose of medication or poisoning, sudden paralysis or
slurred speech, burns, cuts, and broken bones.
The symptoms that led you to believe you needed emergency care, as
coded by the provider and recorded by the hospital, or the final
diagnosis – whichever reasonably indicated an emergency medical
condition – will be the basis for the determination of coverage provided
such symptoms reasonably indicate an emergency.
Evidence of Insurability (EOI) – Proof that you are insurable based on
the requirements of the insurance carrier. For example, the results of a
blood test or a doctor’s signature on a form may be required for you to be
covered by/for Optional Life insurance.
Explanation of Benefits — The health insurance company’s written
explanation of how a medical claim was paid. It contains detailed
information about what the company paid and what portion of the costs
are your responsibility.
Flexible Spending Account (FSA) – The Flexible Spending Account
(FSA) is a healthcare benefit that allows employees to set aside funds
annually to cover the costs of qualified medical expenses.
In-Network – The term “in-network” refers to health care services or
items provided by your Primary Care Physician (PCP) or services/items
provided by another participating provider and authorized by your PCP or
the review organization. Authorization by your PCP or the review
organization is not required in the case of mental health and substance
abuse treatment other than hospital confinement solely for detoxification.
Emergency Care that meets the definition of “emergency services” and
is authorized as such by either the PCP or the review organization is
considered in-network.
Out-of-Network - The term “out-of-network” refers to care that does not
qualify as in-network.
Maximum Out of Pocket — The most money you will pay during a year
for coverage. It includes deductibles, copayments and coinsurance, but
is in addition to your regular premiums. Beyond this amount, the
insurance company will pay all expenses for the remainder of the year.
Medically Necessary/Medical Necessity – Required to diagnose or
treat an illness, injury, disease, or its symptoms; in accordance with
generally accepted standards of medical practice; clinically appropriate
in terms of type, frequency, extent, site, and duration; not primarily for
the convenience of the patient, physician, or other health care provider;
and rendered in the least intensive setting that is appropriate for the
delivery of the services and supplies.
Participating Provider – A hospital, physician, or any other health care
practitioner or entity that has a direct or indirect contractual arrangement
with Cigna to provide covered services with regard to a particular plan
under which the participant is covered.
Post-Tax – An option to have the payment to your benefits deducted
from your gross pay after your taxes have been withheld. Therefore,
your tax contributions will be calculated based on a higher amount. Your
statutory deductions (federal income tax, Social Security, Medicare) will
be calculated based on a higher amount.
Pre-Tax – An option to have the payment to your benefits deducted from
your gross pay before your taxes have been withheld. Therefore, your
tax contributions will be calculated based on a lesser amount. Your
statutory deductions (federal income tax, Social Security, Medicare) will
be calculated based on a lesser amount.
Primary Care Dentist (PCD) – The term “Primary Care Dentist” means a
dentist who (a) qualifies as a participating provider in general practice,
referrals, or specialized care; and (b) has been selected by you, as
authorized by the provider organization, to provide or arrange for dental
care for you or any of your insured dependents.
Primary Care Physician (PCP) – The term “Primary Care
Physician” means a physician who (a) qualifies as a participating
provider in general practice, obstetrics/gynecology, internal
medicine, family practice, or pediatrics; and (b) has been selected
by you, as authorized by the provider organization, to provide or
arrange for medical care for you or any of your insured
dependents.
Proof of Relationship Documentation – Documents that show a
dependent is lawfully your dependent. Documents can include
marriage certificates, birth certificates, adoption agreements, previous
years’ tax returns, court orders, and/or divorce decrees showing your
or your spouse’s responsibility for the dependent.
GLOSSARY OF TERMS
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IMPORTANT
CONTACT
INFORMATION
United Healthcare Medical Group Number: 0909120
Customer Service
(866) 844-4864
www.myuhc.com
Flexible Spending Account (FSA)
(800) 331-0480
FSA Group Number: 912912
www.myuhc.com
Wellness Clinic
Fairfield County Employee Health &
Wellness Clinic
(740) 689-4404
Delta Dental Group Number: 1471
Customer Service
(800) 524-0149
www.deltadental.com
VSP Vision Group Number: 30069927
Customer Service
(800) 877-7195
www.vsp.com
Symetra Life/AD&D & Disability
Customer Service
(877) 377-6773
www.symetra.com/MyGO
Optum EAP
Employee Assistance Program
(866) 248-4094
www.liveandworkwell.com
Access Code: FairfieldCo
OPERS Retirement Plan
Customer Service
(800) 222-7377
www.opers.org
The Mobile Wallet Card keeps all of your benefit
contacts in one place. For easy access to your
benefit carriers’ group numbers, phone numbers and
websites visit
https://mymobilewalletcard.com/fairfieldco/
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This Benefit Enrollment Guide Is Provided By:
NFP Corp. and its subsidiaries do not provide legal or tax advice.
Compliance, regulatory and related content is for general informational
purposes and is not guaranteed to be accurate or complete. You should
consult an attorney or tax professional regarding the application or potential
implications of laws, regulations or policies to your specific circumstances.
NFP © 2021. All rights reserved.
