Bell County2020-2021 Employee Benefits Booklet

Table of Contents

Health and Dental Insurance Rates and Benefits 2020-2021

Baylor Scott & White Preferred HMO Member Guide

Summary of Benefits and Coverage - BSW Preferred HMO

Baylor Scott & White Plus HMO Member Guide

Summary of Benefits and Coverage - BSW Plus HMO

MDLIVE- Virtual Care

Ameritas Dental Fusion Core Plan

Ameritas Dental Fusion Buy Up Plan

Eyewear Savings Card

COVID-19 for Dental

Flexible Spending Account Introduction

Flexible Spending Account Overview for Medical

Flexible Spending Account Overview for Dependent Care

FSA Store Flyer

Colonial Life Voluntary Insurance

Medicare D Notice

HIPAA Model Privacy Notice 2020-2021

Chipra Notice

Special Enrollment Notice

Women’s Health and Cancer Rights Act

Newborns Act Disclosure

Notes

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BELL COUNTY

INSURANCE RATES FOR CONTRACT YEAR 2020 - 2021

Costs (with Tax Credit) - Current Benefits Package (employee to pay 1.5% of the premium for Employee Only, Baylor Scott & White Preferred Network (Smaller Network))

(contribution matching rate for Employee Only, Ameritas Dental, Base Plan)

COVERAGE FOR ALL INSURANCES (Health, Dental, & Life)

will be effective the First of the Month following 30 days of employment.

Baylor Scott & White Preferred Network (Smaller Network) Cost County Employee Employee Cost

($30 Copay, $1,250/$2,500 Ded, Co-Insurance 80/20%) per Month Contribution Cost per Month per Pay Period

{RX - Unlimited Maximum}

EMPLOYEE ONLY 573.83 565.22 8.61 4.31

EMPLOYEE/SPOUSE 1,416.94 565.22 851.72 425.86

EMPLOYEE/CHILDREN 1,004.89 565.22 439.67 219.84

FAMILY 1,722.80 565.22 1,157.58 578.79

5% increase. Baylor Scott & White Preferred providers belong to the Baylor Scott & White Quality Alliance Accountable

Care Organization and are contracted with Scott & White Health Plan to provide care for you.

No change to Plan Design.

Scott & White HMO (Broader Network) Cost County Employee Employee Cost

($30 Copay, $1,250/$2,500 Ded, Co-Insurance 80/20%) per Month Contribution Cost per Month per Pay Period

{RX - Unlimited Maximum}

EMPLOYEE ONLY 658.27 565.22 93.05 46.53

EMPLOYEE/SPOUSE 1,625.48 565.22 1,060.26 530.13

EMPLOYEE/CHILDREN 1,152.79 565.22 587.57 293.79

FAMILY 1,976.35 565.22 1,411.13 705.57

10% increase. Network is a Broader Network within Scott & White - Allows members to go to Doctors and Hospitals in a

larger network within the Scott & White Network . Example to include Seton in Harker Heights.

No change to Plan Design.

Ameritas Dental Coverage - Employer Sponsored Base Cost County Employee Employee Cost

(Dental with Preventive Plus / Maximum Allowable Charges per Month Contribution Cost per Month per Pay Period

and a Vision Reimbursement Benefit)

EMPLOYEE ONLY 19.56 19.56 0.00 0.00

FAMILY 69.48 19.56 49.92 24.96

0% Increase. No change to Plan Design.

Ameritas Dental Coverage - Voluntary Buy-Up Cost County Employee Employee Cost

(Dental with Preventive Plus / 90th Percentile per Month Contribution Cost per Month per Pay Period

and a Vision Reimbursement Benefit)

EMPLOYEE ONLY 28.24 19.56 8.68 4.34

FAMILY 92.40 19.56 72.84 36.42

0% Increase. No change to Plan Design.

Visit www.https://bellcounty.swhp.org for details on the health insurance.

Visit www.https://ameritas.com for details on the dental insurance.

Dated 07/13/2020

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Annual Deductible

Applies to Out of Pocket Max

$1,250 Individual

$2,500 Family

Annual Out of Pocket Maximum$3,750 Individual

$7,500 Family

Max Lifetime Benefit per member None

Primary Care Office Visit $30 copay; deductible waived

Specialty Care Office Visit $30 copay; deductible waived

BSW Virtual Visit / MD Live No Charge

Preventive Services No Charge

Standard Lab & X-ray No Charge

Diagnostic/Radiology Procedures20% after deductible

Up to the out of pocket maximum

Eye Exam

(1 refraction annually)$30 copay; deductible waived

Outpatient Surgery20% after deductible

Up to the out of pocket maximum

Inpatient Hospital 20% after deductible

Up to the out of pocket maximum

Emergency Room Services$250 copay, plus 20% of charges

Up to the out of pocket maximum

Urgent Care Services $75 Copay

Ambulance20% after deductible

Up to the out of pocket maximum

Prescription Drug Plan

Retail Quantity

(All Network Pharmacies)

(up to a 34-day supply or 100 units,

whichever is less)

No Annual Maximum

No Deductible

Preferred Generic: $10 copay

Preferred Brand: $40 copay

Non-Preferred: Lesser of $100 or 50%

Specialty Drug 10%/20%/30%

Prescription Drug Plan

Maintenance Quantity

(SWHP Pharmacies Only)

(up to a 90-day supply or 360 units,

whichever is less)

No Annual Maximum

No Deductible

Preferred Generic: $20 copay

Preferred Brand: $80 copay

Non-Preferred: Lesser of $200 or 50%

Ameritas Dental Plan Benefits Employer Sponsored Base Plan Voluntary Buy-Up

Deductible

$10 per Visit for Preventive;

$50/Policy Year/Individual for Basic and

Major; Ortho Exempt

$10 per Visit for Preventive;

$50/Policy Year/Individual for Basic and

Major; Ortho Exempt

Reimbursement Level

(Out-of-Network)Maximum Allowable Charges 90th Percentile

Preventive Services

$10 per visit charge

Cleanings (2 per policy year), x-rays,

exams, flouride, sealants

$10 per visit charge

Cleanings (2 per policy year), x-rays,

exams, flouride, sealants

Basic Services

20% after deductible

Basic restorative, simple extractions, root

canals

20% after deductible

Basic restorative, simple extractions, root

canals

Major Services

50% after deductible

Onlays, crowns, bridges, dentures, and

implants

50% after deductible

Onlays, crowns, bridges, dentures, and

implants

Orthodontic Services

50%, No deductible

Dependent under age 19

Lifetime Max. $1,000

50%, No deductible

Dependent under age 19

Lifetime Max. $1,000

Vision Reimbursement

Reimbursement up to $150 for exams,

frames, lenses, and contact lenses. Not

limited to any provider.

Reimbursement up to $150 for exams,

frames, lenses, and contact lenses. Not

limited to any provider.

RX Savings

Members and dependents (even their pets)

can save on prescription medications

through any Walmart or Sam's Club

pharmacy nationwide.

Members and dependents (even their pets)

can save on prescription medications

through any Walmart or Sam's Club

pharmacy nationwide.

Policy Year Maximum (Nov. 1 - Oct. 31)$1,000 per Individual

excludes Preventive

$1,000 per Individual

excludes Preventive

Dated 07/13/2020

Scott & White Health Plan Benefits

Benefits are the same for the Baylor

Scott & White Preferred Network and

Scott & White HMO

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Scott & White Care Plans2021 Member Guide BSW Preferred HMO

Got a question?..........................................................................................................1

Get to know your ID card .....................................................................................2

Explore your member portal .............................................................................3

Download the MyBSWHealth App ..................................................................4

Experience Virtual Care........................................................................................4

Eligibility map..............................................................................................................5

Find a provider............................................................................................................5

Access pharmacy services.................................................................................6

Know your care options ... ....................................................................................7

Better health starts with you.............................................................................9

Naturally Slim® .........................................................................................................10

Expecting the Best®..............................................................................................10

Get details on your claims .................................................................................11

Stay better, longer .................................................................................................13

Table of Contents

SWCP_GR_BellCountyPreferred_MemberGuide_2020-21

HMO products are offered through Scott and White Health Plan and Scott & White Care Plans. Insured PPO and EPO products are offered through Insurance Company of Scott and White. All are Texas registered insurance companies. Scott & White Care Plans and Insurance Company of Scott and White are wholly owned subsidiaries of Scott and White Health Plan.

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Got a question? Our highly trained Customer Advocates can help you with things like finding a provider and answering questions about your benefits or claims. Whatever your question or concern may be, our Customer Advocates will work with you to resolve it as quickly as possible—in most cases, before you hang up the phone.

Contact us through the member portalLog in at bellcounty.swhp.org to send a secure email and receive a secure response.

Nurse Advice LineNurses are available 24/7 to talk through your symptoms and help you make decisions on next steps, whether that’s an appointment or an at-home remedy. The Nurse Advice Line phone number is on the back of your member ID card.

Welcome to Scott & White Care Plans!Welcome to Scott & White Care Plans (SWCP), a wholly owned subsidiary of Scott and White Health Plan, and part of the Baylor Scott & White family of companies. With Scott & White Care Plans, you will have access to the renowned doctors, specialists and facilities of the Baylor Scott & White Health system. Baylor Scott & White Health (BSWH) provides full-range, inpatient, outpatient, rehabilitation and emergency medical services.

Beyond the Baylor Scott & White Health system, Scott & White Care Plans offers access to thousands of providers throughout North, Central and West Texas to ensure members have plenty of in-network options for care. You’ll find useful information about what we have to offer in this booklet—and if you have questions, we’re happy to answer them.

Contact us by phone 844.633.53257 AM – 7 PM Monday – Friday

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The ID card above is a sample. The exact location of certain elements may vary on your card.

Get to know your member ID card

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Group name

Group ID number

Network name

Benefit effective date

Member name

Member ID number

Copays/coinsurance

Deductible

Pharmacy/prescription drug info9

Customer service phone number

24/7 Nurse Line

Information for providers

Claims mailing address

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B

C

D

You can request a replacement ID card through the member portal oraccess an electronic card at any time through the MyBSWHealth app.

billing, find a provider at swhp.org

Self-service portal: ers.swhp.orgSWHP24/7 Nurse Line 1-000-000-0000

(TTY: 711)

00/00/0000

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TDI

SUBSCRIBERJohn Sample

DOB: 00/00/0000

DEPENDENTSJane SampleJack SampleJill SampleJames SampleJulie SampleJoe SampleJackie Sample

MEMBER ID 00000000000

00000000000000000000000000000000000000000000000000000000000000000000000000000

IN-NETWORK PLAN BENEFITSAdult PCP/Spec: 00%Pediatric PCP/Spec: 00% Emergency Room: 00%* Coinsurance:

N/A Deductible: I/$0000 F/$0000 Rx: 00%*Deductible:

I/$500, F/$1000PHARMACISTS ONLYOptumRx® Help Desk: 855-205-9182BIN: 610011 PCN: IRX GRP:

Group: Group #: 000000Network:

*Deductible may apply.

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bellcounty.swhp.org

Bell County

SWPBSWCP

FOR PROVIDERSElectronic Claims:Availity: 94999

Paper Claims:Scott and White Health PlanPO Box 211342Eagan, MN 55121

Prior Authorization: Visit the provider portal Fax: 800-626-3042 Phone: 866-384-3488

Provider Portal:

Card Issue Date: 08/01/2020

FOR MEMBER S

not guarantee coverage or payment for the service or procedure reviewed.

Important Information:• In a medical emergency, call 9-1-1 or go to the nearest

emergency facility.

• Telehealth: Download the MyBSWHealth App• 24/7 Nurse Line: 877-505-7947• Self-Service Portal: my.bswhealth.com• To avoid out-of-network costs and provider balance

DC

AB

CUSTOMER SERVICE: 844.633.5325 bellcounty.swhp.org

billing, find a provider at bellcounty.swhp.org

Customer Service: 844-633-5325 (TTY/TDD: 7-1-1)•

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3Explore your member portalThere’s a wealth of information, resources, and functionality available 24/7 in our member portal, accessible from your computer or mobile device. You’ll find a link to the portal on our website: bellcounty.swhp.org.

Download and/or print:

ID cards

Benefit Plan Documents

Claims summaries and Explanations of Benefits

Prescription medication history

Drug formulary

Pending, approved and denied authorizations

Plus you can:

Find a provider

Make an appointment with a BSWH doctor

Complete a health assessment

Access virtual care options (eVisit and Video Visit)

Track your deductible and out-of-pocket maximum

Message your BSWH doctor

Refill a prescription at BSWH pharmacies

Verify eligibility

View/update demographic information

Learn about, and register for, theExpecting the Best® Maternity Program

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Download the MyBSWHealth appVirtually all of the information in the member portal is available on your phone through the MyBSWHealth app. For example, you can view a digital copy of your ID card, see plan details, and track your deductible and out-of-pocket maximum for yourself and your dependents. Use the same user name and password you set up for the member portal to log in to the app. To learn more, visit our website: bellcounty.swhp.org

Be sure to link your account in the app:

Experience virtual care $0 copay

1. Tap the gear icon (top right corner of app welcome screen)2. Tap “Manage Linked Accounts”3. Tap “Link Account”4. Enter member information

Conduct an eVisit for common medical conditions and get care fast

Click the eVisit icon under "URGENT CARE OPTIONS" Complete an online questionnare about your symptoms; it takes only 5-10 minutes You will get a response from a Baylor Scott & White Health provider within one hour Prescriptions (if needed) will be sent immediately to your preferred pharmacy

Schedule a same-day Video Visit with a provider, face-to-face

Click the video visit icon under “URGENT CARE OPTIONS” to schedule your appointment Talk with a Baylor Scott & White Health provider live about your symptoms Visits are quick: just 10-15 minutes Prescriptions (if needed) will be sent immediately to your preferred pharmacy

MyBSWHealth 8 AM - 8 PM CT, 7 days a week Receive care from the comfort of your home, or anywhere in Texas, at no cost to you.

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Find a Provider

Need more help? Call the Baylor Scott & White Quality Alliance Health Access Line:

844.279.7589

Our provider search tool at bellcounty.swhp.org allows you to:

• Search by name, specialty and/or ZIP code

• Add filters for gender, board certification, accepting new patients and more

• See practice locations, contact information and maps

• Get details, including network participation and hospital affiliations

• Customize your own profile

Go to bellcounty.swhp.org and click on “Find a Provider-BSW Preferred” and you will be on your way.

Service Areas BSW Preferred HMO Network

Service Areas

AustinBastrop

Bell

Blanco

Bosque

Brazos

Brown

Burleson

Burnet

Caldwell

Comanche

Cooke

Coryell

Dallas

Denton

Ellis

Falls

Fannin

Fayette

Gillespie

Grayson

Grimes

Hamilton

Hays

Henderson

Hill

Hood

Hunt

Kaufman

Lampasas

Lee

Limestone

Llano

McCulloch

McLennan

Madison

Mason Milam

Mills

Navarro

Parker

Robertson

Rockwall

San Saba

Tarrant

Travis

Waller

Williamson

Wise

Johnson

Collin

Somervell

Washington

HMO: Only certain ZIP codes in Johnson, Milam and Travis counties are included.

PPO/ EPO: Only certain ZIP codes in Johnson and Travis counties are included.

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Access pharmacy servicesSWCP members may access more than 68,000 pharmacies nationwide, including most national chains and a large selection of local pharmacies.

To find your nearest pharmacy, click here:

We also offer 90-day prescription refills for select medications at Baylor Scott & White Health pharmacies.

Get the convenience of home delivery with mail order service. Call our mail order pharmacy and we will walk you through the transfer process.

Call toll-free at 855.388.3090 Monday through Friday, from 7 AM to 7 PM CT, and on Saturday, from 9 AM to 1 PM CT.

If you need detailed pharmacy claim information, pharmacy deductible information, explanation of benefits, or drug information and pricing, visit bellcounty.swhp.org or call Customer Service at 844.633.5325.

To view a formulary (a list of covered drugs), click here:

PHARMACY SEARCH

FORMULARY

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Visit your Primary Care Physicianwhen you’re sick or have a minor injury1

Your doctor knows your health history and underlying conditions. For routine illnesses and less significant injuries, many doctors’ offices are open on weekends and some evenings. This can be a good alternative to more costly urgent care or emergency care centers. Although a Primary Care Physician is not required, we encourage you to establish a relationship with a doctor.

If your doctor’s office is closed, consider an Urgent Care center2

Urgent Care centers typically have extended and weekend hours. Although costs are higher than primary care, urgent care copays are lower than those for emergency care.

Know your care optionsHow do you decide when a health-related issue is an emergency? Understanding your healthcare options can save your life... and your money.

Or opt for Virtual Care — or our Nurse Advice LineSee page 4 for information on Virtual Care. Nurses are available to our members 24 hours a day, 365 days a year. Our nurses provide information about taking care of yourself at home or they can help you decide if an appointment, an urgent care visit, or an emergency room visit is best for your symptoms. To locate your appropriate Nurse Advice Line phone number, please look on the back of your member card or log in to the Member Portal.

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If you need to speak to us, contact us in the way that works for you. In addition to the Member Portal, customer support is available by phone at 844.633.5325.

Scott & White Care Plans pays out-of-network emergency services according to Usual and Customary rates (industry standard), and members can be balance-billed for expenses beyond what insurance will pay. Your coverage documents contain additional information about emergency treatment and definitions of the terms, including a definition of emergency care. The coverage documents also contain information related to state-mandated consumer protections for facility-based provider charges.

To save on out-of-pocket costs, visit in-network emergency care facilities when possible. You can find in-network emergency care facilities by using the provider search tool at bellcounty.swhp.org.

Remember: Out-of-network emergency care costs more

Emergency Roomsare best for treating severe and life-threatening conditions and they’re always open.3

The wider range of services offered through emergency rooms, and the hospitals they are connected to, makes emergency care a more expensive option, but sometimes the best option for you.

It’s important to understand your options, and to use your best judgment when deciding which option is right for you.

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Assessment for Members

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WELL-BEING ASSESSMENTThe Well-Being Assessment is a simple, digital health survey that helps you take steps toward a more vibrant and healthier life. The Well-Being Assessment asks questions about your life and delivers customized action steps from our Lifestyle Management Program. Modules are self-paced, available online, and convenient for promoting physical and mental health — all things to help you feel your best.

Digital Health Coaching – 6-week coaching modules with action plans, important articles, online seminars and video content on topics that include:

• Live Tobacco Free• Healthy Weight

Progress Tracker – The digital platform has a dashboard to help you keep track of important health information like A1C, weight/BMI, cholesterol, blood pressure and physical activity. These biometric measurements can be charted over time to monitor your long-term health.

Fitness Tracker Integration – Synchronize your personal fitness tracker with the wellness platform to monitor your physical activity progress on the dashboard.

Digital Health Library – Access to articles, videos, recipes and other content to support a healthier life. You can search for condition-specific information or explore highlighted topics.

Challenges – Sometimes you need extra motivation to go the extra mile. You can participate in step challenges, hydration and even relaxation challenges.

Online Community – Access to online community forums where you can give and receive support for goals as well as get feedback from health coaches in the community.

• Healthier Diet• Active Living

Elevate your well-being with Scott & White Care Plans’ comprehensive suite of digital resources. Log in to your member portal to get started.

• Less Stress

Better health starts with you

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Expecting the Best® Maternity ProgramWe are pleased to offer a maternity program for pregnant Scott & White Care Plans members. This initiative is focused on helping expectant mothers enjoy a healthy pregnancy.

Once enrolled, participants can benefit from diverse program features for the duration of their pregnancy and one year postpartum.Participants receive helpful educational materials across distinct categories, including proper nutrition, early identification of pregnancy risk factors and available resources for any complications.

Sign up by calling the customer service number on the back of your ID card or send an email to: HPMaternityCaseManagement@BSWHealth.org.

Ever wonder how some people can eat all their favorite foods and not gain weight? Naturally Slim is an online program that will teach you how. And here’s a hint: it doesn’t include starving, counting calories or spending hours prepping ‘approved’ foods. SWCP is giving you the chance to learn how to eat the foods you love while reducing your risk of developing serious conditions, like diabetes or heart disease.

Naturally Slim is available at NO COST to you and is accessible via computer and mobile device so you can participate whenever it’s convenient, wherever you are.

For more information about Naturally Slim, visit bellcounty.swhp.org

You don’t have to give up your favorite foods to lose weight and feel your best.

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ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (800) 321-7947 (TTY: 711).

Scott & White Care Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (800) 321-7947 (TTY: 711).

Scott & White Care Plans cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.Gọi số (800) 321-7947 (TTY: 711).

Scott & White Care Plans tuân thủ luật dân quyền hiện hành của Liên bang và không phân biệt đối xử dựa trên chủng tộc, màu da, nguồn gốc quốc gia, độ tuổi, khuyết tật, hoặc giới tính.

Allowed Amount -This is the amount considered for payment based on our provider contracts and your benefits.

Amount Billed -This is the amount your provider billed for the services you requested. Note: this amount does not reflect discounts that the plan has negotiated with the provider or facility.

Amount Paid -This is the amount we paid to you or your provider.

Copay -This represents the amount you are responsible to pay for certain services, typically paid at the time of service.

Coinsurance - The coinsurance is a percentage of the “allowed amount” you are responsible for paying for services after your deductible is met. Providers may require payment when you receive services.

Deductible - A fixed-dollar amount the member is responsible for paying each plan year before the plan begins to pay for covered services. Note: “Non-Covered” amounts don’t count toward meeting the yearly deductible. Your provider may bill you for these charges.

Discount Amount -The amount you saved by using the plan’s preferred providers.

Non-Covered Amount - An amount you are responsible for paying because it is for a service that is not covered by your benefit plan. Also, if you’ve used an out-of-network provider, “non-covered amount” includes any amount the out-of-network provider bills in excess of the plan-negotiated network rates.

Other Coverage Payment -This is the amount paid by your other insurance carrier.

Out-of-Pocket Maximum -The most you have to pay for in-network health services every year. Once you have paid this amount, the Health Plan typically pays 100% of your allowed health care charges, subject to any policy limitations.

Helpful Definitions

If you suspect fraud, contact the Scott and White Health Plan Compliance HelpLine at (888) 484-6977.

Report Fraud

Language Assistance/ Nondiscrimination Notice

Get details on your claimswith your monthly insurance statement

Subscriber: John Smith

Member ID: 12345678

Group Name: SampleCompany Inc.

Group Number: 012345

Now...the Detailed VersionHere’s a detailed breakdown or Explanation of Benefits for this service. In case there’s any doubt - this is NOT a bill!

Notes:IJ THE PROVIDER IS NOT IN NETWORK AND/OR THERE IS NO AUTH ON FILE*If you elected to use your out-of-network benefit, the provider or facility may bill you for an amount greaterthan the amount reimbursed by the Health Plan. Out-of-network providers or facilities may not bill you foran amount greater than the copay/coinsurance/deductible indicated above in the following circumstances:emergency care services, treatment from an out-of-network provider while receiving services at an in-networkfacility, or for out-of network imaging or laboratory services if related to treatment from an in-network provider.

Patient: Ann SmithClaim Number: 123x456x788Provider: Test Provider 1

Out-of-Network*

Date of Service Description Amount

BilledAllowed Amount

Non-Covered Amount

Other Coverage Payment

Plan Paid Copay Deductible Coinsurance What You May Owe Notes

2/04/20 Emergency Dept Visit $1000.00 $500.00 $0.00 $0.00 $400.00 $100.00 $0.00 $0.00 $100.00 IJ

Total $1000.00 $500.00 $0.00 $0.00 $400.00 $100.00 $0.00 $0.00 $100.00

Patient: Ann SmithClaim Number: 123x456x789Provider: Test Provider 2

In-Network

Date of Service Description Amount

BilledAllowed Amount

Non-Covered Amount

Other Coverage Payment

Plan Paid Copay Deductible Coinsurance What You May Owe Notes

2/04/20 Office Visit $250.00 $150.00 $0.00 $0.00 $100.00 $50.00 $0.00 $0.00 $50.00

Total $250.00 $150.00 $0.00 $0.00 $100.00 $50.00 $0.00 $0.00 $50.00

QUESTIONS?

Customer service: (800) 321-7947 Hours: 7 a.m. to 7 p.m. CT

Website: swhp.org

Explanation of BenefitsThis is NOT a bill

1206 West Campus DriveTemple, TX 76502

Forwarding Service Requested

Member ID: 12345678Group Number: 012345Group Name: Sample Company Inc.Print date: 02/18/2020

John Smith789 TEST STREETREDCARD, MO 63141

Hi John,This document summarizes your recent benefit activity. It confirms the amount charged by your provider(s) and the amount we paid for those charges.

Cost breakdown

Amount billed: $1250.00

Plan discount: $600.00

Plan paid: $500.00

Not covered: $0.00

What you may owe

$150.00This is the portion of the billed amount you may

owe the provider(s) if payment was not collected at thetime of service. This amount may include

your deductible, copay, coinsurance, and/or non-covered amount.

Account Summary

Place holder for misc. communications

TotalAmount

AppliedAmount

Family Deductible

Family Out-of-pocket max$1,500.00

$2,477.84

$3,000.00($1,500.00 remaining)

$4,500.00($2,022.16 remaining)

Member Deductible

Member Out-of-pocket max

$250.00

$199.71

$1,500.00($1,250.00 remaining)

$2,250.00($2,050.29 remaining)

An electronic Monthly Insurance Statement, also known as an Explanation of Benefits (EOB), is available through the Member Portal an to help you manage your claims expenses at a detailed level. The statement provides line-item detail on charges for that month, including what was billed and covered by SWCP. The amount you owe is included in this statement.

Remaining balances for deductibles and out-of-pocket expenses are also reported. Information for the current month and year-to-date is included. Statements are not provided for prescription claims or claims where the member does not owe anything.

Your EOBs will be available on the Member Portal unless you specifically request to receive paper EOBs in the mail. To request paper EOBs, log in to the Member Portal and select “Update Preferences.”

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Complex Case Management If you have chronic conditions or complex care needs, our nurse case managers will work with you, your family, and your physician to create and manage your care plan. Case managers advocate for you and can help you navigate the healthcare system and arrange the services you need. They can also answer questions and help you understand your condition and care plan. If Disease Management is right for you, they’ll incorporate the program into your care. There is no additional cost to you for this voluntary program. It’s all part of our goal to help you get the best possible results and the greatest value from your health plan.

Disease ManagementDisease Management empowers you to manage your chronic condition and help prevent complications. We work with your healthcare providers to identify chronic conditions quickly and treat them effectively. We can also identify self-care activities that help you manage your condition at home. Together, we’ll work to slow down the progression of your disease and help you stay better, longer.

Stay better, longer

Accountable Care OrganizationAs a member of a health plan working with an Accountable Care Organization, you can expect care that is:

HIGH-QUALITY. You should expect the care you receive to be safe, timely, effective, efficient, equitable and patient-centered.

COORDINATED. Your doctor guides your care team and coordinates appropriate services across all sites of care that might include a specialist’s office, the hospital, or laboratory and imaging services.

CONVENIENT. Many of our doctors and facilities offer same-day appointments, extended hours, and onsite laboratory and imaging services. Urgent care centers and retail care clinics like Walgreen’s and CVS are in the BSW Preferred network.

COMPREHENSIVE. The BSW Preferred network of primary and specialty care doctors and facilities is broad. We are confident we can meet your care needs.

COST-EFFECTIVE. Copays and out-of-pocket expenses are kept in check when your care needs are delivered inside the BSW Preferred network (doctors, hospitals, laboratory, imaging and post-acute care.) All other providers are considered out-of-network and no benefits are available for services other than emergency situations.

16

HMO products are offered through Scott and White Health Plan and Scott & White Care Plans. Insured PPO and EPO products are offered through Insurance Company of Scott and White. All are Texas registered insurance companies. Scott & White Care Plans and Insurance Company of Scott and White are wholly owned subsidiaries of Scott and White Health Plan.

Thank you for choosing Scott & White Care Plans for your healthcare coverage needs.

17

The

Sum

mar

y of

Ben

efits

and

Cov

erag

e (S

BC) d

ocum

ent w

ill he

lp y

ou c

hoos

e a

healt

h pl

an. T

he S

BC s

hows

you

how

you

and

the

plan

wou

ld

shar

e the

cost

for c

over

ed h

ealth

care

serv

ices.

NOTE

: Inf

orm

atio

n ab

out t

he co

st o

f thi

s plan

(call

ed th

e pre

miu

m) w

ill be

pro

vided

sepa

rate

ly.

This

is on

ly a

sum

mar

y. Fo

r mor

e inf

orma

tion

abou

t you

r cov

erag

e, or

to g

et a

copy

of t

he c

omple

te ter

ms o

f cov

erag

e, vis

it be

llcou

nty.sw

hp.or

g or

call

1-

844-

633-

5325

. For

gen

eral

defin

itions

of c

ommo

n ter

ms, s

uch

as a

llowe

d am

ount,

bala

nce

billin

g, co

insur

ance

, cop

ayme

nt, d

educ

tible,

pro

vider

, or

other

unde

rlined

term

s see

the G

lossa

ry. Y

ou ca

n view

the G

lossa

ry at

healt

hcar

e.gov

/sbc-g

lossa

ry or

call 1

-844

-633

-532

5 to r

eque

st a c

opy.

Impo

rtant

Que

stio

ns

Answ

ers

Why

Thi

s Mat

ters

:

Wha

t is t

he o

vera

ll de

duct

ible?

$1

,250 i

ndivi

dual

/ $2,5

00 fa

mily

Gene

rally

, you

mus

t pay

all o

f the c

osts

from

prov

iders

up to

the d

educ

tible

amou

nt be

fore

this p

lan be

gins t

o pay

. If yo

u hav

e othe

r fam

ily m

embe

rs on

the p

lan, e

ach f

amily

me

mber

mus

t mee

t their

own i

ndivi

dual

dedu

ctible

until

the to

tal am

ount

of de

ducti

ble

expe

nses

paid

by al

l fami

ly me

mber

s mee

ts the

over

all fa

mily

dedu

ctible

.

Are t

here

serv

ices

cove

red

befo

re yo

u m

eet

your

ded

uctib

le?

Yes.

Pre

venti

ve ca

re an

d prim

ary c

are

servi

ces a

re co

vere

d befo

re yo

u mee

t yo

ur de

ducti

ble.

This

plan c

over

s som

e item

s and

servi

ces e

ven i

f you

have

n’t ye

t met

the de

ducti

ble

amou

nt. B

ut a c

opay

ment

or co

insur

ance

may

apply

. For

exam

ple, th

is pla

n cov

ers c

ertai

n pr

even

tive s

ervic

es w

ithou

t cos

t-sha

ring a

nd be

fore y

ou m

eet y

our d

educ

tible.

See

a lis

t of

cove

red p

reve

ntive

servi

ces a

t hea

lthca

re.go

v/cov

erag

e/pre

venti

ve-ca

re-b

enefi

ts.

Are t

here

oth

er

dedu

ctib

les fo

r spe

cific

serv

ices?

No

Yo

u don

’t hav

e to m

eet d

educ

tibles

for s

pecif

ic se

rvice

s.

Wha

t is t

he o

ut-o

f-poc

ket

limit

for t

his p

lan?

$3,75

0 ind

ividu

al / $

7,500

fami

ly Th

e out-

of-po

cket

limit i

s the

mos

t you

could

pay i

n a ye

ar fo

r cov

ered

servi

ces.

If you

ha

ve ot

her f

amily

mem

bers

in thi

s plan

, they

have

to m

eet th

eir ow

n out-

of-po

cket

limits

un

til the

over

all fa

mily

out-o

f-poc

ket li

mit h

as be

en m

et.

Wha

t is n

ot in

clude

d in

th

e out

-of-p

ocke

t lim

it?

Copa

ymen

ts on

certa

in se

rvice

s, pr

emium

s, ba

lance

-billi

ng ch

arge

s, an

d he

alth c

are t

his pl

an do

es no

t cov

er.

Even

thou

gh yo

u pay

thes

e exp

ense

s, the

y don

’t cou

nt tow

ard t

he ou

t–of–p

ocke

t limi

t.

Will

you

pay l

ess i

f you

us

e a n

etwo

rk p

rovid

er?

Yes.

See b

ellco

unty.

swhp

.org o

r call

1-

844-

633-

5325

for a

list o

f netw

ork

prov

iders.

This

plan u

ses a

prov

ider n

etwor

k. Yo

u will

pay l

ess i

f you

use a

prov

ider in

the p

lan’s

netw

ork.

You w

ill pa

y the

mos

t if yo

u use

an ou

t-of-n

etwor

k pro

vider

, and

you m

ight

rece

ive a

bill fr

om a

prov

ider f

or th

e diffe

renc

e betw

een t

he pr

ovide

r’s ch

arge

and w

hat

your

plan

pays

(bala

nce b

illing

). Be

awar

e, yo

ur ne

twor

k pro

vider

migh

t use

an ou

t-of-

netw

ork p

rovid

er fo

r som

e ser

vices

(suc

h as l

ab w

ork).

Che

ck w

ith yo

ur pr

ovide

r befo

re

you g

et se

rvice

s. Do

you

need

a re

ferra

l to

see a

spec

ialist

? No

Yo

u can

see t

he sp

ecial

ist yo

u cho

ose w

ithou

t a re

ferra

l.

18

All c

opay

men

t and

coin

sura

nce c

osts

show

n in t

his ch

art a

re af

ter yo

ur d

educ

tible

has b

een m

et, if

a ded

uctib

le ap

plies

.

Com

mon

Me

dica

l Eve

nt

Serv

ices Y

ou M

ay N

eed

Wha

t You

Will

Pay

Lim

itatio

ns, E

xcep

tions

, & O

ther

Impo

rtant

In

form

atio

n Ne

twor

k Pro

vider

(Y

ou w

ill pa

y the

leas

t) Ou

t-of-N

etwo

rk P

rovid

er

(You

will

pay t

he m

ost)

If yo

u vis

it a h

ealth

ca

re p

rovid

er’s

offic

e or

clin

ic

Prim

ary c

are v

isit to

trea

t an

injur

y or il

lness

$3

0 cop

ayme

nt/vis

it No

t cov

ered

No

ne

Sp

ecial

ist vi

sit

$30 c

opay

ment/

visit

Not c

over

ed

Prev

entiv

e ca

re/sc

reen

ing/

immu

nizati

on

No ch

arge

No

t cov

ered

Yo

u may

have

to pa

y for

servi

ces t

hat a

ren’t

pr

even

tive.

Ask y

our p

rovid

er if

the se

rvice

s ne

eded

are p

reve

ntive

. The

n che

ck w

hat y

our

plan w

ill pa

y for

.

If yo

u ha

ve a

test

Diag

nosti

c tes

t (X-

ray,

blood

wor

k) No

char

ge

Not c

over

ed

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d. Re

fer to

bellc

ounty

.swhp

.org o

r Cu

stome

r Ser

vice a

t 1-8

44-6

33-5

325.

Imag

ing (C

T/PE

T sc

ans,

MRIs)

20

% af

ter de

ducti

ble

Not c

over

ed

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d.

If yo

u ne

ed d

rugs

to

treat

your

illne

ss o

r co

nditi

on

More

infor

matio

n abo

ut pr

escr

iptio

n dr

ug

cove

rage

is av

ailab

le at

bellc

ounty

.swhp

.org/p

harm

acy-i

nform

ation

.

ACA

Prev

entiv

e Dru

gs

$0 co

paym

ent/p

resc

riptio

n De

ducti

ble do

es no

t app

ly No

t cov

ered

Copa

ymen

ts ar

e per

30-d

ay su

pply.

Ma

inten

ance

-elig

ible d

rugs

are a

llowe

d up t

o a

90-d

ay su

pply

for tw

o cop

ayme

nts if

obtai

ned

throu

gh a

Baylo

r Sco

tt & W

hite P

harm

acy o

rpa

rticipa

ting 9

0-da

y reta

il or m

ail or

der

phar

macy

prov

ider.

Mail O

rder

: Ava

ilable

for a

1- to

90-d

ay su

pply.

Non-

maint

enan

ce dr

ugs o

btaine

d thr

ough

mail

orde

r are

limite

d to a

30-d

ay su

pply

maxim

um.

Some

Spe

cialty

drug

s may

requ

ire pr

iorau

thoriz

ation

. 30-

day s

upply

only.

Tier 1

: Pre

ferre

d Gen

eric

Drug

s $1

0 cop

ayme

nt/pr

escri

ption

De

ducti

ble do

es no

t app

ly No

t cov

ered

Tier 2

: Pre

ferre

d Bra

nd

Name

Dru

gs

$40 c

opay

ment/

pres

cripti

on

Dedu

ctible

does

not a

pply

Not c

over

ed

Tier 3

: Non

-Pre

ferre

d Ge

neric

/ Bra

nd N

ame

Drug

s

The l

esse

r of $

100

copa

ymen

t or 5

0%

copa

ymen

t De

ducti

ble do

es no

t app

ly No

t cov

ered

Spec

ialty

Drug

s T1

: 10%

of ch

arge

s T2

: 20%

of ch

arge

s T3

: 30%

of ch

arge

s De

ducti

ble do

es no

t app

ly No

t cov

ered

19

Com

mon

Me

dica

l Eve

nt

Serv

ices Y

ou M

ay N

eed

Wha

t You

Will

Pay

Lim

itatio

ns, E

xcep

tions

, & O

ther

Impo

rtant

In

form

atio

n Ne

twor

k Pro

vider

(Y

ou w

ill pa

y the

leas

t) Ou

t-of-N

etwo

rk P

rovid

er

(You

will

pay t

he m

ost)

If yo

u ha

ve o

utpa

tient

su

rger

y

Facil

ity fe

e (e.g

., am

bulat

ory s

urge

ry ce

nter)

20%

after

dedu

ctible

No

t cov

ered

Se

rvice

s tha

t are

not p

reau

thoriz

ed w

ill be

de

nied.

Refer

to be

llcou

nty.sw

hp.or

g or

Custo

mer S

ervic

e at 1

-844

-633

-532

5.

Phys

ician

/surg

eon f

ees

20%

after

dedu

ctible

No

t cov

ered

If yo

u ne

ed im

med

iate

med

ical a

ttent

ion

Emer

genc

y roo

m ca

re

$250

copa

ymen

t/visi

t, plus

20

% of

char

ges

$250

copa

ymen

t/visi

t, the

n 20

% of

char

ges

Copa

ymen

t waiv

ed if

episo

de re

sults

in

hosp

italiz

ation

for t

he sa

me co

nditio

n with

in 24

ho

urs.

Emer

genc

y med

ical

trans

porta

tion

20%

after

dedu

ctible

20

% af

ter de

ducti

ble

None

Ur

gent

care

$7

5 cop

ayme

nt/vis

it $7

5 cop

ayme

nt/vis

it

If yo

u ha

ve a

hosp

ital

stay

Facil

ity fe

e (e.g

., hos

pital

room

) 20

% af

ter de

ducti

ble

Not c

over

ed

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d. Ph

ysici

an/su

rgeo

n fee

s 20

% af

ter de

ducti

ble

Not c

over

ed

If yo

u ne

ed m

enta

l he

alth,

beh

avio

ral

healt

h, o

r sub

stan

ce

abus

e ser

vices

Outpa

tient

servi

ces

$30 c

opay

ment/

visit

Not c

over

ed

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d. Re

fer to

bellc

ounty

.swhp

.org o

r Cu

stome

r Ser

vice a

t 1-8

44-6

33-5

325.

Inpati

ent s

ervic

es

20%

after

dedu

ctible

No

t cov

ered

Se

rvice

s tha

t are

not p

reau

thoriz

ed w

ill be

de

nied.

If yo

u ar

e pre

gnan

t

Offic

e visi

ts $3

0 cop

ayme

nt/vis

it No

t cov

ered

Cost

shar

ing do

es no

t app

ly for

prev

entiv

e se

rvice

s. De

pend

ing on

the t

ype o

f ser

vices

, a

copa

ymen

t, coin

sura

nce,

or de

ducti

ble m

ay

apply

. Mate

rnity

care

may

inclu

de te

sts an

d se

rvice

s des

cribe

d else

wher

e in t

he S

BC (i.

e. ult

raso

und)

. Ch

ildbir

th/de

liver

y pr

ofess

ional

servi

ces

20%

after

dedu

ctible

No

t cov

ered

Th

e hea

lth pl

an m

ust b

e noti

fied o

f the

deliv

ery.

If a le

ngth

of sta

y for

an

unco

mplic

ated d

elive

ry ex

ceed

s 48 h

ours

for

vagin

al, or

96 ho

urs f

or ca

esar

ean,

prea

uthor

izatio

n is r

equir

ed. F

ailur

e to n

otify

or

prea

uthor

ize, w

hen r

equir

ed, m

ay re

sult o

f a

denia

l of th

e ser

vice.

Refer

to

bellc

ounty

.swhp

.org o

r Cus

tomer

Ser

vice a

t 1-

844-

633-

5325

.

Child

birth/

deliv

ery f

acilit

y se

rvice

s 20

% af

ter de

ducti

ble

Not c

over

ed

20

Com

mon

Me

dica

l Eve

nt

Serv

ices Y

ou M

ay N

eed

Wha

t You

Will

Pay

Lim

itatio

ns, E

xcep

tions

, & O

ther

Impo

rtant

In

form

atio

n Ne

twor

k Pro

vider

(Y

ou w

ill pa

y the

leas

t) Ou

t-of-N

etwo

rk P

rovid

er

(You

will

pay t

he m

ost)

If yo

u ne

ed h

elp

reco

verin

g or

hav

e ot

her s

pecia

l hea

lth

need

s

Home

healt

h car

e $3

0 cop

ay/vi

sit

Not c

over

ed

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d.

Reha

bilita

tion s

ervic

es

$30 c

opay

ment/

visit

Not c

over

ed

Limite

d to 2

0 com

bined

PT/

OT/S

P ou

tpatie

nt vis

its an

d an a

dditio

nal 1

0 visi

ts for

Hom

e Se

tting p

er pl

an ye

ar. L

imits

may

not a

pply

for

Ther

apies

for C

hildr

en w

ith D

evelo

pmen

tal

Delay

s and

Auti

sm S

pectr

um D

isord

er.

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d.

Habil

itatio

n ser

vices

$3

0 cop

ayme

nt/vis

it No

t cov

ered

Limite

d to 2

0 com

bined

PT/

OT/S

P ou

tpatie

nt vis

its an

d an a

dditio

nal 1

0 visi

ts for

Hom

e Se

tting p

er pl

an ye

ar. L

imits

may

not a

pply

for

Ther

apies

for C

hildr

en w

ith D

evelo

pmen

tal

Delay

s and

Auti

sm S

pectr

um D

isord

er.

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d.

Skille

d nur

sing c

are

20%

after

dedu

ctible

No

t cov

ered

Se

rvice

s tha

t are

not p

reau

thoriz

ed w

ill be

de

nied.

Dura

ble m

edica

l eq

uipme

nt 50

% af

ter de

ducti

ble

Not c

over

ed

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d.

Hosp

ice se

rvice

s No

char

ge

Not c

over

ed

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d. Re

fer to

bellc

ounty

.swhp

.org o

r Cu

stome

r Ser

vice a

t 1-8

44-6

33-5

325.

If yo

ur ch

ild n

eeds

de

ntal

or ey

e car

e

Child

ren’s

eye e

xam

$30 c

opay

ment/

visit

Not c

over

ed

Limite

d to o

ne ey

e exa

m pe

r plan

year

.

Child

ren’s

glas

ses

Not c

over

ed

Not c

over

ed

None

Child

ren’s

denta

l che

ck-

up

Not c

over

ed

Not c

over

ed

None

21

Exclu

ded

Serv

ices &

Oth

er C

over

ed S

ervic

es:

Serv

ices Y

our P

lan G

ener

ally D

oes N

OT C

over

(Che

ck yo

ur p

olicy

or p

lan d

ocum

ent f

or m

ore i

nfor

mat

ion

and

a list

of a

ny o

ther

exclu

ded

serv

ices.)

•

Acup

unctu

re•

Baria

tric su

rger

y•

Child

ren’s

glas

ses

•Co

smeti

c sur

gery

•De

ntal c

are (

Adult

and C

hild)

•Inf

ertili

ty tre

atmen

t•

Long

-term

care

•No

n-em

erge

ncy c

are w

hen t

rave

ling o

utside

the U

.S.

•Pr

ivate-

duty

nursi

ng•

Routi

ne fo

ot ca

re•

Weig

ht los

s pro

gram

s

Othe

r Cov

ered

Ser

vices

(Lim

itatio

ns m

ay ap

ply t

o th

ese s

ervic

es. T

his i

sn’t

a com

plet

e list

. Plea

se se

e you

r plan

doc

umen

t.)

•Ch

iropr

actic

care

(limi

ted to

35 vi

sits p

er pl

an ye

ar)

•He

aring

aids

(limi

ted to

one d

evice

per e

ar ev

ery 3

year

s; lim

ited t

o cov

ered

mem

bers

throu

gh th

e age

of 18

)•

Routi

ne ey

e car

e (Ad

ult) (

limite

d to a

n ann

ual e

ye ex

am co

nduc

ted by

a lic

ense

d oph

thalm

ologis

t or o

ptome

trist)

Your

Rig

hts t

o Co

ntin

ue C

over

age:

The

re ar

e age

ncies

that

can h

elp if

you w

ant to

conti

nue y

our c

over

age a

fter it

ends

. The

conta

ct inf

orma

tion f

or th

ose

agen

cies i

s: Sc

ott &

Whit

e Car

e Plan

s, vis

it swh

p.org

, or c

all 1-

844-

633-

5325

; Dep

artm

ent o

f Lab

or’s

Emplo

yee B

enefi

ts Se

curity

Adm

inistr

ation

at 1-

866-

444-

EBSA

(3

272)

or do

l.gov

/ebsa

/healt

hrefo

rm. O

ther c

over

age o

ption

s may

be av

ailab

le to

you t

oo, in

cludin

g buy

ing in

dividu

al ins

uran

ce co

vera

ge th

roug

h the

Hea

lth

Insur

ance

Mar

ketpl

ace.

For m

ore i

nform

ation

abou

t the M

arke

tplac

e, vis

it Hea

lthCa

re.go

v or c

all 1-

800-

318-

2596

.

Your

Grie

vanc

e and

App

eals

Righ

ts: T

here

are a

genc

ies th

at ca

n help

if yo

u hav

e a co

mplai

nt ag

ainst

your

plan

for a

denia

l of a

claim

. This

comp

laint

is ca

lled a

gr

ievan

ce or

appe

al. F

or m

ore i

nform

ation

abou

t you

r righ

ts, lo

ok at

the e

xplan

ation

of be

nefits

you w

ill re

ceive

for t

hat m

edica

l clai

m. Y

our p

lan do

cume

nts al

so

prov

ide co

mplet

e info

rmati

on to

subm

it a cl

aim, a

ppea

l, or a

griev

ance

for a

ny re

ason

to yo

ur pl

an. F

or m

ore i

nform

ation

abou

t you

r righ

ts, th

is no

tice,

or as

sistan

ce,

conta

ct: S

cott &

Whit

e Car

e Plan

s, vis

it swh

p.org

, or c

all 1-

844-

633-

5325

; Tex

as D

epar

tmen

t of In

sura

nce,

visit t

di.tex

as.go

v or c

all 1-

800-

578-

4677

; Dep

artm

ent o

f La

bor’s

Emp

loyee

Ben

efits

Secu

rity A

dmini

strati

on at

1-86

6-44

4-EB

SA (3

272)

or do

l.gov

/ebsa

/healt

hrefo

rm, T

exas

Dep

artm

ent o

f Insu

ranc

e Tex

as H

ealth

Opti

ons a

t 1-

800-

252-

3439

or te

xash

ealth

optio

ns.co

m.

Does

this

plan

pro

vide M

inim

um E

ssen

tial C

over

age?

Yes

If y

ou do

n’t ha

ve M

inimu

m Es

senti

al Co

vera

ge fo

r a m

onth,

you’l

l hav

e to m

ake a

paym

ent w

hen y

ou fil

e you

r tax

retur

n unle

ss yo

u qua

lify fo

r an e

xemp

tion f

rom

the

requ

ireme

nt tha

t you

have

healt

h cov

erag

e for

that

month

.

Does

this

plan

mee

t the

Min

imum

Valu

e Sta

ndar

ds?

Yes

If y

our p

lan do

esn’t

mee

t the M

inimu

m Va

lue S

tanda

rds,

you m

ay be

eligi

ble fo

r a pr

emium

tax c

redit

to he

lp yo

u pay

for a

plan

thro

ugh t

he M

arke

tplac

e.

Lang

uage

Acc

ess S

ervic

es:

Span

ish (E

spañ

ol): P

ara o

btene

r asis

tencia

en E

spañ

ol, lla

me al

1-84

4-63

3-53

25.

––––

––––

––––

––––

––––

––To

see

exam

ples o

f how

this

plan

migh

t cov

er co

sts fo

r a sa

mple

med

ical s

ituat

ion, s

ee th

e ne

xt se

ction

.–––

––––

––––

––––

––––

–––

22

Peg

is Ha

ving

a Bab

y (9

mon

ths of

in-n

etwor

k pre

-nata

l car

e and

a ho

spita

l deli

very)

Mia’s

Sim

ple F

ract

ure

(in-n

etwor

k eme

rgen

cy ro

om vi

sit an

d foll

ow

up ca

re)

Mana

ging

Joe’s

type

2 Di

abet

es

(a ye

ar of

routi

ne in

-netw

ork c

are o

f a w

ell-

contr

olled

cond

ition)

Th

e plan

’s ov

erall

ded

uctib

le $

1,250

Spec

ialist

copa

ymen

t

$30

Ho

spita

l (fa

cility

) coi

nsur

ance

20

%

Ot

her c

oins

uran

ce

20%

This

EXAM

PLE

even

t inc

lude

s ser

vices

like:

Sp

ecial

ist of

fice v

isits

(pre

nata

l car

e)

Child

birth/

Deliv

ery P

rofes

siona

l Ser

vices

Ch

ildbir

th/De

liver

y Fac

ility S

ervic

es

Diag

nosti

c tes

ts (u

ltras

ound

s and

bloo

d wo

rk)

Spec

ialist

visit

(ane

sthes

ia)

Tota

l Exa

mpl

e Cos

t $1

2,800

In th

is ex

ampl

e, Pe

g wo

uld

pay:

Co

st Sh

aring

De

ducti

bles

$1,25

0 Co

paym

ents

$20

Coins

uran

ce

$2,48

0 W

hat is

n’t co

vere

d Lim

its or

exclu

sions

$6

0 Th

e tot

al Pe

g wo

uld

pay i

s $3

,810

Th

e plan

’s ov

erall

ded

uctib

le $

1,250

Spec

ialist

copa

ymen

t

$30

Ho

spita

l (fa

cility

) coi

nsur

ance

20

%

Ot

her c

oins

uran

ce

20%

This

EXAM

PLE

even

t inc

lude

s ser

vices

like:

Pr

imar

y car

e phy

sician

offic

e visi

ts (in

cludin

g dis

ease

edu

catio

n)

Diag

nosti

c tes

ts (b

lood

work

) Pr

escri

ption

drug

s Du

rable

med

ical e

quipm

ent (

gluco

se m

eter

)

Tota

l Exa

mpl

e Cos

t $7

,400

In th

is ex

ampl

e, Jo

e wou

ld p

ay:

Cost

Shar

ing

Dedu

ctible

s $1

,250

Copa

ymen

ts $1

,130

Coins

uran

ce

$370

W

hat is

n’t co

vere

d Lim

its or

exclu

sions

$6

0 Th

e tot

al Jo

e wou

ld p

ay is

$2

,810

Th

e plan

’s ov

erall

ded

uctib

le $1

,250

Sp

ecial

ist co

paym

ent

$30

Ho

spita

l (fa

cility

) coi

nsur

ance

20

%

Ot

her c

oins

uran

ce

20%

This

EXAM

PLE

even

t inc

lude

s ser

vices

like:

Em

erge

ncy r

oom

care

(inclu

ding

med

ical

supp

lies)

Diag

nosti

c tes

t (X-

ray)

Dura

ble m

edica

l equ

ipmen

t (cr

utch

es)

Reha

bilita

tion s

ervic

es (p

hysic

al th

erap

y)

Tota

l Exa

mpl

e Cos

t $1

,900

In th

is ex

ampl

e, Mi

a wou

ld p

ay:

Cost

Shar

ing

Dedu

ctible

s $1

,120

Copa

ymen

ts $4

60

Coins

uran

ce

$290

W

hat is

n’t co

vere

d Lim

its or

exclu

sions

$0

Th

e tot

al Mi

a wou

ld p

ay is

$1

,870

Abou

t the

se C

over

age E

xam

ples

:

Th

is is

not a

cost

estim

ator

. Tre

atmen

ts sh

own a

re ju

st ex

ample

s of h

ow th

is pla

n migh

t cov

er m

edica

l car

e. Yo

ur ac

tual c

osts

will b

e dif

feren

t dep

endin

g on t

he ac

tual c

are y

ou re

ceive

, the p

rices

your

prov

iders

char

ge, a

nd m

any o

ther f

actor

s. Fo

cus o

n the

cost

shar

ing

amou

nts (d

educ

tibles

, cop

ayme

nts an

d coin

sura

nce)

and e

xclud

ed se

rvice

s und

er th

e plan

. Use

this

infor

matio

n to c

ompa

re th

e por

tion o

f co

sts yo

u migh

t pay

unde

r diffe

rent

healt

h plan

s. Pl

ease

note

these

cove

rage

exam

ples a

re ba

sed o

n self

-only

cove

rage

.

23

No

ndis

crim

inat

ion

No

tice

SW

CP_Nondiscrimination_Notice_01/2019_C

ATTE

NTI

ON

: If

you

spea

k En

glish

, lan

guag

e as

sista

nce

serv

ices

, fre

e of

char

ge, a

re av

aila

ble

to y

ou.

Cal

l 1-8

00-3

21-7

947

(TTY

: 711

).Sc

ott &

Whi

te C

are

Plan

s com

plie

s with

appl

icab

le F

eder

al ci

vil r

ight

s law

s and

doe

s not

disc

rimin

ate

on th

e ba

sis o

f rac

e, co

lor,

natio

nal o

rigin

, age

, di

sabi

lity,

or se

x. S

cott

& W

hite

Car

e Plan

s doe

s not

exclu

de p

eopl

e or t

reat

them

diff

eren

tly b

ecau

se o

f rac

e, co

lor,

natio

nal o

rigin

, age

, disa

bilit

y, or

sex.

Scot

t & W

hite

Car

e Pl

ans:

•Pro

vide

s fre

e ai

ds a

nd se

rvic

es to

peo

ple

with

disa

bilit

ies t

o co

mm

unic

ate

effec

tivel

y w

ith u

s, su

ch a

s:-W

ritte

n in

form

atio

n in

oth

er fo

rmat

s (la

rge

prin

t and

acc

essib

le el

ectr

onic

form

ats)

•Pro

vide

s fre

e la

ngua

ge se

rvic

es to

peo

ple

who

se p

rimar

y la

ngua

ge is

not

Eng

lish,

such

as:

-Qua

lified

inte

rpre

ters

-Inf

orm

atio

n w

ritte

n in

oth

er la

ngua

ges

If yo

u ne

ed th

ese

serv

ices

, con

tact

the

Scot

t & W

hite

Car

e Pl

ans C

ompl

ianc

e O

ffice

r at 1

-214

-820

-888

8 or

send

an

emai

l to

SWH

PCom

plia

nceD

epar

tmen

t@BS

WH

ealth

.org

If yo

u be

lieve

that

Sco

tt &

Whi

te C

are

Plan

s has

faile

d to

pro

vide

thes

e se

rvic

es o

r disc

rimin

ated

in a

noth

er w

ay o

n th

e ba

sis o

f rac

e, co

lor,

natio

nal

orig

in, a

ge, d

isabi

lity,

or se

x, y

ou c

an fi

le a

grie

vanc

e w

ith:

Scot

t & W

hite

Car

e Pl

ans,

Com

plia

nce

Offi

cer

1206

Wes

t Cam

pus D

rive,

Suite

151

Tem

ple,

Texa

s 765

02

Com

plia

nce

Hel

pLin

e; 1-

888-

484-

6977

or h

ttps:/

/app

.myc

ompl

ianc

erep

ort.c

om/r

epor

t.asp

x?ci

d=sw

hpYo

u ca

n fil

e a

grie

vanc

e in

per

son

or b

y m

ail,

onlin

e, or

em

ail.

If yo

u ne

ed h

elp

filin

g a

grie

vanc

e, th

e C

ompl

ianc

e O

ffice

r is a

vaila

ble

to h

elp

you.

Yo

u ca

n al

so fi

le a

civi

l rig

hts c

ompl

aint

with

the

U.S

. Dep

artm

ent o

f Hea

lth a

nd H

uman

Ser

vice

s, O

ffice

for C

ivil

Righ

ts, e

lect

roni

cally

thro

ugh

the

Offi

ce fo

r Civ

il Ri

ghts

Com

plai

nt P

orta

l, av

aila

ble

at h

ttps:/

/ocr

port

al.h

hs.g

ov/o

cr/p

orta

l/lob

by.js

f, or

by

mai

l or p

hone

at:

U.S

. Dep

artm

ent o

f Hea

lth a

nd H

uman

Ser

vice

s20

0 In

depe

nden

ce A

venu

e, SW

Room

509

F, H

HH

Bui

ldin

gW

ashi

ngto

n, D

.C. 2

0201

1-

800-

368-

1019

, 1-8

00-5

37-7

697

(TD

D)

Com

plai

nt fo

rms a

re av

aila

ble

at h

ttps:/

/ww

w.hh

s.gov

/civ

il-rig

hts/

filin

g-a-

com

plai

nt/in

dex.

htm

l.

24

Lang

uag

e A

ssis

tanc

e/ A

sist

enci

a d

e id

iom

as

SW

CP_LanguageAssistance_11/2

018

Eng

lish:

AT

TEN

TIO

N: I

f you

spea

k En

glis

h, la

ngua

ge a

ssis

tanc

e se

rvic

es, f

ree

of c

harg

e, a

re a

vaila

ble

to y

ou. C

all 1

-800

-321

-794

7 (T

TY: 7

11).

Span

ish:

AT

ENC

IÓN

: Si

hab

la e

spañ

ol, t

iene

a su

dis

posi

ción

serv

icio

s gra

tuito

s de

asis

tenc

ia li

ngüí

stic

a. L

lam

e al

1-8

00-3

21-7

947

(TTY

: 711

).

Vie

tnam

ese:

C

HÚ

Ý:

Nếu

bạn

nói

Tiế

ng V

iệt,

có c

ác d

ịch

vụ h

ỗ trợ

ngô

n ng

ữ m

iễn

phí d

ành

cho

bạn.

Gọi

số 1

-800

-321

-794

7 (T

TY: 7

11).

Chi

nese

: 注

意：如

果 使

用繁

體中

文，可

以免

費獲

得語

言援

助服

務。請

致電

1-80

0-32

1-79

47(T

TY：7

11)。

Kor

ean:

주

의:

한국

어를

사용

하시

는 경

우, 언

어 지

원 서

비스

를 무

료로

이용

하실

수 있

습니

다. 1

-800

-321

-794

7 (T

TY: 7

11) 번

으로

전화

해 주

십시

오.

Ara

bic:

رقم

) 800

-321

-794

7-1

رقمل ب

ص ات

ن.جا

المك ب

ر لواف

تتویة

للغة ا

عدسا

المت

دما خ

إن، ف

غة الل

كر اذ

ثحد

تتت

كنإذا

ة: وظ

لح .م

711

كم:الب

وصم

الف

ھات

Urd

u:

ال۔ ک

ں ہی

بتیا

دسں

میت

مفت

دما خ

کیدد

ی من ک

زباو

پ کو آ

، تیں

ے ہولت

و برد

پ ار آ

اگر:

رداخب

1-8

00-3

21-7

947

(TTY

: 711

). یں

کر

Taga

log:

PAU

NAW

A:

Kun

g na

gsas

alita

ka

ng T

agal

og, m

aaar

i kan

g gu

mam

it ng

mga

serb

isyo

ng

tulo

ng sa

wik

a na

ng w

alan

g ba

yad.

Tum

awag

sa

1-80

0-32

1-79

47 (T

TY: 7

11).

Fren

ch:

ATTE

NTI

ON

: Si

vou

s par

lez

fran

çais

, des

serv

ices

d’a

ide

lingu

istiq

ue v

ous s

ont p

ropo

sés g

ratu

item

ent.

App

elez

le 1

-800

-321

-794

7 (A

TS :

711)

.

Hin

di:

धयान

द:

यदि आ

प हि

दी ब

ोलत

ह तो

आपक

लिए

मफत

म भ

ाषा स

हायत

ा सवा

ए उप

लबध

ह। 1

-800

-321

-794

7 (T

TY: 7

11) प

र कॉल

कर।

Pers

ian:

شما

ی را

ن بگا

رایت

ورص

ی ببان

زت

یالسھ

، تنید

ی کو م

تگ گف

سیار

ن فزبا

بھ ر

اگجھ:

تود.

ریگی

س بتما

1-8

00-3

21-7

947

(TTY

: 711

ا (. ب

شد با

میھم

راف

Ger

man

: A

CH

TUN

G:

Wen

n Si

e D

euts

ch sp

rech

en, s

tehe

n Ih

nen

kost

enlo

s spr

achl

iche

Hilf

sdie

nstle

istu

ngen

zur

Ver

fügu

ng.

Ruf

num

mer

: 1-8

00-3

21-7

947

(TTY

: 711

).

Guj

arat

i: સચ

ના: જ

ો તમ

ગજરાત

ી બોલ

તા હ

ો, તો

નિ:શ

લક ભ

ાષા સ

હાય

સવાઓ

તમા

રા મા

ટ ઉપ

લબધ

છ. ફ

ોન કર

ો 1-

800-

321-

7947

(TTY

: 711

).

Rus

sian

: В

НИ

МА

НИ

Е: Е

сли

вы го

вори

те н

а ру

сско

м яз

ыке

, то

вам

дост

упны

бес

плат

ные

услу

ги п

ерев

ода.

Зво

ните

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25

Scott & White Care Plans2021 Member GuideBSW Plus HMO

Got a question?..........................................................................................................1

Get to know your ID card .....................................................................................2

Explore your member portal .............................................................................3

Download the MyBSWHealth App ..................................................................4

Experience Virtual Care........................................................................................4

Eligibility map..............................................................................................................5

Find a provider............................................................................................................5

Access pharmacy services.................................................................................6

Know your care options ... ....................................................................................7

Better health starts with you.............................................................................9

Naturally Slim® ..........................................................................................................10

Expecting the Best®..............................................................................................10

Get details on your claims .................................................................................11

Stay better, longer .................................................................................................13

Table of Contents

SWCP_GR_BellCountyBSWPlusHMO_MemberGuide_PY2021

HMO products are offered through Scott and White Health Plan and Scott & White Care Plans. Insured PPO and EPO products are offered through Insurance Company of Scott and White. All are Texas registered insurance companies. Scott & White Care Plans and Insurance Company of Scott and White are wholly owned subsidiaries of Scott and White Health Plan.

26

1

Got a question? Our highly trained Customer Advocates can help you with things like finding a provider and answering questions about your benefits or claims. Whatever your question or concern may be, our Customer Advocates will work with you to resolve it as quickly as possible—in most cases, before you hang up the phone.

Contact us through the member portalLog in at bellcounty.swhp.org to send a secure email and receive a secure response.

Nurse Advice LineNurses are available 24/7 to talk through your symptoms and help you make decisions on next steps, whether that’s an appointment or an at-home remedy. The Nurse Advice Line phone number is on the back of your member ID card.

Welcome to Scott & White Care Plans!Welcome to Scott & White Care Plans (SWCP), a wholly owned subsidiary of Scott and White Health Plan, and part of the Baylor Scott & White family of companies. With Scott & White Care Plans, you will have access to the renowned doctors, specialists and facilities of the Baylor Scott & White Health system. Baylor Scott & White Health (BSWH) provides full-range, inpatient, outpatient, rehabilitation and emergency medical services.

Beyond the Baylor Scott & White Health system, Scott & White Care Plans offers access to thousands of providers throughout North, Central and West Texas to ensure members have plenty of in-network options for care. You’ll find useful information about what we have to offer in this booklet—and if you have questions, we’re happy to answer them.

Contact us by phone 844.633.5325 7 AM – 7 PM Monday – Friday

27

2

The ID card above is a sample. The exact location of certain elements may vary on your card.

Get to know your member ID card

1

2

3

45

6

7

8

Group name

Group ID number

Network name

Benefit effective date

Member name

Member ID number

Copays/coinsurance

Deductible

Pharmacy/prescription drug info9

Customer service phone number

24/7 Nurse Line

Information for providers

Claims mailing address

A

B

C

D

You can request a replacement ID card through the member portal oraccess an electronic card at any time through the MyBSWHealth app.

1 2

7

4

8 3

TDI

SUBSCRIBERJohn Sample

DOB: 00/00/0000

DEPENDENTSJane SampleJack SampleJill SampleJames SampleJulie SampleJoe SampleJackie Sample

MEMBER ID 00000000000

00000000000000000000000000000000000000000000000000000000000000000000000000000

IN-NETWORK PLAN BENEFITSAdult PCP/Spec: 00%Pediatric PCP/Spec: 00% Emergency Room: 00%* Coinsurance:

N/A Deductible: I/$0000 F/$0000 Rx: 00%*Deductible:

I/$500, F/$1000PHARMACISTS ONLYOptumRx® Help Desk: 855-205-9182BIN: 610011 PCN: IRX GRP:

Group: Group #: 000000Network:

*Deductible may apply.

3

1

4

2

5 6 7

9

8

bellcounty.swhp.org

Bell County

SWPBSWCP

billing, find a provider at swhp.org

Self-service portal: ers.swhp.orgSWHP24/7 Nurse Line 1-000-000-0000

(TTY: 711)

00/00/0000

FOR PROVIDERSElectronic Claims:Availity: 94999

Paper Claims:Scott and White Health PlanPO Box 211342Eagan, MN 55121

Prior Authorization: Visit the provider portal Fax: 800-626-3042 Phone: 866-384-3488

Provider Portal:

Card Issue Date: 08/01/2020

FOR MEMBER S

not guarantee coverage or payment for the service or procedure reviewed.

Important Information:• In a medical emergency, call 9-1-1 or go to the nearest

emergency facility.

• Telehealth: Download the MyBSWHealth App• 24/7 Nurse Line: 877-505-7947• Self-Service Portal: my.bswhealth.com• To avoid out-of-network costs and provider balance

DC

AB

CUSTOMER SERVICE: 844.633.5325 bellcounty.swhp.org

billing, find a provider at bellcounty.swhp.org

Customer Service: 844-633-5325 (TTY/TDD: 7-1-1)•

28

3Explore your member portalThere’s a wealth of information, resources, and functionality available 24/7 in our member portal, accessible from your computer or mobile device. You’ll find a link to the portal on our website: bellcounty.swhp.org.

Download and/or print:

ID cards

Benefit Plan Documents

Claims summaries and Explanations of Benefits

Prescription medication history

Drug formulary

Pending, approved and denied authorizations

Plus you can:

Find a provider

Make an appointment with a BSWH doctor

Complete a health assessment

Access virtual care options (eVisit and Video Visit)

Track your deductible and out-of-pocket maximum

Message your BSWH doctor

Refill a prescription at BSWH pharmacies

Verify eligibility

View/update demographic information

Learn about, and register for, theExpecting the Best® Maternity Program

29

Download the MyBSWHealth appVirtually all of the information in the member portal is available on your phone through the MyBSWHealth app. For example, you can view a digital copy of your ID card, see plan details, and track your deductible and out-of-pocket maximum for yourself and your dependents. Use the same user name and password you set up for the member portal to log in to the app. To learn more, visit our website: bellcounty.swhp.org

Be sure to link your account in the app:

Experience virtual care $0 copay

1. Tap the gear icon (top right corner of app welcome screen)2. Tap “Manage Linked Accounts”3. Tap “Link Account”4. Enter member information

Conduct an eVisit for common medical conditions and get care fast

Click the eVisit icon under "URGENT CARE OPTIONS" Complete an online questionnare about your symptoms; it takes only 5-10 minutes You will get a response from a Baylor Scott & White Health provider within one hour Prescriptions (if needed) will be sent immediately to your preferred pharmacy

Schedule a same-day Video Visit with a provider, face-to-face

Click the video visit icon under “URGENT CARE OPTIONS” to schedule your appointment Talk with a Baylor Scott & White Health provider live about your symptoms Visits are quick: just 10-15 minutes Prescriptions (if needed) will be sent immediately to your preferred pharmacy

MyBSWHealth 8 AM - 8 PM CT, 7 days a week Receive care from the comfort of your home, or anywhere in Texas, at no cost to you.

4

30

5

Find a ProviderOur provider search tool at bellcounty.swhp.org allows you to:

• Search by name, specialty and/or ZIP code

• Add filters for gender, board certification, accepting new patients and more

• See practice locations, contact information and maps

• Get details, including network participation and hospital affiliations

• Customize your own profile

Go to bellcounty.swhp.org and click on “Find a Provider-BSW Plus HMO” and you will be on your way.

If you live or work in one of the blue counties, you are eligible to participate in the BSW Plus HMO Plan.

2021 Service Area BSW Plus HMO

Sevice Area

31

Access pharmacy servicesSWCP members may access more than 68,000 pharmacies nationwide, including most national chains and a large selection of local pharmacies.

To find your nearest pharmacy, click here:

We also offer 90-day prescription refills for select medications at Baylor Scott & White Health pharmacies.

Get the convenience of home delivery with mail order service. Call our mail order pharmacy and we will walk you through the transfer process.

Call toll-free at 855.388.3090 Monday through Friday, from 7 AM to 7 PM CT, and on Saturday, from 9 AM to 1 PM CT.

If you need detailed pharmacy claim information, pharmacy deductible information, explanation of benefits, or drug information and pricing, visit bellcounty.swhp.org or call Customer Service at 844.633.5325.

To view a formulary (a list of covered drugs), click here:

PHARMACY SEARCH

FORMULARY

32

Visit your Primary Care Physicianwhen you’re sick or have a minor injury1

Your doctor knows your health history and underlying conditions. For routine illnesses and less significant injuries, many doctors’ offices are open on weekends and some evenings. This can be a good alternative to more costly urgent care or emergency care centers. Although a Primary Care Physician is not required, we encourage you to establish a relationship with a doctor.

If your doctor’s office is closed, consider an Urgent Care center2

Urgent Care centers typically have extended and weekend hours. Although costs are higher than primary care, urgent care copays are lower than those for emergency care.

Know your care optionsHow do you decide when a health-related issue is an emergency? Understanding your healthcare options can save your life... and your money.

Or opt for Virtual Care — or our Nurse Advice LineSee page 4 for information on Virtual Care. Nurses are available to our members 24 hours a day, 365 days a year. Our nurses provide information about taking care of yourself at home or they can help you decide if an appointment, an urgent care visit, or an emergency room visit is best for your symptoms. To locate your appropriate Nurse Advice Line phone number, please look on the back of your member card or log in to the Member Portal.

7

33

back to top

If you need to speak to us, contact us in the way that works for you. In addition to the Member Portal, customer support is available by phone at 844.633.5325.

Scott & White Care Plans pays out-of-network emergency services according to Usual and Customary rates (industry standard), and members can be balance-billed for expenses beyond what insurance will pay. Your coverage documents contain additional information about emergency treatment and definitions of the terms, including a definition of emergency care. The coverage documents also contain information related to state-mandated consumer protections for facility-based provider charges.

To save on out-of-pocket costs, visit in-network emergency care facilities when possible. You can find in-network emergency care facilities by using the provider search tool at bellcounty.swhp.org.

Remember: Out-of-network emergency care costs more

Emergency Roomsare best for treating severe and life-threatening conditions and they’re always open.3

The wider range of services offered through emergency rooms, and the hospitals they are connected to, makes emergency care a more expensive option, but sometimes the best option for you.

It’s important to understand your options, and to use your best judgment when deciding which option is right for you.

8

34

Assessment for Members

9

WELL-BEING ASSESSMENTThe Well-Being Assessment is a simple, digital health survey that helps you take steps toward a more vibrant and healthier life. The Well-Being Assessment asks questions about your life and delivers customized action steps from our Lifestyle Management Program. Modules are self-paced, available online, and convenient for promoting physical and mental health — all things to help you feel your best.

Digital Health Coaching – 6-week coaching modules with action plans, important articles, online seminars and video content on topics that include:

• Live Tobacco Free• Healthy Weight

Progress Tracker – The digital platform has a dashboard to help you keep track of important health information like A1C, weight/BMI, cholesterol, blood pressure and physical activity. These biometric measurements can be charted over time to monitor your long-term health.

Fitness Tracker Integration – Synchronize your personal fitness tracker with the wellness platform to monitor your physical activity progress on the dashboard.

Digital Health Library – Access to articles, videos, recipes and other content to support a healthier life. You can search for condition-specific information or explore highlighted topics.

Challenges – Sometimes you need extra motivation to go the extra mile. You can participate in step challenges, hydration and even relaxation challenges.

Online Community – Access to online community forums where you can give and receive support for goals as well as get feedback from health coaches in the community.

• Healthier Diet• Active Living

Elevate your well-being with Scott & White Care Plans’ comprehensive suite of digital resources. Log in to your member portal to get started.

• Less Stress

Better health starts with you

35

Expecting the Best® Maternity ProgramWe are pleased to offer a maternity program for pregnant Scott & White Care Plans members. This initiative is focused on helping expectant mothers enjoy a healthy pregnancy.

Once enrolled, participants can benefit from diverse program features for the duration of their pregnancy and one year postpartum.Participants receive helpful educational materials across distinct categories, including proper nutrition, early identification of pregnancy risk factors and available resources for any complications.

Sign up by calling the customer service number on the back of your ID card or send an email to: HPMaternityCaseManagement@BSWHealth.org.

Ever wonder how some people can eat all their favorite foods and not gain weight? Naturally Slim is an online program that will teach you how. And here’s a hint: it doesn’t include starving, counting calories or spending hours prepping ‘approved’ foods. SWCP is giving you the chance to learn how to eat the foods you love while reducing your risk of developing serious conditions, like diabetes or heart disease.

Naturally Slim is available at NO COST to you and is accessible via computer and mobile device so you can participate whenever it’s convenient, wherever you are.

For more information about Naturally Slim, visit bellcounty.swhp.org

You don’t have to give up your favorite foods to lose weight and feel your best.

36

11

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (800) 321-7947 (TTY: 711).

Scott & White Care Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (800) 321-7947 (TTY: 711).

Scott & White Care Plans cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.Gọi số (800) 321-7947 (TTY: 711).

Scott & White Care Plans tuân thủ luật dân quyền hiện hành của Liên bang và không phân biệt đối xử dựa trên chủng tộc, màu da, nguồn gốc quốc gia, độ tuổi, khuyết tật, hoặc giới tính.

Allowed Amount -This is the amount considered for payment based on our provider contracts and your benefits.

Amount Billed -This is the amount your provider billed for the services you requested. Note: this amount does not reflect discounts that the plan has negotiated with the provider or facility.

Amount Paid -This is the amount we paid to you or your provider.

Copay -This represents the amount you are responsible to pay for certain services, typically paid at the time of service.

Coinsurance - The coinsurance is a percentage of the “allowed amount” you are responsible for paying for services after your deductible is met. Providers may require payment when you receive services.

Deductible - A fixed-dollar amount the member is responsible for paying each plan year before the plan begins to pay for covered services. Note: “Non-Covered” amounts don’t count toward meeting the yearly deductible. Your provider may bill you for these charges.

Discount Amount -The amount you saved by using the plan’s preferred providers.

Non-Covered Amount - An amount you are responsible for paying because it is for a service that is not covered by your benefit plan. Also, if you’ve used an out-of-network provider, “non-covered amount” includes any amount the out-of-network provider bills in excess of the plan-negotiated network rates.

Other Coverage Payment -This is the amount paid by your other insurance carrier.

Out-of-Pocket Maximum -The most you have to pay for in-network health services every year. Once you have paid this amount, the Health Plan typically pays 100% of your allowed health care charges, subject to any policy limitations.

Helpful Definitions

If you suspect fraud, contact the Scott and White Health Plan Compliance HelpLine at (888) 484-6977.

Report Fraud

Language Assistance/ Nondiscrimination Notice

Get details on your claimswith your monthly insurance statement

Subscriber: John Smith

Member ID: 12345678

Group Name: SampleCompany Inc.

Group Number: 012345

Now...the Detailed VersionHere’s a detailed breakdown or Explanation of Benefits for this service. In case there’s any doubt - this is NOT a bill!

Notes:IJ THE PROVIDER IS NOT IN NETWORK AND/OR THERE IS NO AUTH ON FILE*If you elected to use your out-of-network benefit, the provider or facility may bill you for an amount greaterthan the amount reimbursed by the Health Plan. Out-of-network providers or facilities may not bill you foran amount greater than the copay/coinsurance/deductible indicated above in the following circumstances:emergency care services, treatment from an out-of-network provider while receiving services at an in-networkfacility, or for out-of network imaging or laboratory services if related to treatment from an in-network provider.

Patient: Ann SmithClaim Number: 123x456x788Provider: Test Provider 1

Out-of-Network*

Date of Service Description Amount

BilledAllowed Amount

Non-Covered Amount

Other Coverage Payment

Plan Paid Copay Deductible Coinsurance What You May Owe Notes

2/04/20 Emergency Dept Visit $1000.00 $500.00 $0.00 $0.00 $400.00 $100.00 $0.00 $0.00 $100.00 IJ

Total $1000.00 $500.00 $0.00 $0.00 $400.00 $100.00 $0.00 $0.00 $100.00

Patient: Ann SmithClaim Number: 123x456x789Provider: Test Provider 2

In-Network

Date of Service Description Amount

BilledAllowed Amount

Non-Covered Amount

Other Coverage Payment

Plan Paid Copay Deductible Coinsurance What You May Owe Notes

2/04/20 Office Visit $250.00 $150.00 $0.00 $0.00 $100.00 $50.00 $0.00 $0.00 $50.00

Total $250.00 $150.00 $0.00 $0.00 $100.00 $50.00 $0.00 $0.00 $50.00

QUESTIONS?

Customer service: (800) 321-7947 Hours: 7 a.m. to 7 p.m. CT

Website: swhp.org

Explanation of BenefitsThis is NOT a bill

1206 West Campus DriveTemple, TX 76502

Forwarding Service Requested

Member ID: 12345678Group Number: 012345Group Name: Sample Company Inc.Print date: 02/18/2020

John Smith789 TEST STREETREDCARD, MO 63141

Hi John,This document summarizes your recent benefit activity. It confirms the amount charged by your provider(s) and the amount we paid for those charges.

Cost breakdown

Amount billed: $1250.00

Plan discount: $600.00

Plan paid: $500.00

Not covered: $0.00

What you may owe

$150.00This is the portion of the billed amount you may

owe the provider(s) if payment was not collected at thetime of service. This amount may include

your deductible, copay, coinsurance, and/or non-covered amount.

Account Summary

Place holder for misc. communications

TotalAmount

AppliedAmount

Family Deductible

Family Out-of-pocket max$1,500.00

$2,477.84

$3,000.00($1,500.00 remaining)

$4,500.00($2,022.16 remaining)

Member Deductible

Member Out-of-pocket max

$250.00

$199.71

$1,500.00($1,250.00 remaining)

$2,250.00($2,050.29 remaining)

An electronic Monthly Insurance Statement, also known as an Explanation of Benefits (EOB), is available through the Member Portal an to help you manage your claims expenses at a detailed level. The statement provides line-item detail on charges for that month, including what was billed and covered by SWCP. The amount you owe is included in this statement.

Remaining balances for deductibles and out-of-pocket expenses are also reported. Information for the current month and year-to-date is included. Statements are not provided for prescription claims or claims where the member does not owe anything.

Your EOBs will be available on the Member Portal unless you specifically request to receive paper EOBs in the mail. To request paper EOBs, log in to the Member Portal and select “Update Preferences.”

37

Complex Case Management

If you have chronic conditions or complex care needs, our nurse case managers will work with you, your family, and your physician to create and manage your care plan. Case managers advocate for you and can help you navigate the healthcare system and arrange the services you need. They can also answer questions and help you understand your condition and care plan. If Disease Management is right for you, they’ll incorporate the program into your care. There is no additional cost to you for this voluntary program. It’s all part of our goal to help you get the best possible results and the greatest value from your health plan.

Members can access the program by calling 888.360.1555.

Disease Management

Disease Management empowers you to manage your chronic condition and help prevent complications. We work with your healthcare providers to identify chronic conditions quickly and treat them effectively. We can also identify self-care activities that help you manage your condition at home. Together, we’ll work to slow down the progression of your disease and help you stay better, longer.

For more information, please log in to the Member Portal, select Wellness Programs and request a screening to see if Complex Case Management is the right program for your needs.

Stay better, longer

38

HMO products are offered through Scott and White Health Plan and Scott & White Care Plans. Insured PPO and EPO products are offered through Insurance Company of Scott and White. All are Texas registered insurance companies. Scott & White Care Plans and Insurance Company of Scott and White are wholly owned subsidiaries of Scott and White Health Plan.

Thank you for choosing Scott & White Care Plans for your healthcare coverage needs.

39

The

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t limi

t.

Will

you

pay l

ess i

f you

us

e a n

etwo

rk p

rovid

er?

Yes.

See b

ellco

unty.

swhp

.org o

r call

1-

844-

633-

5325

for a

list o

f netw

ork

prov

iders.

This

plan u

ses a

prov

ider n

etwor

k. Yo

u will

pay l

ess i

f you

use a

prov

ider in

the p

lan’s

netw

ork.

You w

ill pa

y the

mos

t if yo

u use

an ou

t-of-n

etwor

k pro

vider

, and

you m

ight

rece

ive a

bill fr

om a

prov

ider f

or th

e diffe

renc

e betw

een t

he pr

ovide

r’s ch

arge

and w

hat

your

plan

pays

(bala

nce b

illing

). Be

awar

e, yo

ur ne

twor

k pro

vider

migh

t use

an ou

t-of-

netw

ork p

rovid

er fo

r som

e ser

vices

(suc

h as l

ab w

ork).

Che

ck w

ith yo

ur pr

ovide

r befo

re

you g

et se

rvice

s. Do

you

need

a re

ferra

l to

see a

spec

ialist

? No

Yo

u can

see t

he sp

ecial

ist yo

u cho

ose w

ithou

t a re

ferra

l.

40

All c

opay

men

t and

coin

sura

nce c

osts

show

n in t

his ch

art a

re af

ter yo

ur d

educ

tible

has b

een m

et, if

a ded

uctib

le ap

plies

.

Com

mon

Me

dica

l Eve

nt

Serv

ices Y

ou M

ay N

eed

Wha

t You

Will

Pay

Lim

itatio

ns, E

xcep

tions

, & O

ther

Impo

rtant

In

form

atio

n Ne

twor

k Pro

vider

(Y

ou w

ill pa

y the

leas

t) Ou

t-of-N

etwo

rk P

rovid

er

(You

will

pay t

he m

ost)

If yo

u vis

it a h

ealth

ca

re p

rovid

er’s

offic

e or

clin

ic

Prim

ary c

are v

isit to

trea

t an

injur

y or il

lness

$3

0 cop

ayme

nt/vis

it No

t cov

ered

No

ne

Sp

ecial

ist vi

sit

$30 c

opay

ment/

visit

Not c

over

ed

Prev

entiv

e ca

re/sc

reen

ing/

immu

nizati

on

No ch

arge

No

t cov

ered

Yo

u may

have

to pa

y for

servi

ces t

hat a

ren’t

pr

even

tive.

Ask y

our p

rovid

er if

the se

rvice

s ne

eded

are p

reve

ntive

. The

n che

ck w

hat y

our

plan w

ill pa

y for

.

If yo

u ha

ve a

test

Diag

nosti

c tes

t (X-

ray,

blood

wor

k) No

char

ge

Not c

over

ed

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d. Re

fer to

bellc

ounty

.swhp

.org o

r Cu

stome

r Ser

vice a

t 1-8

44-6

33-5

325.

Imag

ing (C

T/PE

T sc

ans,

MRIs)

20

% af

ter de

ducti

ble

Not c

over

ed

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d.

If yo

u ne

ed d

rugs

to

treat

your

illne

ss o

r co

nditi

on

More

infor

matio

n abo

ut pr

escr

iptio

n dr

ug

cove

rage

is av

ailab

le at

bellc

ounty

.swhp

.org/p

harm

acy-i

nform

ation

.

ACA

Prev

entiv

e Dru

gs

$0 co

paym

ent/p

resc

riptio

n De

ducti

ble do

es no

t app

ly No

t cov

ered

Copa

ymen

ts ar

e per

30-d

ay su

pply.

Ma

inten

ance

-elig

ible d

rugs

are a

llowe

d up t

o a

90-d

ay su

pply

for tw

o cop

ayme

nts if

obtai

ned

throu

gh a

Baylo

r Sco

tt & W

hite P

harm

acy o

rpa

rticipa

ting 9

0-da

y reta

il or m

ail or

der

phar

macy

prov

ider.

Mail O

rder

: Ava

ilable

for a

1- to

90-d

ay su

pply.

Non-

maint

enan

ce dr

ugs o

btaine

d thr

ough

mail

orde

r are

limite

d to a

30-d

ay su

pply

maxim

um.

Some

Spe

cialty

drug

s may

requ

ire pr

iorau

thoriz

ation

. 30-

day s

upply

only.

Tier 1

: Pre

ferre

d Gen

eric

Drug

s $1

0 cop

ayme

nt/pr

escri

ption

De

ducti

ble do

es no

t app

ly No

t cov

ered

Tier 2

: Pre

ferre

d Bra

nd

Name

Dru

gs

$40 c

opay

ment/

pres

cripti

on

Dedu

ctible

does

not a

pply

Not c

over

ed

Tier 3

: Non

-Pre

ferre

d Ge

neric

/ Bra

nd N

ame

Drug

s

The l

esse

r of $

100

copa

ymen

t or 5

0%

copa

ymen

t De

ducti

ble do

es no

t app

ly No

t cov

ered

Spec

ialty

Drug

s T1

: 10%

of ch

arge

s T2

: 20%

of ch

arge

s T3

: 30%

of ch

arge

s De

ducti

ble do

es no

t app

ly No

t cov

ered

41

Com

mon

Me

dica

l Eve

nt

Serv

ices Y

ou M

ay N

eed

Wha

t You

Will

Pay

Lim

itatio

ns, E

xcep

tions

, & O

ther

Impo

rtant

In

form

atio

n Ne

twor

k Pro

vider

(Y

ou w

ill pa

y the

leas

t) Ou

t-of-N

etwo

rk P

rovid

er

(You

will

pay t

he m

ost)

If yo

u ha

ve o

utpa

tient

su

rger

y

Facil

ity fe

e (e.g

., am

bulat

ory s

urge

ry ce

nter)

20%

after

dedu

ctible

No

t cov

ered

Se

rvice

s tha

t are

not p

reau

thoriz

ed w

ill be

de

nied.

Refer

to be

llcou

nty.sw

hp.or

g or

Custo

mer S

ervic

e at 1

-844

-633

-532

5.

Phys

ician

/surg

eon f

ees

20%

after

dedu

ctible

No

t cov

ered

If yo

u ne

ed im

med

iate

med

ical a

ttent

ion

Emer

genc

y roo

m ca

re

$250

copa

ymen

t/visi

t, plus

20

% of

char

ges

$250

copa

ymen

t/visi

t, the

n 20

% of

char

ges

Copa

ymen

t waiv

ed if

episo

de re

sults

in

hosp

italiz

ation

for t

he sa

me co

nditio

n with

in 24

ho

urs.

Emer

genc

y med

ical

trans

porta

tion

20%

after

dedu

ctible

20

% af

ter de

ducti

ble

None

Ur

gent

care

$7

5 cop

ayme

nt/vis

it $7

5 cop

ayme

nt/vis

it

If yo

u ha

ve a

hosp

ital

stay

Facil

ity fe

e (e.g

., hos

pital

room

) 20

% af

ter de

ducti

ble

Not c

over

ed

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d. Ph

ysici

an/su

rgeo

n fee

s 20

% af

ter de

ducti

ble

Not c

over

ed

If yo

u ne

ed m

enta

l he

alth,

beh

avio

ral

healt

h, o

r sub

stan

ce

abus

e ser

vices

Outpa

tient

servi

ces

$30 c

opay

ment/

visit

Not c

over

ed

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d. Re

fer to

bellc

ounty

.swhp

.org o

r Cu

stome

r Ser

vice a

t 1-8

44-6

33-5

325.

Inpati

ent s

ervic

es

20%

after

dedu

ctible

No

t cov

ered

Se

rvice

s tha

t are

not p

reau

thoriz

ed w

ill be

de

nied.

If yo

u ar

e pre

gnan

t

Offic

e visi

ts $3

0 cop

ayme

nt/vis

it No

t cov

ered

Cost

shar

ing do

es no

t app

ly for

prev

entiv

e se

rvice

s. De

pend

ing on

the t

ype o

f ser

vices

, a

copa

ymen

t, coin

sura

nce,

or de

ducti

ble m

ay

apply

. Mate

rnity

care

may

inclu

de te

sts an

d se

rvice

s des

cribe

d else

wher

e in t

he S

BC (i.

e. ult

raso

und)

. Ch

ildbir

th/de

liver

y pr

ofess

ional

servi

ces

20%

after

dedu

ctible

No

t cov

ered

Th

e hea

lth pl

an m

ust b

e noti

fied o

f the

deliv

ery.

If a le

ngth

of sta

y for

an

unco

mplic

ated d

elive

ry ex

ceed

s 48 h

ours

for

vagin

al, or

96 ho

urs f

or ca

esar

ean,

prea

uthor

izatio

n is r

equir

ed. F

ailur

e to n

otify

or

prea

uthor

ize, w

hen r

equir

ed, m

ay re

sult o

f a

denia

l of th

e ser

vice.

Refer

to

bellc

ounty

.swhp

.org o

r Cus

tomer

Ser

vice a

t 1-

844-

633-

5325

.

Child

birth/

deliv

ery f

acilit

y se

rvice

s 20

% af

ter de

ducti

ble

Not c

over

ed

42

Com

mon

Me

dica

l Eve

nt

Serv

ices Y

ou M

ay N

eed

Wha

t You

Will

Pay

Lim

itatio

ns, E

xcep

tions

, & O

ther

Impo

rtant

In

form

atio

n Ne

twor

k Pro

vider

(Y

ou w

ill pa

y the

leas

t) Ou

t-of-N

etwo

rk P

rovid

er

(You

will

pay t

he m

ost)

If yo

u ne

ed h

elp

reco

verin

g or

hav

e ot

her s

pecia

l hea

lth

need

s

Home

healt

h car

e $3

0 cop

ayme

nt/vis

it No

t cov

ered

Se

rvice

s tha

t are

not p

reau

thoriz

ed w

ill be

de

nied.

Reha

bilita

tion s

ervic

es

$30 c

opay

ment/

visit

Not c

over

ed

Limite

d to 2

0 com

bined

PT/

OT/S

P ou

tpatie

nt vis

its an

d an a

dditio

nal 1

0 visi

ts for

Hom

e Se

tting p

er pl

an ye

ar. L

imits

may

not a

pply

for

Ther

apies

for C

hildr

en w

ith D

evelo

pmen

tal

Delay

s and

Auti

sm S

pectr

um D

isord

er.

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d.

Habil

itatio

n ser

vices

$3

0 cop

ayme

nt/vis

it No

t cov

ered

Limite

d to 2

0 com

bined

PT/

OT/S

P ou

tpatie

nt vis

its an

d an a

dditio

nal 1

0 visi

ts for

Hom

e Se

tting p

er pl

an ye

ar. L

imits

may

not a

pply

for

Ther

apies

for C

hildr

en w

ith D

evelo

pmen

tal

Delay

s and

Auti

sm S

pectr

um D

isord

er.

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d.

Skille

d nur

sing c

are

20%

after

dedu

ctible

No

t cov

ered

Se

rvice

s tha

t are

not p

reau

thoriz

ed w

ill be

de

nied.

Dura

ble m

edica

l eq

uipme

nt 50

% af

ter de

ducti

ble

Not c

over

ed

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d.

Hosp

ice se

rvice

s No

char

ge

Not c

over

ed

Servi

ces t

hat a

re no

t pre

autho

rized

will

be

denie

d. Re

fer to

bellc

ounty

.swhp

.org o

r Cu

stome

r Ser

vice a

t 1-8

44-6

33-5

325.

If yo

ur ch

ild n

eeds

de

ntal

or ey

e car

e

Child

ren’s

eye e

xam

$30 c

opay

ment/

visit

Not c

over

ed

Limite

d to o

ne ey

e exa

m pe

r plan

year

.

Child

ren’s

glas

ses

Not c

over

ed

Not c

over

ed

None

Child

ren’s

denta

l che

ck-

up

Not c

over

ed

Not c

over

ed

None

43

Exclu

ded

Serv

ices &

Oth

er C

over

ed S

ervic

es:

Serv

ices Y

our P

lan G

ener

ally D

oes N

OT C

over

(Che

ck yo

ur p

olicy

or p

lan d

ocum

ent f

or m

ore i

nfor

mat

ion

and

a list

of a

ny o

ther

exclu

ded

serv

ices.)

•

Acup

unctu

re•

Baria

tric su

rger

y•

Child

ren’s

glas

ses

•Co

smeti

c sur

gery

•De

ntal c

are (

Adult

and C

hild)

•Inf

ertili

ty tre

atmen

t•

Long

-term

care

•No

n-em

erge

ncy c

are w

hen t

rave

ling o

utside

the U

.S.

•Pr

ivate-

duty

nursi

ng•

Routi

ne fo

ot ca

re•

Weig

ht los

s pro

gram

s

Othe

r Cov

ered

Ser

vices

(Lim

itatio

ns m

ay ap

ply t

o th

ese s

ervic

es. T

his i

sn’t

a com

plet

e list

. Plea

se se

e you

r plan

doc

umen

t.)

•Ch

iropr

actic

care

(limi

ted to

35 vi

sits p

er pl

an ye

ar)

•He

aring

aids

(limi

ted to

one d

evice

per e

ar ev

ery 3

year

s; lim

ited t

o cov

ered

mem

bers

throu

gh th

e age

of 18

)•

Routi

ne ey

e car

e (Ad

ult) (

limite

d to a

n ann

ual e

ye ex

am co

nduc

ted by

a lic

ense

d oph

thalm

ologis

t or o

ptome

trist)

Your

Rig

hts t

o Co

ntin

ue C

over

age:

The

re ar

e age

ncies

that

can h

elp if

you w

ant to

conti

nue y

our c

over

age a

fter it

ends

. The

conta

ct inf

orma

tion f

or th

ose

agen

cies i

s: Sc

ott &

Whit

e Car

e Plan

s, vis

it swh

p.org

, or c

all 1-

844-

633-

5325

; Dep

artm

ent o

f Lab

or’s

Emplo

yee B

enefi

ts Se

curity

Adm

inistr

ation

at 1-

866-

444-

EBSA

(3

272)

or do

l.gov

/ebsa

/healt

hrefo

rm. O

ther c

over

age o

ption

s may

be av

ailab

le to

you t

oo, in

cludin

g buy

ing in

dividu

al ins

uran

ce co

vera

ge th

roug

h the

Hea

lth

Insur

ance

Mar

ketpl

ace.

For m

ore i

nform

ation

abou

t the M

arke

tplac

e, vis

it Hea

lthCa

re.go

v or c

all 1-

800-

318-

2596

.

Your

Grie

vanc

e and

App

eals

Righ

ts: T

here

are a

genc

ies th

at ca

n help

if yo

u hav

e a co

mplai

nt ag

ainst

your

plan

for a

denia

l of a

claim

. This

comp

laint

is ca

lled a

gr

ievan

ce or

appe

al. F

or m

ore i

nform

ation

abou

t you

r righ

ts, lo

ok at

the e

xplan

ation

of be

nefits

you w

ill re

ceive

for t

hat m

edica

l clai

m. Y

our p

lan do

cume

nts al

so

prov

ide co

mplet

e info

rmati

on to

subm

it a cl

aim, a

ppea

l, or a

griev

ance

for a

ny re

ason

to yo

ur pl

an. F

or m

ore i

nform

ation

abou

t you

r righ

ts, th

is no

tice,

or as

sistan

ce,

conta

ct: S

cott &

Whit

e Car

e Plan

s, vis

it swh

p.org

, or c

all 1-

844-

633-

5325

; Tex

as D

epar

tmen

t of In

sura

nce,

visit t

di.tex

as.go

v or c

all 1-

800-

578-

4677

; Dep

artm

ent o

f La

bor’s

Emp

loyee

Ben

efits

Secu

rity A

dmini

strati

on at

1-86

6-44

4-EB

SA (3

272)

or do

l.gov

/ebsa

/healt

hrefo

rm, T

exas

Dep

artm

ent o

f Insu

ranc

e Tex

as H

ealth

Opti

ons a

t 1-

800-

252-

3439

or te

xash

ealth

optio

ns.co

m.

Does

this

plan

pro

vide M

inim

um E

ssen

tial C

over

age?

Yes

If y

ou do

n’t ha

ve M

inimu

m Es

senti

al Co

vera

ge fo

r a m

onth,

you’l

l hav

e to m

ake a

paym

ent w

hen y

ou fil

e you

r tax

retur

n unle

ss yo

u qua

lify fo

r an e

xemp

tion f

rom

the

requ

ireme

nt tha

t you

have

healt

h cov

erag

e for

that

month

.

Does

this

plan

mee

t the

Min

imum

Valu

e Sta

ndar

ds?

Yes

If y

our p

lan do

esn’t

mee

t the M

inimu

m Va

lue S

tanda

rds,

you m

ay be

eligi

ble fo

r a pr

emium

tax c

redit

to he

lp yo

u pay

for a

plan

thro

ugh t

he M

arke

tplac

e.

Lang

uage

Acc

ess S

ervic

es:

Span

ish (E

spañ

ol): P

ara o

btene

r asis

tencia

en E

spañ

ol, lla

me al

1-84

4-63

3-53

25.

––––

––––

––––

––––

––––

––To

see

exam

ples o

f how

this

plan

migh

t cov

er co

sts fo

r a sa

mple

med

ical s

ituat

ion, s

ee th

e ne

xt se

ction

.–––

––––

––––

––––

––––

–––

44

Peg

is Ha

ving

a Bab

y (9

mon

ths of

in-n

etwor

k pre

-nata

l car

e and

a ho

spita

l deli

very)

Mia’s

Sim

ple F

ract

ure

(in-n

etwor

k eme

rgen

cy ro

om vi

sit an

d foll

ow

up ca

re)

Mana

ging

Joe’s

type

2 Di

abet

es

(a ye

ar of

routi

ne in

-netw

ork c

are o

f a w

ell-

contr

olled

cond

ition)

Th

e plan

’s ov

erall

ded

uctib

le $

1,250

Spec

ialist

copa

ymen

t

$30

Ho

spita

l (fa

cility

) coi

nsur

ance

20

%

Ot

her c

oins

uran

ce 2

0%

This

EXAM

PLE

even

t inc

lude

s ser

vices

like:

Sp

ecial

ist of

fice v

isits

(pre

nata

l car

e)

Child

birth/

Deliv

ery P

rofes

siona

l Ser

vices

Ch

ildbir

th/De

liver

y Fac

ility S

ervic

es

Diag

nosti

c tes

ts (u

ltras

ound

s and

bloo

d wo

rk)

Spec

ialist

visit

(ane

sthes

ia)

Tota

l Exa

mpl

e Cos

t $1

2,800

In th

is ex

ampl

e, Pe

g wo

uld

pay:

Co

st Sh

aring

De

ducti

bles

$1,25

0 Co

paym

ents

$20

Coins

uran

ce

$2,48

0 W

hat is

n’t co

vere

d Lim

its or

exclu

sions

$6

0 Th

e tot

al Pe

g wo

uld

pay i

s $3

,810

Th

e plan

’s ov

erall

ded

uctib

le $

1,250

Spec

ialist

copa

ymen

t

$30

Ho

spita

l (fa

cility

) coi

nsur

ance

20

%

Ot

her c

oins

uran

ce

20%

This

EXAM

PLE

even

t inc

lude

s ser

vices

like:

Pr

imar

y car

e phy

sician

offic

e visi

ts (in

cludin

g dis

ease

edu

catio

n)

Diag

nosti

c tes

ts (b

lood

work

) Pr

escri

ption

drug

s Du

rable

med

ical e

quipm

ent (

gluco

se m

eter

)

Tota

l Exa

mpl

e Cos

t $7

,400

In th

is ex

ampl

e, Jo

e wou

ld p

ay:

Cost

Shar

ing

Dedu

ctible

s $1

,250

Copa

ymen

ts $1

,130

Coins

uran

ce

$370

W

hat is

n’t co

vere

d Lim

its or

exclu

sions

$6

0 Th

e tot

al Jo

e wou

ld p

ay is

$2

,810

Th

e plan

’s ov

erall

ded

uctib

le $1

,250

Sp

ecial

ist co

paym

ent

$30

Ho

spita

l (fa

cility

) coi

nsur

ance

20

%

Ot

her c

oins

uran

ce

20%

This

EXAM

PLE

even

t inc

lude

s ser

vices

like:

Em

erge

ncy r

oom

care

(inclu

ding

med

ical

supp

lies)

Diag

nosti

c tes

t (X-

ray)

Dura

ble m

edica

l equ

ipmen

t (cr

utch

es)

Reha

bilita

tion s

ervic

es (p

hysic

al th

erap

y)

Tota

l Exa

mpl

e Cos

t $1

,900

In th

is ex

ampl

e, Mi

a wou

ld p

ay:

Cost

Shar

ing

Dedu

ctible

s $1

,120

Copa

ymen

ts $4

60

Coins

uran

ce

$290

W

hat is

n’t co

vere

d Lim

its or

exclu

sions

$0

Th

e tot

al Mi

a wou

ld p

ay is

$1

,870

Abou

t the

se C

over

age E

xam

ples

:

Th

is is

not a

cost

estim

ator

. Tre

atmen

ts sh

own a

re ju

st ex

ample

s of h

ow th

is pla

n migh

t cov

er m

edica

l car

e. Yo

ur ac

tual c

osts

will b

e dif

feren

t dep

endin

g on t

he ac

tual c

are y

ou re

ceive

, the p

rices

your

prov

iders

char

ge, a

nd m

any o

ther f

actor

s. Fo

cus o

n the

cost

shar

ing

amou

nts (d

educ

tibles

, cop

ayme

nts an

d coin

sura

nce)

and e

xclud

ed se

rvice

s und

er th

e plan

. Use

this

infor

matio

n to c

ompa

re th

e por

tion o

f co

sts yo

u migh

t pay

unde

r diffe

rent

healt

h plan

s. Pl

ease

note

these

cove

rage

exam

ples a

re ba

sed o

n self

-only

cove

rage

.

45

No

ndis

crim

inat

ion

No

tice

SW

CP_Nondiscrimination_Notice_01/2019_C

ATTE

NTI

ON

: If

you

spea

k En

glish

, lan

guag

e as

sista

nce

serv

ices

, fre

e of

char

ge, a

re av

aila

ble

to y

ou.

Cal

l 1-8

00-3

21-7

947

(TTY

: 711

).Sc

ott &

Whi

te C

are

Plan

s com

plie

s with

appl

icab

le F

eder

al ci

vil r

ight

s law

s and

doe

s not

disc

rimin

ate

on th

e ba

sis o

f rac

e, co

lor,

natio

nal o

rigin

, age

, di

sabi

lity,

or se

x. S

cott

& W

hite

Car

e Plan

s doe

s not

exclu

de p

eopl

e or t

reat

them

diff

eren

tly b

ecau

se o

f rac

e, co

lor,

natio

nal o

rigin

, age

, disa

bilit

y, or

sex.

Scot

t & W

hite

Car

e Pl

ans:

•Pro

vide

s fre

e ai

ds a

nd se

rvic

es to

peo

ple

with

disa

bilit

ies t

o co

mm

unic

ate

effec

tivel

y w

ith u

s, su

ch a

s:-W

ritte

n in

form

atio

n in

oth

er fo

rmat

s (la

rge

prin

t and

acc

essib

le el

ectr

onic

form

ats)

•Pro

vide

s fre

e la

ngua

ge se

rvic

es to

peo

ple

who

se p

rimar

y la

ngua

ge is

not

Eng

lish,

such

as:

-Qua

lified

inte

rpre

ters

-Inf

orm

atio

n w

ritte

n in

oth

er la

ngua

ges

If yo

u ne

ed th

ese

serv

ices

, con

tact

the

Scot

t & W

hite

Car

e Pl

ans C

ompl

ianc

e O

ffice

r at 1

-214

-820

-888

8 or

send

an

emai

l to

SWH

PCom

plia

nceD

epar

tmen

t@BS

WH

ealth

.org

If yo

u be

lieve

that

Sco

tt &

Whi

te C

are

Plan

s has

faile

d to

pro

vide

thes

e se

rvic

es o

r disc

rimin

ated

in a

noth

er w

ay o

n th

e ba

sis o

f rac

e, co

lor,

natio

nal

orig

in, a

ge, d

isabi

lity,

or se

x, y

ou c

an fi

le a

grie

vanc

e w

ith:

Scot

t & W

hite

Car

e Pl

ans,

Com

plia

nce

Offi

cer

1206

Wes

t Cam

pus D

rive,

Suite

151

Tem

ple,

Texa

s 765

02

Com

plia

nce

Hel

pLin

e; 1-

888-

484-

6977

or h

ttps:/

/app

.myc

ompl

ianc

erep

ort.c

om/r

epor

t.asp

x?ci

d=sw

hpYo

u ca

n fil

e a

grie

vanc

e in

per

son

or b

y m

ail,

onlin

e, or

em

ail.

If yo

u ne

ed h

elp

filin

g a

grie

vanc

e, th

e C

ompl

ianc

e O

ffice

r is a

vaila

ble

to h

elp

you.

Yo

u ca

n al

so fi

le a

civi

l rig

hts c

ompl

aint

with

the

U.S

. Dep

artm

ent o

f Hea

lth a

nd H

uman

Ser

vice

s, O

ffice

for C

ivil

Righ

ts, e

lect

roni

cally

thro

ugh

the

Offi

ce fo

r Civ

il Ri

ghts

Com

plai

nt P

orta

l, av

aila

ble

at h

ttps:/

/ocr

port

al.h

hs.g

ov/o

cr/p

orta

l/lob

by.js

f, or

by

mai

l or p

hone

at:

U.S

. Dep

artm

ent o

f Hea

lth a

nd H

uman

Ser

vice

s20

0 In

depe

nden

ce A

venu

e, SW

Room

509

F, H

HH

Bui

ldin

gW

ashi

ngto

n, D

.C. 2

0201

1-

800-

368-

1019

, 1-8

00-5

37-7

697

(TD

D)

Com

plai

nt fo

rms a

re av

aila

ble

at h

ttps:/

/ww

w.hh

s.gov

/civ

il-rig

hts/

filin

g-a-

com

plai

nt/in

dex.

htm

l.

46

Lang

uag

e A

ssis

tanc

e/ A

sist

enci

a d

e id

iom

as

SW

CP_LanguageAssistance_11/2

018

Eng

lish:

AT

TEN

TIO

N: I

f you

spea

k En

glis

h, la

ngua

ge a

ssis

tanc

e se

rvic

es, f

ree

of c

harg

e, a

re a

vaila

ble

to y

ou. C

all 1

-800

-321

-794

7 (T

TY: 7

11).

Span

ish:

AT

ENC

IÓN

: Si

hab

la e

spañ

ol, t

iene

a su

dis

posi

ción

serv

icio

s gra

tuito

s de

asis

tenc

ia li

ngüí

stic

a. L

lam

e al

1-8

00-3

21-7

947

(TTY

: 711

).

Vie

tnam

ese:

C

HÚ

Ý:

Nếu

bạn

nói

Tiế

ng V

iệt,

có c

ác d

ịch

vụ h

ỗ trợ

ngô

n ng

ữ m

iễn

phí d

ành

cho

bạn.

Gọi

số 1

-800

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7 (T

TY: 7

11).

Chi

nese

: 注

意：如

果 使

用繁

體中

文，可

以免

費獲

得語

言援

助服

務。請

致電

1-80

0-32

1-79

47(T

TY：7

11)。

Kor

ean:

주

의:

한국

어를

사용

하시

는 경

우, 언

어 지

원 서

비스

를 무

료로

이용

하실

수 있

습니

다. 1

-800

-321

-794

7 (T

TY: 7

11) 번

으로

전화

해 주

십시

오.

Ara

bic:

رقم

) 800

-321

-794

7-1

رقمل ب

ص ات

ن.جا

المك ب

ر لواف

تتویة

للغة ا

عدسا

المت

دما خ

إن، ف

غة الل

كر اذ

ثحد

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ة: وظ

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711

كم:الب

وصم

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u:

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ں ہی

بتیا

دسں

میت

مفت

دما خ

کیدد

ی من ک

زباو

پ کو آ

، تیں

ے ہولت

و برد

پ ار آ

اگر:

رداخب

1-8

00-3

21-7

947

(TTY

: 711

). یں

کر

Taga

log:

PAU

NAW

A:

Kun

g na

gsas

alita

ka

ng T

agal

og, m

aaar

i kan

g gu

mam

it ng

mga

serb

isyo

ng

tulo

ng sa

wik

a na

ng w

alan

g ba

yad.

Tum

awag

sa

1-80

0-32

1-79

47 (T

TY: 7

11).

Fren

ch:

ATTE

NTI

ON

: Si

vou

s par

lez

fran

çais

, des

serv

ices

d’a

ide

lingu

istiq

ue v

ous s

ont p

ropo

sés g

ratu

item

ent.

App

elez

le 1

-800

-321

-794

7 (A

TS :

711)

.

Hin

di:

धयान

द:

यदि आ

प हि

दी ब

ोलत

ह तो

आपक

लिए

मफत

म भ

ाषा स

हायत

ा सवा

ए उप

लबध

ह। 1

-800

-321

-794

7 (T

TY: 7

11) प

र कॉल

कर।

Pers

ian:

شما

ی را

ن بگا

رایت

ورص

ی ببان

زت

یالسھ

، تنید

ی کو م

تگ گف

سیار

ن فزبا

بھ ر

اگجھ:

تود.

ریگی

س بتما

1-8

00-3

21-7

947

(TTY

: 711

ا (. ب

شد با

میھم

راف

Ger

man

: A

CH

TUN

G:

Wen

n Si

e D

euts

ch sp

rech

en, s

tehe

n Ih

nen

kost

enlo

s spr

achl

iche

Hilf

sdie

nstle

istu

ngen

zur

Ver

fügu

ng.

Ruf

num

mer

: 1-8

00-3

21-7

947

(TTY

: 711

).

Guj

arat

i: સચ

ના: જ

ો તમ

ગજરાત

ી બોલ

તા હ

ો, તો

નિ:શ

લક ભ

ાષા સ

હાય

સવાઓ

તમા

રા મા

ટ ઉપ

લબધ

છ. ફ

ોન કર

ો 1-

800-

321-

7947

(TTY

: 711

).

Rus

sian

: В

НИ

МА

НИ

Е: Е

сли

вы го

вори

те н

а ру

сско

м яз

ыке

, то

вам

дост

упны

бес

плат

ные

услу

ги п

ерев

ода.

Зво

ните

1-8

00-3

21-7

947

(тел

етай

п: 7

11).

Japa

nese

:注

意事

項：日

本語

を話

され

る場

合、無

料の

言語

支援

をご

利用

いた

だけ

ます

。1-8

00-3

21-7

947

(TTY

:711

）まで

、お電

話に

てご

連絡

くだ

さい

。L

aotia

n:

ໂປດ

ຊາບ

: ຖ

າວ

າ ທ

ານ

ເວ

າພ

າສາ

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ການ

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ວຍເຫ

ອດ

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1-80

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TY: 7

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47

Virtual Care—Powered by MDLIVEWe’ve teamed up with MDLIVE to provide our members with access to board-certified doctors as well as licensed therapists and more—using your phone, smartphone, tablet or computer—all for a $0 copayment.*

Some common conditions treated include:

*Members with high-deductible health plans must first meet their deductibleCopyright © 2019 MDLIVE Inc. All Rights Reserved. MDLIVE may not be available in certain states and is subject to state regulations. MDLIVE does not replace the primary care physician, is not an insurance product and may not be able to substitute for traditional in person care in every case or for every condition. MDLIVE does not prescribe DEA controlled substances and may not prescribe non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE does not guarantee patients will receive a prescription. Healthcare professionals using the platform have the right to deny care if based on professional judgment a case is inappropriate for telehealth or for misuse of services. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit https://www.MDLIVE.com/terms-of-use/. MCR-1316

SWHP-MDLIVE-$0_08.2019

General Health• Common cold / Flu• Cough• Fever• Insect bites• Allergies• Diarrhea• Nausea / Vomiting• Pink eye• Sore throat• Constipation• Ear problems• Headache

Behavioral Health• Addictions• Stress / Anxiety• Bipolar disorders• Depression• Eating disorders• Grief and loss• Life changes• Panic disorders• Parenting issues• Postpartum depression• Relationship and

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High-quality healthcare with board-certified

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48

CORE PLAN Effective Date: 11/1/2020 FUSION: THE ULTIMATE CHOICESM combines dental and eye care benefits in one easy-to-administer plan. This plan combines the annual maximum between the dental and eye care plans. For the maximum:

⚫ The member can use up to $1,000 toward any covered dental expense.⚫ The member can use up to $150 towards any covered eye care expense.⚫ Total benefits paid between the two coverages will not exceed $1,000.

Dental Plan Summary subject to FUSION plan design listed above

Plan Benefit Type 1 100% Type 2 80% Type 3 50%

Deductible $10/visit Type 1

$50 Policy Year Type 2,3

No Family Maximum

Maximum (per person) $1,000 per policy year

Preventive PlusSM Included

Allowance Discounted Fee

Waiting Period None

Orthodontia Summary - Child Only Coverage

Allowance U&C

Plan Benefit 50%

Lifetime Maximum (per person) $1,000

Waiting Period None

Dental Procedure Summary Type 1 Type 2 Type 3

⚫ Routine Exam (2 per benefit period)

⚫ Bitewing X-rays (2 per benefit period)

⚫ Full Mouth/Panoramic X-rays

(1 in 3 years)

⚫ Periapical X-rays

⚫ Cleaning (2 per benefit period)

⚫ Fluoride for Children 18 and under

(1 per benefit period)

⚫ Sealants (age 16 and under)

⚫ Space Maintainers

⚫ Restorative Amalgams

⚫ Restorative Composites

⚫ Endodontics (nonsurgical)

⚫ Endodontics (surgical)

⚫ Periodontics (nonsurgical)

⚫ Periodontics (surgical)

⚫ Denture Repair

⚫ Simple Extractions

⚫ Complex Extractions

⚫ Anesthesia

⚫ Onlays

⚫ Crowns

(1 in 5 years per tooth)

⚫ Crown Repair

⚫ Implants

⚫ Prosthodontics (fixed bridge; removable

complete/partial dentures)

(1 in 5 years)

Current Dental Terminology © American Dental Association.

Eye Care Summary subject to FUSION plan design listed above

Allowances

Exam Subject to maximum

Lenses (per pair) Single Subject to maximum Bifocal Subject to maximum Trifocal Subject to maximum Lenticular Subject to maximum Progressive Subject to maximum

Contacts

Elective/Medically Necessary Subject to maximum

Frames Subject to maximum

Frequencies Based on date of service

Exam None

Lenses None

Frames None

Maximum $150

Deductibles (None) $0*

*Deductible applies to the first service received

49

Ameritas Information We're Here to Help This plan was designed specifically for the associates of Bell County. At Ameritas Group, we do more than provide coverage - we make sure there's always a friendly voice to explain your benefits, listen to your concerns, and answer your questions. Our customer relations associates will be pleased to assist you 7 a.m. to midnight (Central Time) Monday through Thursday, and 7 a.m. to 6:30 p.m. on Friday. You can speak to them by calling toll-free: 800-487-5553. For plan information any time, access our automated voice response system or go online to ameritas.com. NOTICE OF CLAIM: Written notice of a claim must be given to Ameritas within 90

days after the incurred date of the services provided for which benefits are payable.

Rx Savings Our valued plan members and their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam's Club pharmacy across the nation. This Rx discount is offered at no additional cost, and it is not insurance. To receive the Walmart Rx discount, Ameritas plan members just need to visit us at ameritas.com and sign into (or create) a secure member account where they can access and print an online-only Rx discount savings ID card.

Eyewear Savings Ameritas plan members may receive up to 10% off eyewear frames and lenses purchased at any Walmart Vision Center nationwide. Members may also bring in their current vision prescription from any vision care provider and purchase eyewear at Walmart. This savings arrangement is not insurance: it is available to members at no additional cost to their plan premium. To receive the eyewear savings identification card, Ameritas plan members can visit ameritas.com and sign-in (or create) a secure member account. Members

must present the Ameritas Eyewear Savings Card at time of purchase to receive the discount.

Preventive PlusSM With this plan option, benefits for Type 1/Preventive procedures are not deducted from the plan member's annual maximum benefit. This saves the entire annual maximum for the Type 2/Basic and Type 3/Major procedures that are covered by your plan.

Dental Network Information To find a provider, visit ameritas.com and select FIND A PROVIDER, then DENTAL. Enter your criteria to search by location or for a specific dentist or practice. California Residents: When prompted to select your network, choose the Ameritas Network found on your ID Card or contact Customer Connections at 800-487-5553.

Pretreatment While we don't require a pretreatment authorization form for any procedure, we recommend them for any dental work you consider expensive. As a smart consumer, it's best for you to know your share of the cost up front. Simply ask your dentist to submit the information for a pretreatment estimate to our customer relations department. We'll inform both you and your dentist of the exact amount your insurance will cover and the amount that you will be responsible for. That way, there won't be any surprises once the work has been completed.

Late Entrant Provision We strongly encourage you to sign up for coverage when you are initially eligible. If you choose not to sign up during this initial enrollment period, you will become a late entrant. Late entrants will be eligible for only exams, cleanings, and fluoride applications for the first 12 months they are covered.

Language Services We recognize the importance of communicating with our growing number of multilingual customers. That is why we offer a language assistance program that gives you access to: Spanish-speaking claims contact center representatives, telephone interpretation services in a wide range of languages, online dental network provider search in Spanish and a variety of Spanish documents such as enrollment forms, claim forms and certificates of insurance.

This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator.

50

BUY-UP PLAN Effective Date: 11/1/2020 FUSION: THE ULTIMATE CHOICESM combines dental and eye care benefits in one easy-to-administer plan. This plan combines the annual maximum between the dental and eye care plans. For the maximum:

⚫ The member can use up to $1,000 toward any covered dental expense.⚫ The member can use up to $150 towards any covered eye care expense.⚫ Total benefits paid between the two coverages will not exceed $1,000.

Dental Plan Summary subject to FUSION plan design listed above

Plan Benefit Type 1 100% Type 2 80% Type 3 50%

Deductible $10/visit Type 1

$50 Policy Year Type 2,3

No Family Maximum

Maximum (per person) $1,000 per policy year

Preventive PlusSM Included

Allowance 90th U&C

Waiting Period None

Orthodontia Summary - Child Only Coverage

Allowance U&C

Plan Benefit 50%

Lifetime Maximum (per person) $1,000

Waiting Period None

Dental Procedure Summary Type 1 Type 2 Type 3

⚫ Routine Exam (2 per benefit period)

⚫ Bitewing X-rays (2 per benefit period)

⚫ Full Mouth/Panoramic X-rays

(1 in 3 years)

⚫ Periapical X-rays

⚫ Cleaning (2 per benefit period)

⚫ Fluoride for Children 18 and under

(1 per benefit period)

⚫ Sealants (age 16 and under)

⚫ Space Maintainers

⚫ Restorative Amalgams

⚫ Restorative Composites

⚫ Endodontics (nonsurgical)

⚫ Endodontics (surgical)

⚫ Periodontics (nonsurgical)

⚫ Periodontics (surgical)

⚫ Denture Repair

⚫ Simple Extractions

⚫ Complex Extractions

⚫ Anesthesia

⚫ Onlays

⚫ Crowns

(1 in 5 years per tooth)

⚫ Crown Repair

⚫ Implants

⚫ Prosthodontics (fixed bridge; removable

complete/partial dentures)

(1 in 5 years)

Current Dental Terminology © American Dental Association.

Eye Care Summary subject to FUSION plan design listed above

Allowances

Exam Subject to maximum

Lenses (per pair) Single Subject to maximum Bifocal Subject to maximum Trifocal Subject to maximum Lenticular Subject to maximum Progressive Subject to maximum

Contacts

Elective/Medically Necessary Subject to maximum

Frames Subject to maximum

Frequencies Based on date of service

Exam None

Lenses None

Frames None

Maximum $150

Deductibles (None) $0*

*Deductible applies to the first service received

51

Ameritas Information We're Here to Help This plan was designed specifically for the associates of Bell County. At Ameritas Group, we do more than provide coverage - we make sure there's always a friendly voice to explain your benefits, listen to your concerns, and answer your questions. Our customer relations associates will be pleased to assist you 7 a.m. to midnight (Central Time) Monday through Thursday, and 7 a.m. to 6:30 p.m. on Friday. You can speak to them by calling toll-free: 800-487-5553. For plan information any time, access our automated voice response system or go online to ameritas.com. NOTICE OF CLAIM: Written notice of a claim must be given to Ameritas within 90 days after the incurred date of the services provided for which benefits are payable.

Rx Savings Our valued plan members and their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam's Club pharmacy across the nation. This Rx discount is offered at no additional cost, and it is not insurance. To receive the Walmart Rx discount, Ameritas plan members just need to visit us at ameritas.com and sign into (or create) a secure member account where they can access and print an online-only Rx discount savings ID card.

Eyewear Savings Ameritas plan members may receive up to 10% off eyewear frames and lenses purchased at any Walmart Vision Center nationwide. Members may also bring in their current vision prescription from any vision care provider and purchase eyewear at Walmart. This savings arrangement is not insurance: it is available to members at no additional cost to their plan premium. To receive the eyewear savings identification card, Ameritas plan members can visit ameritas.com and sign-in (or create) a secure member account. Members must present the Ameritas Eyewear Savings Card at time of purchase to receive the discount.

Preventive PlusSM With this plan option, benefits for Type 1/Preventive procedures are not deducted from the plan member's annual maximum benefit. This saves the entire annual maximum for the Type 2/Basic and Type 3/Major procedures that are covered by your plan.

Dental Network Information To find a provider, visit ameritas.com and select FIND A PROVIDER, then DENTAL. Enter your criteria to search by location or for a specific dentist or practice. California Residents: When prompted to select your network, choose the Ameritas Network found on your

ID Card or contact Customer Connections at 800-487-5553.

Pretreatment While we don't require a pretreatment authorization form for any procedure, we recommend them for any dental work you consider expensive. As a smart consumer, it's best for you to know your share of the cost up front. Simply ask your dentist to submit the information for a pretreatment estimate to our customer relations department. We'll inform both you and your dentist of the exact amount your insurance will cover and the amount that you will be responsible for. That way, there won't be any surprises once the work has been completed.

Late Entrant Provision We strongly encourage you to sign up for coverage when you are initially eligible. If you choose not to sign up during this initial enrollment period, you will become a late entrant. Late entrants will be eligible for only exams, cleanings, and fluoride applications for the first 12 months they are covered.

Language Services We recognize the importance of communicating with our growing number of multilingual customers. That is why we offer a language assistance program that gives you access to: Spanish-speaking claims contact center representatives, telephone interpretation services in a wide range of languages, online dental network provider search in Spanish and a variety of Spanish documents such as enrollment

forms, claim forms and certificates of insurance.

This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator.

52

What is the eyewear frames and lenses savings?It provides our plan members with savings on the following vision care products at Walmart Vision Centers:

• Top-quality frames for the entire family including today’smost popular brands

• Wide selection of lens options; all lenses come withscratch-resistant coating at no additional charge

• Safety eyewear

Contact lenses and prescription sunglasses are not included in this savings arrangement.

The eyewear savings cannot be combined with any other coupon or promotion, or most insurance.

What ID card can I use?Carefully cut your ID card from this sheet or save a picture of it on your device to retain for future use. Members also can visit ameritas.com, Account Access and sign in (or create) a secure member account where they can access and print a savings card.

When making an appointment at a Walmart Vision Center, you must mention you have eyewear savings through your Ameritas plan and present the savings ID card.

GR 6436 4-20

Who do I call for insurance benefit questions?If you have questions regarding insurance benefits, you can call Ameritas toll free at 800-487-5553 or in New York at 800-659-5556. This savings arrangement is not insuranceand not intended as a replacement for insurance.

Is a vision exam required to receive the eyewear savings?No. You may bring in your current vision prescription from another vision care provider to purchase eyewear frames and lenses.

How do I find a Walmart Vision Center?Vision Centers are located in more than 2,500 Walmart stores nationwide. To find a Walmart location nearby, visit walmart.com and do a search for Vision Center.

GuaranteesWalmart Vision Centers stand behind their products and workmanship by offering:

• 60-day frame and lens satisfaction guarantee• 12-month replacement guarantee on broken or

damaged frames or lenses• Lifetime adjustments and cleanings

Save Money on Your Prescription Eyeglasses

This information is provided by Ameritas Life Insurance Corp. (Ameritas Life) and Ameritas Life Insurance Corp. of New York (Ameritas of New York). Ameritas, the bison design, “fulfilling life” and product names designated with SM or ® are service marks or registered service marks of Ameritas Life, affiliate Ameritas Holding Company or Ameritas Mutual Holding Company. All other brands are property of their respective owners. © 2020 Ameritas Mutual Holding Company

Ameritas Life Insurance Corp. Ameritas Life Insurance Corp. of New York

For all participating states, except New York. For New York.

Ameritas Eyewear Savings Card

Member Name: �������������������������������������������������Members: To locate a Walmart Vision Center near you, visit http://www.walmart.com/cservice/ca�storefinder.gsp. Call 800-487-5553 with questions.Walmart Vision Center Associates: Use plan name SAVINGS 10 in BOSS. Call 700-277-7710 with questions.

GR 6269 Eyewear 11-19

Ameritas Eyewear Savings Card

GR 6269 NY Eyewear 11-19

Member Name: �������������������������������������������������Members: To locate a Walmart Vision Center near you, visit http://www.walmart.com/cservice/ca�storefinder.gsp. Call 800-659-5556 with questions.Walmart Vision Center Associates: Use plan name SAVINGS 10 in BOSS. Call 700-277-7710 with questions.

Ameritas Life Insurance Corp. of New York

53

GR 7593 5-20

Continue to get the most from your dental benefitsThe COVID-19 pandemic has had significant financial and physical impact on millions of Americans. It’s more important than ever to seek the health care you need, but many find it difficult financially.

You purchased your Ameritas dental plan to make going to the dentist easy and affordable. And we want to make sure that continues.

Here are a couple ways Ameritas is helping you access dental care.

Elimination of dental deductible. We will waive the deductible for all dental claims incurred July 1 through December 31, 2020. Your plan benefits kick in right away. The deductible waiver does not apply to orthodontia claims.

Elimination of dental exam and cleaning frequency limitations. Ameritas dental plans typically cover the cost of one or two exams and cleanings each year. Your plan’s frequency limitation will be waived July 1 through December 31, 2020. So you can see the dentist when you need to and know you’re covered.

Your well-being is our top priority We want to make sure you have the confidence to obtain the dental care you need, without worrying about your coverage.

If you have questions about your dental coverage, or if there are changes to your treatment because of the pandemic, we can help. Please contact our claims contact center:

group@ameritas.com or 800-487-5553Monday – Thursday, 7 a.m. – Midnight (CST)Friday, 7 a.m. – 6:30 p.m. (CST

We will work with you to meet your needs.

Get the Dental Care You Need NowAmeritas offers benefit enhancements during the pandemic

This information is provided by Ameritas Life Insurance Corp. (Ameritas Life). Group dental, vision and hearing care products (9000 Rev. 03-16, dates may vary by state) are issued by Ameritas Life. Ameritas, the bison design, “fulfilling life” and product names designated with SM or ® are service marks or registered service marks of Ameritas Life, affiliate Ameritas Holding Company or Ameritas Mutual Holding Company. © 2020 Ameritas Mutual Holding Company.

800-776-9446 ameritas.com

54

Hello Bell County Employees,

It’s that time of the year - your annual opportunity to review and choose the best benefit options for you and your family. As part of our company benefits package, we are excited to offer you the opportunity to enroll in a flexible spending account (FSA).

FSA Overview - Medical Think of an FSA like a spending account for healthcare. The account is tax-advantaged, meaning you can save up to 40% on thousands of everyday expenses. You decide how much money to set aside each year to pay for eligible expenses, such as:

• Deductibles• Copays• Prescriptions• Teeth Cleaning• LASIK• Glasses and contact lenses• Band-aids• Sunscreen• View all eligible expenses

FSA Overview – Dependent Care The Dependent Care is a spending account that can be used to pay for services like daycare, nursery school, and elder care.

Why you’ll love it • An FSA can be used to pay for thousands of eligible medical expenses• Savings on daycare and other dependent care services you are already paying for• You can use your entire yearly contribution starting day one of the plan year• The account is funded through payroll deductions, before taxes, which in turn reduces your

taxable income

Employees don't need to enroll in one FSA to get the other. They can enroll in the medical FSA without enrolling in the dependent care FSA and vice versa.

To learn more about the benefits of an FSA, visit myameriflex/participants.

Be on the lookout for more information and enrollment instructions during our annual open enrollment meeting.

55

Getting real about your healthcare savings starts hereYou made a great decision by enrolling in a flexible spending account (FSA)! Now that you’ve gotten the difficult decisions out of the way, use this packet to learn how to best take advantage of your account. Let’s get started!

HOW YOUR FSA WORKS

Your FSA is a spending account that can be used to pay for a variety of healthcare expenses.

TWO GREAT PERKS COME WITH YOUR FSA:

You will have access to your entire election on the first day of the plan year.

The funds are taken out of your paycheck “pre-tax” (meaning they are subtracted from your gross earnings before taxes) throughout the course of the year. That means you are increasing your take-home pay simply by participating!

WHAT CAN I SPEND MY FSA FUNDS ON?

The IRS determines what expenses are eligible under an FSA. Below are some examples of common eligible expenses.

GETTING STARTED CHECKLIST

Use this checklist to take full advantage of all the great resources made available to you through your FSA.

Set up your MyAmeriflex account MyAmeriflex is where you’ll have real-time access to all of your account information, including your current balance, transaction history, payment status, and more. To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

Enroll in MyPlanConnectThere are instances when you may be asked to submit documentation to Ameriflex to verify the eligibility of an expense. MyPlanConnect does the heavy lifting for you by automatically detecting when you swipe your MyAmeriflex Debit Mastercard and matching the purchase with your insurance plan. After enrolling, all of your expenses moving forward will be processed through MyPlanConnect. To enroll, log into your MyAmeriflex account and select “MyPlanConnect.” If you aren't sure if your employer offers MyPlanConnect, please check with your HR department or call our Participant Services department at 888.868.FLEX (3539).

Download mobile app The MyAmeriflex App lets you access and manage your account anywhere you go, 24/7. It puts all of the great features of the MyAmeriflex Portal right at your fingertips. You can download the app on the Apple App Store and Google Play.

Register for complimentary ID theft protection Ameriflex is pleased to offer our cardholders complimentary access to Mastercard’s comprehensive Identity Theft Protection program*, powered by CSID®. You can rest assured knowing that if your MyAmeriflex Debit Mastercard (or any other debit/credit cards you choose to register!) gets misplaced or stolen, you can utilize Mastercard’s industry-leading ID theft protection and restoration services for everything you may need. To register, visit myameriflex.com/IDtheftprotection.

Use your cardYou will receive a MyAmeriflex Debit Mastercard that can be used to make eligible purchases. Your card will be mailed within 7-10 business days after your enrollment is processed by Ameriflex.

Enroll for direct depositBy enrolling for direct deposit, getting reimbursed is easier and faster anytime you need to pay for an eligible expenses out of pocket. Login to MyAmeriflex to set up direct deposit.

Start spendingYou’re ready to make purchases! Be sure to hang on to your receipts anytime you make a purchase. Login to MyAmeriflex for a full list of eligible expenses.

HOW TO GET REIMBURSED FOR OUT-OF-POCKET EXPENSES

As you begin to use your account, it’s important to understand how to submit a request for reimbursement or payment to a provider.

Two most common reasons for requesting a reimbursement or payment:

You paid an eligible expense out of pocket.

To request a payment be made directly to a provider

Your MyAmeriflex Debit Mastercard is the quickest and easiest way to access your account funds. But if you can’t use your card, getting reimbursed is quick and painless.

STEP 1: Login in to your MyAmeriflex account online or through the MyAmeriflex App

STEP 2: Click the Submit Claim button

STEP 3: Fill out all of the required fields and attach documentation

STEP 4: If requesting to pay a provider, enter the provider’s information, including address, and select “Pay Provider.” Once processed, the reimbursement will be sent directly to the provider. You can also save the provider for any future

reimbursements.

STEP 5: Click submit

You can view the status of a pending reimbursement anytime through MyAmeriflex or the MyAmeriflex App. If any further action is needed before the reimbursement is processed, you will receive a message through your account.

REQUEST FOR ADDITIONAL DOCUMENTATION

Due to the tax-advantaged nature of your account, the IRS has guidelines in place to ensure that purchases made with the account are for eligible medical, dental, or vision expenses. There are instances when additional documentation—like itemized receipts–are needed to verify the eligibility of your expenses.

HERE’S HOW IT WORKS:

STEP 1: You make a payment with your MyAmeriflex Debit Mastercard. This could be a copay for a doctor’s visit, prescription, etc. It’s important to note that when you

swipe your card, the provider is paid.

STEP 2: We will attempt to auto-verify the transaction instantly using stored copays, stored recurring expense values, electronic data feeds, or Inventory Information Approval Systems (IIAS).

STEP 3: If the transaction can’t be auto-verified at the point of purchase, this is normally because the merchant’s (e.g. hospital) payment terminal can’t distinguish if the transaction was for surgery (eligible) or flowers from the hospital gift store (not eligible). You’ll receive a notification if we need more information about the expense, such as an itemized receipt or insurance explanation of benefits (EOB). In some cases, a letter of medical necessity may be required for certain eligible expenses (e.g. therapy).

STEP 4: You can login to MyAmeriflex or use the MyAmeriflex App to upload the itemized receipt or EOB. You can also mail, fax, or email a manual claim form, documentation, and the request for documentation letter to:

Email: claims@myameriflex.com Fax: 888.631.1038 (Attention: Claims Department) Mail: Ameriflex Claims Department P.O. Box 269009 Plano, TX 75026

Please do not send original documents. If damaged or lost during processing.

FREQUENTLY ASKED QUESTIONS

How do I check my account balance?You can check your real-time balance online by logging into MyAmeriflex or through the MyAmeriflex Mobile App. Ameriflex also provides 24/7 access to automated account information via telephone. Call 888.868.FLEX (3539) and follow the prompts to listen to balance and transaction information for your account.

How do I access my account?If you’re a new user, setting up your account is easy! To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your MyAmeriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

What expenses are eligible? The IRS, and sometimes your employer, determine what goods and services are eligible. This will vary based on what type of account you have. For more information about your account and expenses eligibility, visit myameriflex.com/participants. Login to MyAmeriflex for a full list of eligible expenses.

How do I order a new card?You can request a free replacement card online through your Ameriflex account or through the MyAmeriflex Mobile App.

What happens if I don’t use my FSA account balance by the end the year?Employers may offer a $500 roll over or 2.5-month grace period to help employees use their unused money at the end of the plan year. If your employer offers a roll over, up to $500 of unused money will carry over to the next plan year. If your employer offers a 2.5-month grace period, you can continue using your unused money 2.5 months into the new plan year. Please refer to your plan documents or contact Ameriflex to verify the specific rules and features associated with your company's plan.

Can I have an FSA and an HSA?You can’t contribute to an FSA and HSA within the same plan year. However, you can contribute to an HSA and a limited purpose FSA, which only covers dental and vision expenses.

How do these programs save me money on taxes?Since the accounts are tax-advantaged, you get to leverage pre-tax payroll deductions -- increasing your take-home pay and saving you money on everyday expenses. In many cases, you can experience savings of up to 40% on expenses eligible under your employer-sponsored plan.

If I leave my employer, can I still use my funds?No, your funds are forfeited if you leave your employer.

What does pre-tax dollars mean and why is this important?Essentially, “pre-taxing,” which can be used for life insurance, disability insurance, health FSA contributions, dependent care contributions, health savings account contributions and commuter account contributions, means taking income that would otherwise be taxable and diverting it to something else before (so: “pre”) is becomes taxable.

By making pre-tax contributions to an FSA, HSA, HRA, you are lowering the amount your income is taxed, which results in taking home a bigger paycheck.

Can I change my annual election amount?FSA elections are irrevocable and cannot be changed during the period of coverage unless there is a permitted change in election event, such as a change in marital status, birth or adoption of a child, change in an employment status, etc. The event and contribution change must coincide.

How can I get more information about my account?There are several options to get more information about your account. For an overview of account features, visit myameriflex.com/participants.

You can manage your account, check your balance, file and claim anytime online through MyAmeriflex or through the MyAmeriflex App.

How can I change my reimbursement setting to add direct deposit?To set up direct deposit, simply login to MyAmeriflex, select reimbursement settings under the my account tab, then enter your banking information. We also offer a paper direct deposit form that can be mailed, faxed, or emailed to Ameriflex.

If you have any questions you can contact the Ameriflex Participant Services team Monday - Friday, 8:30 a.m. - 8:00 p.m. (ET).

Phone: 888.868.FLEX (3539)Email: service@myameriflex.comChat: myameriflex.com

Flexible Spending Account

56

Getting real about your healthcare savings starts hereYou made a great decision by enrolling in a flexible spending account (FSA)! Now that you’ve gotten the difficult decisions out of the way, use this packet to learn how to best take advantage of your account. Let’s get started!

HOW YOUR FSA WORKS

Your FSA is a spending account that can be used to pay for a variety of healthcare expenses.

TWO GREAT PERKS COME WITH YOUR FSA:

You will have access to your entire election on the first day of the plan year.

The funds are taken out of your paycheck “pre-tax” (meaning they are subtracted from your gross earnings before taxes) throughout the course of the year. That means you are increasing your take-home pay simply by participating!

WHAT CAN I SPEND MY FSA FUNDS ON?

The IRS determines what expenses are eligible under an FSA. Below are some examples of common eligible expenses.

GETTING STARTED CHECKLIST

Use this checklist to take full advantage of all the great resources made available to you through your FSA.

Set up your MyAmeriflex account MyAmeriflex is where you’ll have real-time access to all of your account information, including your current balance, transaction history, payment status, and more. To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

Enroll in MyPlanConnectThere are instances when you may be asked to submit documentation to Ameriflex to verify the eligibility of an expense. MyPlanConnect does the heavy lifting for you by automatically detecting when you swipe your MyAmeriflex Debit Mastercard and matching the purchase with your insurance plan. After enrolling, all of your expenses moving forward will be processed through MyPlanConnect. To enroll, log into your MyAmeriflex account and select “MyPlanConnect.” If you aren't sure if your employer offers MyPlanConnect, please check with your HR department or call our Participant Services department at 888.868.FLEX (3539).

Download mobile app The MyAmeriflex App lets you access and manage your account anywhere you go, 24/7. It puts all of the great features of the MyAmeriflex Portal right at your fingertips. You can download the app on the Apple App Store and Google Play.

Register for complimentary ID theft protection Ameriflex is pleased to offer our cardholders complimentary access to Mastercard’s comprehensive Identity Theft Protection program*, powered by CSID®. You can rest assured knowing that if your MyAmeriflex Debit Mastercard (or any other debit/credit cards you choose to register!) gets misplaced or stolen, you can utilize Mastercard’s industry-leading ID theft protection and restoration services for everything you may need. To register, visit myameriflex.com/IDtheftprotection.

Use your cardYou will receive a MyAmeriflex Debit Mastercard that can be used to make eligible purchases. Your card will be mailed within 7-10 business days after your enrollment is processed by Ameriflex.

Enroll for direct depositBy enrolling for direct deposit, getting reimbursed is easier and faster anytime you need to pay for an eligible expenses out of pocket. Login to MyAmeriflex to set up direct deposit.

Start spendingYou’re ready to make purchases! Be sure to hang on to your receipts anytime you make a purchase. Login to MyAmeriflex for a full list of eligible expenses.

HOW TO GET REIMBURSED FOR OUT-OF-POCKET EXPENSES

As you begin to use your account, it’s important to understand how to submit a request for reimbursement or payment to a provider.

Two most common reasons for requesting a reimbursement or payment:

You paid an eligible expense out of pocket.

To request a payment be made directly to a provider

Your MyAmeriflex Debit Mastercard is the quickest and easiest way to access your account funds. But if you can’t use your card, getting reimbursed is quick and painless.

STEP 1: Login in to your MyAmeriflex account online or through the MyAmeriflex App

STEP 2: Click the Submit Claim button

STEP 3: Fill out all of the required fields and attach documentation

STEP 4: If requesting to pay a provider, enter the provider’s information, including address, and select “Pay Provider.” Once processed, the reimbursement will be sent directly to the provider. You can also save the provider for any future

reimbursements.

STEP 5: Click submit

You can view the status of a pending reimbursement anytime through MyAmeriflex or the MyAmeriflex App. If any further action is needed before the reimbursement is processed, you will receive a message through your account.

REQUEST FOR ADDITIONAL DOCUMENTATION

Due to the tax-advantaged nature of your account, the IRS has guidelines in place to ensure that purchases made with the account are for eligible medical, dental, or vision expenses. There are instances when additional documentation—like itemized receipts–are needed to verify the eligibility of your expenses.

HERE’S HOW IT WORKS:

STEP 1: You make a payment with your MyAmeriflex Debit Mastercard. This could be a copay for a doctor’s visit, prescription, etc. It’s important to note that when you

swipe your card, the provider is paid.

STEP 2: We will attempt to auto-verify the transaction instantly using stored copays, stored recurring expense values, electronic data feeds, or Inventory Information Approval Systems (IIAS).

STEP 3: If the transaction can’t be auto-verified at the point of purchase, this is normally because the merchant’s (e.g. hospital) payment terminal can’t distinguish if the transaction was for surgery (eligible) or flowers from the hospital gift store (not eligible). You’ll receive a notification if we need more information about the expense, such as an itemized receipt or insurance explanation of benefits (EOB). In some cases, a letter of medical necessity may be required for certain eligible expenses (e.g. therapy).

STEP 4: You can login to MyAmeriflex or use the MyAmeriflex App to upload the itemized receipt or EOB. You can also mail, fax, or email a manual claim form, documentation, and the request for documentation letter to:

Email: claims@myameriflex.com Fax: 888.631.1038 (Attention: Claims Department) Mail: Ameriflex Claims Department P.O. Box 269009 Plano, TX 75026

Please do not send original documents. If damaged or lost during processing.

FREQUENTLY ASKED QUESTIONS

How do I check my account balance?You can check your real-time balance online by logging into MyAmeriflex or through the MyAmeriflex Mobile App. Ameriflex also provides 24/7 access to automated account information via telephone. Call 888.868.FLEX (3539) and follow the prompts to listen to balance and transaction information for your account.

How do I access my account?If you’re a new user, setting up your account is easy! To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your MyAmeriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

What expenses are eligible? The IRS, and sometimes your employer, determine what goods and services are eligible. This will vary based on what type of account you have. For more information about your account and expenses eligibility, visit myameriflex.com/participants. Login to MyAmeriflex for a full list of eligible expenses.

How do I order a new card?You can request a free replacement card online through your Ameriflex account or through the MyAmeriflex Mobile App.

What happens if I don’t use my FSA account balance by the end the year?Employers may offer a $500 roll over or 2.5-month grace period to help employees use their unused money at the end of the plan year. If your employer offers a roll over, up to $500 of unused money will carry over to the next plan year. If your employer offers a 2.5-month grace period, you can continue using your unused money 2.5 months into the new plan year. Please refer to your plan documents or contact Ameriflex to verify the specific rules and features associated with your company's plan.

Can I have an FSA and an HSA?You can’t contribute to an FSA and HSA within the same plan year. However, you can contribute to an HSA and a limited purpose FSA, which only covers dental and vision expenses.

How do these programs save me money on taxes?Since the accounts are tax-advantaged, you get to leverage pre-tax payroll deductions -- increasing your take-home pay and saving you money on everyday expenses. In many cases, you can experience savings of up to 40% on expenses eligible under your employer-sponsored plan.

If I leave my employer, can I still use my funds?No, your funds are forfeited if you leave your employer.

What does pre-tax dollars mean and why is this important?Essentially, “pre-taxing,” which can be used for life insurance, disability insurance, health FSA contributions, dependent care contributions, health savings account contributions and commuter account contributions, means taking income that would otherwise be taxable and diverting it to something else before (so: “pre”) is becomes taxable.

By making pre-tax contributions to an FSA, HSA, HRA, you are lowering the amount your income is taxed, which results in taking home a bigger paycheck.

Can I change my annual election amount?FSA elections are irrevocable and cannot be changed during the period of coverage unless there is a permitted change in election event, such as a change in marital status, birth or adoption of a child, change in an employment status, etc. The event and contribution change must coincide.

How can I get more information about my account?There are several options to get more information about your account. For an overview of account features, visit myameriflex.com/participants.

You can manage your account, check your balance, file and claim anytime online through MyAmeriflex or through the MyAmeriflex App.

How can I change my reimbursement setting to add direct deposit?To set up direct deposit, simply login to MyAmeriflex, select reimbursement settings under the my account tab, then enter your banking information. We also offer a paper direct deposit form that can be mailed, faxed, or emailed to Ameriflex.

If you have any questions you can contact the Ameriflex Participant Services team Monday - Friday, 8:30 a.m. - 8:00 p.m. (ET).

Phone: 888.868.FLEX (3539)Email: service@myameriflex.comChat: myameriflex.com

1

2

myameriflex.com/participants

Copays, deductibles, and other payments you are responsible for under your health plan.

Routine exams, dental care, prescription drugs, eye care, and hearing aids.

Prescription glasses and sunglasses.

Certain over-the-counter (OTC) healthcare expenses such as Band-aids, medicine, First Aid supplies, etc. Note: OTC medicines require a doctor’s prescription to be eligible.

Diabetic equipment and supplies, durable medical equipment, and qualified medical products or services provided by a doctor.

57

Getting real about your healthcare savings starts hereYou made a great decision by enrolling in a flexible spending account (FSA)! Now that you’ve gotten the difficult decisions out of the way, use this packet to learn how to best take advantage of your account. Let’s get started!

HOW YOUR FSA WORKS

Your FSA is a spending account that can be used to pay for a variety of healthcare expenses.

TWO GREAT PERKS COME WITH YOUR FSA:

You will have access to your entire election on the first day of the plan year.

The funds are taken out of your paycheck “pre-tax” (meaning they are subtracted from your gross earnings before taxes) throughout the course of the year. That means you are increasing your take-home pay simply by participating!

WHAT CAN I SPEND MY FSA FUNDS ON?

The IRS determines what expenses are eligible under an FSA. Below are some examples of common eligible expenses.

GETTING STARTED CHECKLIST

Use this checklist to take full advantage of all the great resources made available to you through your FSA.

Set up your MyAmeriflex account MyAmeriflex is where you’ll have real-time access to all of your account information, including your current balance, transaction history, payment status, and more. To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

Enroll in MyPlanConnectThere are instances when you may be asked to submit documentation to Ameriflex to verify the eligibility of an expense. MyPlanConnect does the heavy lifting for you by automatically detecting when you swipe your MyAmeriflex Debit Mastercard and matching the purchase with your insurance plan. After enrolling, all of your expenses moving forward will be processed through MyPlanConnect. To enroll, log into your MyAmeriflex account and select “MyPlanConnect.” If you aren't sure if your employer offers MyPlanConnect, please check with your HR department or call our Participant Services department at 888.868.FLEX (3539).

Download mobile app The MyAmeriflex App lets you access and manage your account anywhere you go, 24/7. It puts all of the great features of the MyAmeriflex Portal right at your fingertips. You can download the app on the Apple App Store and Google Play.

Register for complimentary ID theft protection Ameriflex is pleased to offer our cardholders complimentary access to Mastercard’s comprehensive Identity Theft Protection program*, powered by CSID®. You can rest assured knowing that if your MyAmeriflex Debit Mastercard (or any other debit/credit cards you choose to register!) gets misplaced or stolen, you can utilize Mastercard’s industry-leading ID theft protection and restoration services for everything you may need. To register, visit myameriflex.com/IDtheftprotection.

Use your cardYou will receive a MyAmeriflex Debit Mastercard that can be used to make eligible purchases. Your card will be mailed within 7-10 business days after your enrollment is processed by Ameriflex.

Enroll for direct depositBy enrolling for direct deposit, getting reimbursed is easier and faster anytime you need to pay for an eligible expenses out of pocket. Login to MyAmeriflex to set up direct deposit.

Start spendingYou’re ready to make purchases! Be sure to hang on to your receipts anytime you make a purchase. Login to MyAmeriflex for a full list of eligible expenses.

HOW TO GET REIMBURSED FOR OUT-OF-POCKET EXPENSES

As you begin to use your account, it’s important to understand how to submit a request for reimbursement or payment to a provider.

Two most common reasons for requesting a reimbursement or payment:

You paid an eligible expense out of pocket.

To request a payment be made directly to a provider

Your MyAmeriflex Debit Mastercard is the quickest and easiest way to access your account funds. But if you can’t use your card, getting reimbursed is quick and painless.

STEP 1: Login in to your MyAmeriflex account online or through the MyAmeriflex App

STEP 2: Click the Submit Claim button

STEP 3: Fill out all of the required fields and attach documentation

STEP 4: If requesting to pay a provider, enter the provider’s information, including address, and select “Pay Provider.” Once processed, the reimbursement will be sent directly to the provider. You can also save the provider for any future

reimbursements.

STEP 5: Click submit

You can view the status of a pending reimbursement anytime through MyAmeriflex or the MyAmeriflex App. If any further action is needed before the reimbursement is processed, you will receive a message through your account.

REQUEST FOR ADDITIONAL DOCUMENTATION

Due to the tax-advantaged nature of your account, the IRS has guidelines in place to ensure that purchases made with the account are for eligible medical, dental, or vision expenses. There are instances when additional documentation—like itemized receipts–are needed to verify the eligibility of your expenses.

HERE’S HOW IT WORKS:

STEP 1: You make a payment with your MyAmeriflex Debit Mastercard. This could be a copay for a doctor’s visit, prescription, etc. It’s important to note that when you

swipe your card, the provider is paid.

STEP 2: We will attempt to auto-verify the transaction instantly using stored copays, stored recurring expense values, electronic data feeds, or Inventory Information Approval Systems (IIAS).

STEP 3: If the transaction can’t be auto-verified at the point of purchase, this is normally because the merchant’s (e.g. hospital) payment terminal can’t distinguish if the transaction was for surgery (eligible) or flowers from the hospital gift store (not eligible). You’ll receive a notification if we need more information about the expense, such as an itemized receipt or insurance explanation of benefits (EOB). In some cases, a letter of medical necessity may be required for certain eligible expenses (e.g. therapy).

STEP 4: You can login to MyAmeriflex or use the MyAmeriflex App to upload the itemized receipt or EOB. You can also mail, fax, or email a manual claim form, documentation, and the request for documentation letter to:

Email: claims@myameriflex.com Fax: 888.631.1038 (Attention: Claims Department) Mail: Ameriflex Claims Department P.O. Box 269009 Plano, TX 75026

Please do not send original documents. If damaged or lost during processing.

FREQUENTLY ASKED QUESTIONS

How do I check my account balance?You can check your real-time balance online by logging into MyAmeriflex or through the MyAmeriflex Mobile App. Ameriflex also provides 24/7 access to automated account information via telephone. Call 888.868.FLEX (3539) and follow the prompts to listen to balance and transaction information for your account.

How do I access my account?If you’re a new user, setting up your account is easy! To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your MyAmeriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

What expenses are eligible? The IRS, and sometimes your employer, determine what goods and services are eligible. This will vary based on what type of account you have. For more information about your account and expenses eligibility, visit myameriflex.com/participants. Login to MyAmeriflex for a full list of eligible expenses.

How do I order a new card?You can request a free replacement card online through your Ameriflex account or through the MyAmeriflex Mobile App.

What happens if I don’t use my FSA account balance by the end the year?Employers may offer a $500 roll over or 2.5-month grace period to help employees use their unused money at the end of the plan year. If your employer offers a roll over, up to $500 of unused money will carry over to the next plan year. If your employer offers a 2.5-month grace period, you can continue using your unused money 2.5 months into the new plan year. Please refer to your plan documents or contact Ameriflex to verify the specific rules and features associated with your company's plan.

Can I have an FSA and an HSA?You can’t contribute to an FSA and HSA within the same plan year. However, you can contribute to an HSA and a limited purpose FSA, which only covers dental and vision expenses.

How do these programs save me money on taxes?Since the accounts are tax-advantaged, you get to leverage pre-tax payroll deductions -- increasing your take-home pay and saving you money on everyday expenses. In many cases, you can experience savings of up to 40% on expenses eligible under your employer-sponsored plan.

If I leave my employer, can I still use my funds?No, your funds are forfeited if you leave your employer.

What does pre-tax dollars mean and why is this important?Essentially, “pre-taxing,” which can be used for life insurance, disability insurance, health FSA contributions, dependent care contributions, health savings account contributions and commuter account contributions, means taking income that would otherwise be taxable and diverting it to something else before (so: “pre”) is becomes taxable.

By making pre-tax contributions to an FSA, HSA, HRA, you are lowering the amount your income is taxed, which results in taking home a bigger paycheck.

Can I change my annual election amount?FSA elections are irrevocable and cannot be changed during the period of coverage unless there is a permitted change in election event, such as a change in marital status, birth or adoption of a child, change in an employment status, etc. The event and contribution change must coincide.

How can I get more information about my account?There are several options to get more information about your account. For an overview of account features, visit myameriflex.com/participants.

You can manage your account, check your balance, file and claim anytime online through MyAmeriflex or through the MyAmeriflex App.

How can I change my reimbursement setting to add direct deposit?To set up direct deposit, simply login to MyAmeriflex, select reimbursement settings under the my account tab, then enter your banking information. We also offer a paper direct deposit form that can be mailed, faxed, or emailed to Ameriflex.

If you have any questions you can contact the Ameriflex Participant Services team Monday - Friday, 8:30 a.m. - 8:00 p.m. (ET).

Phone: 888.868.FLEX (3539)Email: service@myameriflex.comChat: myameriflex.com

myameriflex.com/participants

1

2

3

4

5

6

7

58

Getting real about your healthcare savings starts hereYou made a great decision by enrolling in a flexible spending account (FSA)! Now that you’ve gotten the difficult decisions out of the way, use this packet to learn how to best take advantage of your account. Let’s get started!

HOW YOUR FSA WORKS

Your FSA is a spending account that can be used to pay for a variety of healthcare expenses.

TWO GREAT PERKS COME WITH YOUR FSA:

You will have access to your entire election on the first day of the plan year.

The funds are taken out of your paycheck “pre-tax” (meaning they are subtracted from your gross earnings before taxes) throughout the course of the year. That means you are increasing your take-home pay simply by participating!

WHAT CAN I SPEND MY FSA FUNDS ON?

The IRS determines what expenses are eligible under an FSA. Below are some examples of common eligible expenses.

GETTING STARTED CHECKLIST

Use this checklist to take full advantage of all the great resources made available to you through your FSA.

Set up your MyAmeriflex account MyAmeriflex is where you’ll have real-time access to all of your account information, including your current balance, transaction history, payment status, and more. To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

Enroll in MyPlanConnectThere are instances when you may be asked to submit documentation to Ameriflex to verify the eligibility of an expense. MyPlanConnect does the heavy lifting for you by automatically detecting when you swipe your MyAmeriflex Debit Mastercard and matching the purchase with your insurance plan. After enrolling, all of your expenses moving forward will be processed through MyPlanConnect. To enroll, log into your MyAmeriflex account and select “MyPlanConnect.” If you aren't sure if your employer offers MyPlanConnect, please check with your HR department or call our Participant Services department at 888.868.FLEX (3539).

Download mobile app The MyAmeriflex App lets you access and manage your account anywhere you go, 24/7. It puts all of the great features of the MyAmeriflex Portal right at your fingertips. You can download the app on the Apple App Store and Google Play.

Register for complimentary ID theft protection Ameriflex is pleased to offer our cardholders complimentary access to Mastercard’s comprehensive Identity Theft Protection program*, powered by CSID®. You can rest assured knowing that if your MyAmeriflex Debit Mastercard (or any other debit/credit cards you choose to register!) gets misplaced or stolen, you can utilize Mastercard’s industry-leading ID theft protection and restoration services for everything you may need. To register, visit myameriflex.com/IDtheftprotection.

Use your cardYou will receive a MyAmeriflex Debit Mastercard that can be used to make eligible purchases. Your card will be mailed within 7-10 business days after your enrollment is processed by Ameriflex.

Enroll for direct depositBy enrolling for direct deposit, getting reimbursed is easier and faster anytime you need to pay for an eligible expenses out of pocket. Login to MyAmeriflex to set up direct deposit.

Start spendingYou’re ready to make purchases! Be sure to hang on to your receipts anytime you make a purchase. Login to MyAmeriflex for a full list of eligible expenses.

HOW TO GET REIMBURSED FOR OUT-OF-POCKET EXPENSES

As you begin to use your account, it’s important to understand how to submit a request for reimbursement or payment to a provider.

Two most common reasons for requesting a reimbursement or payment:

You paid an eligible expense out of pocket.

To request a payment be made directly to a provider

Your MyAmeriflex Debit Mastercard is the quickest and easiest way to access your account funds. But if you can’t use your card, getting reimbursed is quick and painless.

STEP 1: Login in to your MyAmeriflex account online or through the MyAmeriflex App

STEP 2: Click the Submit Claim button

STEP 3: Fill out all of the required fields and attach documentation

STEP 4: If requesting to pay a provider, enter the provider’s information, including address, and select “Pay Provider.” Once processed, the reimbursement will be sent directly to the provider. You can also save the provider for any future

reimbursements.

STEP 5: Click submit

You can view the status of a pending reimbursement anytime through MyAmeriflex or the MyAmeriflex App. If any further action is needed before the reimbursement is processed, you will receive a message through your account.

REQUEST FOR ADDITIONAL DOCUMENTATION

Due to the tax-advantaged nature of your account, the IRS has guidelines in place to ensure that purchases made with the account are for eligible medical, dental, or vision expenses. There are instances when additional documentation—like itemized receipts–are needed to verify the eligibility of your expenses.

HERE’S HOW IT WORKS:

STEP 1: You make a payment with your MyAmeriflex Debit Mastercard. This could be a copay for a doctor’s visit, prescription, etc. It’s important to note that when you

swipe your card, the provider is paid.

STEP 2: We will attempt to auto-verify the transaction instantly using stored copays, stored recurring expense values, electronic data feeds, or Inventory Information Approval Systems (IIAS).

STEP 3: If the transaction can’t be auto-verified at the point of purchase, this is normally because the merchant’s (e.g. hospital) payment terminal can’t distinguish if the transaction was for surgery (eligible) or flowers from the hospital gift store (not eligible). You’ll receive a notification if we need more information about the expense, such as an itemized receipt or insurance explanation of benefits (EOB). In some cases, a letter of medical necessity may be required for certain eligible expenses (e.g. therapy).

STEP 4: You can login to MyAmeriflex or use the MyAmeriflex App to upload the itemized receipt or EOB. You can also mail, fax, or email a manual claim form, documentation, and the request for documentation letter to:

Email: claims@myameriflex.com Fax: 888.631.1038 (Attention: Claims Department) Mail: Ameriflex Claims Department P.O. Box 269009 Plano, TX 75026

Please do not send original documents. If damaged or lost during processing.

FREQUENTLY ASKED QUESTIONS

How do I check my account balance?You can check your real-time balance online by logging into MyAmeriflex or through the MyAmeriflex Mobile App. Ameriflex also provides 24/7 access to automated account information via telephone. Call 888.868.FLEX (3539) and follow the prompts to listen to balance and transaction information for your account.

How do I access my account?If you’re a new user, setting up your account is easy! To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your MyAmeriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

What expenses are eligible? The IRS, and sometimes your employer, determine what goods and services are eligible. This will vary based on what type of account you have. For more information about your account and expenses eligibility, visit myameriflex.com/participants. Login to MyAmeriflex for a full list of eligible expenses.

How do I order a new card?You can request a free replacement card online through your Ameriflex account or through the MyAmeriflex Mobile App.

What happens if I don’t use my FSA account balance by the end the year?Employers may offer a $500 roll over or 2.5-month grace period to help employees use their unused money at the end of the plan year. If your employer offers a roll over, up to $500 of unused money will carry over to the next plan year. If your employer offers a 2.5-month grace period, you can continue using your unused money 2.5 months into the new plan year. Please refer to your plan documents or contact Ameriflex to verify the specific rules and features associated with your company's plan.

Can I have an FSA and an HSA?You can’t contribute to an FSA and HSA within the same plan year. However, you can contribute to an HSA and a limited purpose FSA, which only covers dental and vision expenses.

How do these programs save me money on taxes?Since the accounts are tax-advantaged, you get to leverage pre-tax payroll deductions -- increasing your take-home pay and saving you money on everyday expenses. In many cases, you can experience savings of up to 40% on expenses eligible under your employer-sponsored plan.

If I leave my employer, can I still use my funds?No, your funds are forfeited if you leave your employer.

What does pre-tax dollars mean and why is this important?Essentially, “pre-taxing,” which can be used for life insurance, disability insurance, health FSA contributions, dependent care contributions, health savings account contributions and commuter account contributions, means taking income that would otherwise be taxable and diverting it to something else before (so: “pre”) is becomes taxable.

By making pre-tax contributions to an FSA, HSA, HRA, you are lowering the amount your income is taxed, which results in taking home a bigger paycheck.

Can I change my annual election amount?FSA elections are irrevocable and cannot be changed during the period of coverage unless there is a permitted change in election event, such as a change in marital status, birth or adoption of a child, change in an employment status, etc. The event and contribution change must coincide.

How can I get more information about my account?There are several options to get more information about your account. For an overview of account features, visit myameriflex.com/participants.

You can manage your account, check your balance, file and claim anytime online through MyAmeriflex or through the MyAmeriflex App.

How can I change my reimbursement setting to add direct deposit?To set up direct deposit, simply login to MyAmeriflex, select reimbursement settings under the my account tab, then enter your banking information. We also offer a paper direct deposit form that can be mailed, faxed, or emailed to Ameriflex.

If you have any questions you can contact the Ameriflex Participant Services team Monday - Friday, 8:30 a.m. - 8:00 p.m. (ET).

Phone: 888.868.FLEX (3539)Email: service@myameriflex.comChat: myameriflex.com

1

2

myameriflex.com/participants59

Getting real about your healthcare savings starts hereYou made a great decision by enrolling in a flexible spending account (FSA)! Now that you’ve gotten the difficult decisions out of the way, use this packet to learn how to best take advantage of your account. Let’s get started!

HOW YOUR FSA WORKS

Your FSA is a spending account that can be used to pay for a variety of healthcare expenses.

TWO GREAT PERKS COME WITH YOUR FSA:

You will have access to your entire election on the first day of the plan year.

The funds are taken out of your paycheck “pre-tax” (meaning they are subtracted from your gross earnings before taxes) throughout the course of the year. That means you are increasing your take-home pay simply by participating!

WHAT CAN I SPEND MY FSA FUNDS ON?

The IRS determines what expenses are eligible under an FSA. Below are some examples of common eligible expenses.

GETTING STARTED CHECKLIST

Use this checklist to take full advantage of all the great resources made available to you through your FSA.

Set up your MyAmeriflex account MyAmeriflex is where you’ll have real-time access to all of your account information, including your current balance, transaction history, payment status, and more. To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

Enroll in MyPlanConnectThere are instances when you may be asked to submit documentation to Ameriflex to verify the eligibility of an expense. MyPlanConnect does the heavy lifting for you by automatically detecting when you swipe your MyAmeriflex Debit Mastercard and matching the purchase with your insurance plan. After enrolling, all of your expenses moving forward will be processed through MyPlanConnect. To enroll, log into your MyAmeriflex account and select “MyPlanConnect.” If you aren't sure if your employer offers MyPlanConnect, please check with your HR department or call our Participant Services department at 888.868.FLEX (3539).

Download mobile app The MyAmeriflex App lets you access and manage your account anywhere you go, 24/7. It puts all of the great features of the MyAmeriflex Portal right at your fingertips. You can download the app on the Apple App Store and Google Play.

Register for complimentary ID theft protection Ameriflex is pleased to offer our cardholders complimentary access to Mastercard’s comprehensive Identity Theft Protection program*, powered by CSID®. You can rest assured knowing that if your MyAmeriflex Debit Mastercard (or any other debit/credit cards you choose to register!) gets misplaced or stolen, you can utilize Mastercard’s industry-leading ID theft protection and restoration services for everything you may need. To register, visit myameriflex.com/IDtheftprotection.

Use your cardYou will receive a MyAmeriflex Debit Mastercard that can be used to make eligible purchases. Your card will be mailed within 7-10 business days after your enrollment is processed by Ameriflex.

Enroll for direct depositBy enrolling for direct deposit, getting reimbursed is easier and faster anytime you need to pay for an eligible expenses out of pocket. Login to MyAmeriflex to set up direct deposit.

Start spendingYou’re ready to make purchases! Be sure to hang on to your receipts anytime you make a purchase. Login to MyAmeriflex for a full list of eligible expenses.

HOW TO GET REIMBURSED FOR OUT-OF-POCKET EXPENSES

As you begin to use your account, it’s important to understand how to submit a request for reimbursement or payment to a provider.

Two most common reasons for requesting a reimbursement or payment:

You paid an eligible expense out of pocket.

To request a payment be made directly to a provider

Your MyAmeriflex Debit Mastercard is the quickest and easiest way to access your account funds. But if you can’t use your card, getting reimbursed is quick and painless.

STEP 1: Login in to your MyAmeriflex account online or through the MyAmeriflex App

STEP 2: Click the Submit Claim button

STEP 3: Fill out all of the required fields and attach documentation

STEP 4: If requesting to pay a provider, enter the provider’s information, including address, and select “Pay Provider.” Once processed, the reimbursement will be sent directly to the provider. You can also save the provider for any future

reimbursements.

STEP 5: Click submit

You can view the status of a pending reimbursement anytime through MyAmeriflex or the MyAmeriflex App. If any further action is needed before the reimbursement is processed, you will receive a message through your account.

REQUEST FOR ADDITIONAL DOCUMENTATION

Due to the tax-advantaged nature of your account, the IRS has guidelines in place to ensure that purchases made with the account are for eligible medical, dental, or vision expenses. There are instances when additional documentation—like itemized receipts–are needed to verify the eligibility of your expenses.

HERE’S HOW IT WORKS:

STEP 1: You make a payment with your MyAmeriflex Debit Mastercard. This could be a copay for a doctor’s visit, prescription, etc. It’s important to note that when you

swipe your card, the provider is paid.

STEP 2: We will attempt to auto-verify the transaction instantly using stored copays, stored recurring expense values, electronic data feeds, or Inventory Information Approval Systems (IIAS).

STEP 3: If the transaction can’t be auto-verified at the point of purchase, this is normally because the merchant’s (e.g. hospital) payment terminal can’t distinguish if the transaction was for surgery (eligible) or flowers from the hospital gift store (not eligible). You’ll receive a notification if we need more information about the expense, such as an itemized receipt or insurance explanation of benefits (EOB). In some cases, a letter of medical necessity may be required for certain eligible expenses (e.g. therapy).

STEP 4: You can login to MyAmeriflex or use the MyAmeriflex App to upload the itemized receipt or EOB. You can also mail, fax, or email a manual claim form, documentation, and the request for documentation letter to:

Email: claims@myameriflex.com Fax: 888.631.1038 (Attention: Claims Department) Mail: Ameriflex Claims Department P.O. Box 269009 Plano, TX 75026

Please do not send original documents. If damaged or lost during processing.

FREQUENTLY ASKED QUESTIONS

How do I check my account balance?You can check your real-time balance online by logging into MyAmeriflex or through the MyAmeriflex Mobile App. Ameriflex also provides 24/7 access to automated account information via telephone. Call 888.868.FLEX (3539) and follow the prompts to listen to balance and transaction information for your account.

How do I access my account?If you’re a new user, setting up your account is easy! To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your MyAmeriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

What expenses are eligible? The IRS, and sometimes your employer, determine what goods and services are eligible. This will vary based on what type of account you have. For more information about your account and expenses eligibility, visit myameriflex.com/participants. Login to MyAmeriflex for a full list of eligible expenses.

How do I order a new card?You can request a free replacement card online through your Ameriflex account or through the MyAmeriflex Mobile App.

What happens if I don’t use my FSA account balance by the end the year?Employers may offer a $500 roll over or 2.5-month grace period to help employees use their unused money at the end of the plan year. If your employer offers a roll over, up to $500 of unused money will carry over to the next plan year. If your employer offers a 2.5-month grace period, you can continue using your unused money 2.5 months into the new plan year. Please refer to your plan documents or contact Ameriflex to verify the specific rules and features associated with your company's plan.

Can I have an FSA and an HSA?You can’t contribute to an FSA and HSA within the same plan year. However, you can contribute to an HSA and a limited purpose FSA, which only covers dental and vision expenses.

How do these programs save me money on taxes?Since the accounts are tax-advantaged, you get to leverage pre-tax payroll deductions -- increasing your take-home pay and saving you money on everyday expenses. In many cases, you can experience savings of up to 40% on expenses eligible under your employer-sponsored plan.

If I leave my employer, can I still use my funds?No, your funds are forfeited if you leave your employer.

What does pre-tax dollars mean and why is this important?Essentially, “pre-taxing,” which can be used for life insurance, disability insurance, health FSA contributions, dependent care contributions, health savings account contributions and commuter account contributions, means taking income that would otherwise be taxable and diverting it to something else before (so: “pre”) is becomes taxable.

By making pre-tax contributions to an FSA, HSA, HRA, you are lowering the amount your income is taxed, which results in taking home a bigger paycheck.

Can I change my annual election amount?FSA elections are irrevocable and cannot be changed during the period of coverage unless there is a permitted change in election event, such as a change in marital status, birth or adoption of a child, change in an employment status, etc. The event and contribution change must coincide.

How can I get more information about my account?There are several options to get more information about your account. For an overview of account features, visit myameriflex.com/participants.

You can manage your account, check your balance, file and claim anytime online through MyAmeriflex or through the MyAmeriflex App.

How can I change my reimbursement setting to add direct deposit?To set up direct deposit, simply login to MyAmeriflex, select reimbursement settings under the my account tab, then enter your banking information. We also offer a paper direct deposit form that can be mailed, faxed, or emailed to Ameriflex.

If you have any questions you can contact the Ameriflex Participant Services team Monday - Friday, 8:30 a.m. - 8:00 p.m. (ET).

Phone: 888.868.FLEX (3539)Email: service@myameriflex.comChat: myameriflex.com

myameriflex.com/participants60

Getting real about your healthcare savings starts hereYou made a great decision by enrolling in a flexible spending account (FSA)! Now that you’ve gotten the difficult decisions out of the way, use this packet to learn how to best take advantage of your account. Let’s get started!

HOW YOUR FSA WORKS

Your FSA is a spending account that can be used to pay for a variety of healthcare expenses.

TWO GREAT PERKS COME WITH YOUR FSA:

You will have access to your entire election on the first day of the plan year.

The funds are taken out of your paycheck “pre-tax” (meaning they are subtracted from your gross earnings before taxes) throughout the course of the year. That means you are increasing your take-home pay simply by participating!

WHAT CAN I SPEND MY FSA FUNDS ON?

The IRS determines what expenses are eligible under an FSA. Below are some examples of common eligible expenses.

GETTING STARTED CHECKLIST

Use this checklist to take full advantage of all the great resources made available to you through your FSA.

Set up your MyAmeriflex account MyAmeriflex is where you’ll have real-time access to all of your account information, including your current balance, transaction history, payment status, and more. To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

Enroll in MyPlanConnectThere are instances when you may be asked to submit documentation to Ameriflex to verify the eligibility of an expense. MyPlanConnect does the heavy lifting for you by automatically detecting when you swipe your MyAmeriflex Debit Mastercard and matching the purchase with your insurance plan. After enrolling, all of your expenses moving forward will be processed through MyPlanConnect. To enroll, log into your MyAmeriflex account and select “MyPlanConnect.” If you aren't sure if your employer offers MyPlanConnect, please check with your HR department or call our Participant Services department at 888.868.FLEX (3539).

Download mobile app The MyAmeriflex App lets you access and manage your account anywhere you go, 24/7. It puts all of the great features of the MyAmeriflex Portal right at your fingertips. You can download the app on the Apple App Store and Google Play.

Register for complimentary ID theft protection Ameriflex is pleased to offer our cardholders complimentary access to Mastercard’s comprehensive Identity Theft Protection program*, powered by CSID®. You can rest assured knowing that if your MyAmeriflex Debit Mastercard (or any other debit/credit cards you choose to register!) gets misplaced or stolen, you can utilize Mastercard’s industry-leading ID theft protection and restoration services for everything you may need. To register, visit myameriflex.com/IDtheftprotection.

Use your cardYou will receive a MyAmeriflex Debit Mastercard that can be used to make eligible purchases. Your card will be mailed within 7-10 business days after your enrollment is processed by Ameriflex.

Enroll for direct depositBy enrolling for direct deposit, getting reimbursed is easier and faster anytime you need to pay for an eligible expenses out of pocket. Login to MyAmeriflex to set up direct deposit.

Start spendingYou’re ready to make purchases! Be sure to hang on to your receipts anytime you make a purchase. Login to MyAmeriflex for a full list of eligible expenses.

HOW TO GET REIMBURSED FOR OUT-OF-POCKET EXPENSES

As you begin to use your account, it’s important to understand how to submit a request for reimbursement or payment to a provider.

Two most common reasons for requesting a reimbursement or payment:

You paid an eligible expense out of pocket.

To request a payment be made directly to a provider

Your MyAmeriflex Debit Mastercard is the quickest and easiest way to access your account funds. But if you can’t use your card, getting reimbursed is quick and painless.

STEP 1: Login in to your MyAmeriflex account online or through the MyAmeriflex App

STEP 2: Click the Submit Claim button

STEP 3: Fill out all of the required fields and attach documentation

STEP 4: If requesting to pay a provider, enter the provider’s information, including address, and select “Pay Provider.” Once processed, the reimbursement will be sent directly to the provider. You can also save the provider for any future

reimbursements.

STEP 5: Click submit

You can view the status of a pending reimbursement anytime through MyAmeriflex or the MyAmeriflex App. If any further action is needed before the reimbursement is processed, you will receive a message through your account.

REQUEST FOR ADDITIONAL DOCUMENTATION

Due to the tax-advantaged nature of your account, the IRS has guidelines in place to ensure that purchases made with the account are for eligible medical, dental, or vision expenses. There are instances when additional documentation—like itemized receipts–are needed to verify the eligibility of your expenses.

HERE’S HOW IT WORKS:

STEP 1: You make a payment with your MyAmeriflex Debit Mastercard. This could be a copay for a doctor’s visit, prescription, etc. It’s important to note that when you

swipe your card, the provider is paid.

STEP 2: We will attempt to auto-verify the transaction instantly using stored copays, stored recurring expense values, electronic data feeds, or Inventory Information Approval Systems (IIAS).

STEP 3: If the transaction can’t be auto-verified at the point of purchase, this is normally because the merchant’s (e.g. hospital) payment terminal can’t distinguish if the transaction was for surgery (eligible) or flowers from the hospital gift store (not eligible). You’ll receive a notification if we need more information about the expense, such as an itemized receipt or insurance explanation of benefits (EOB). In some cases, a letter of medical necessity may be required for certain eligible expenses (e.g. therapy).

STEP 4: You can login to MyAmeriflex or use the MyAmeriflex App to upload the itemized receipt or EOB. You can also mail, fax, or email a manual claim form, documentation, and the request for documentation letter to:

Email: claims@myameriflex.com Fax: 888.631.1038 (Attention: Claims Department) Mail: Ameriflex Claims Department P.O. Box 269009 Plano, TX 75026

Please do not send original documents. If damaged or lost during processing.

FREQUENTLY ASKED QUESTIONS

How do I check my account balance?You can check your real-time balance online by logging into MyAmeriflex or through the MyAmeriflex Mobile App. Ameriflex also provides 24/7 access to automated account information via telephone. Call 888.868.FLEX (3539) and follow the prompts to listen to balance and transaction information for your account.

How do I access my account?If you’re a new user, setting up your account is easy! To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your MyAmeriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

What expenses are eligible? The IRS, and sometimes your employer, determine what goods and services are eligible. This will vary based on what type of account you have. For more information about your account and expenses eligibility, visit myameriflex.com/participants. Login to MyAmeriflex for a full list of eligible expenses.

How do I order a new card?You can request a free replacement card online through your Ameriflex account or through the MyAmeriflex Mobile App.

What happens if I don’t use my FSA account balance by the end the year?Employers may offer a $500 roll over or 2.5-month grace period to help employees use their unused money at the end of the plan year. If your employer offers a roll over, up to $500 of unused money will carry over to the next plan year. If your employer offers a 2.5-month grace period, you can continue using your unused money 2.5 months into the new plan year. Please refer to your plan documents or contact Ameriflex to verify the specific rules and features associated with your company's plan.

Can I have an FSA and an HSA?You can’t contribute to an FSA and HSA within the same plan year. However, you can contribute to an HSA and a limited purpose FSA, which only covers dental and vision expenses.

How do these programs save me money on taxes?Since the accounts are tax-advantaged, you get to leverage pre-tax payroll deductions -- increasing your take-home pay and saving you money on everyday expenses. In many cases, you can experience savings of up to 40% on expenses eligible under your employer-sponsored plan.

If I leave my employer, can I still use my funds?No, your funds are forfeited if you leave your employer.

What does pre-tax dollars mean and why is this important?Essentially, “pre-taxing,” which can be used for life insurance, disability insurance, health FSA contributions, dependent care contributions, health savings account contributions and commuter account contributions, means taking income that would otherwise be taxable and diverting it to something else before (so: “pre”) is becomes taxable.

By making pre-tax contributions to an FSA, HSA, HRA, you are lowering the amount your income is taxed, which results in taking home a bigger paycheck.

Can I change my annual election amount?FSA elections are irrevocable and cannot be changed during the period of coverage unless there is a permitted change in election event, such as a change in marital status, birth or adoption of a child, change in an employment status, etc. The event and contribution change must coincide.

How can I get more information about my account?There are several options to get more information about your account. For an overview of account features, visit myameriflex.com/participants.

You can manage your account, check your balance, file and claim anytime online through MyAmeriflex or through the MyAmeriflex App.

How can I change my reimbursement setting to add direct deposit?To set up direct deposit, simply login to MyAmeriflex, select reimbursement settings under the my account tab, then enter your banking information. We also offer a paper direct deposit form that can be mailed, faxed, or emailed to Ameriflex.

If you have any questions you can contact the Ameriflex Participant Services team Monday - Friday, 8:30 a.m. - 8:00 p.m. (ET).

Phone: 888.868.FLEX (3539)Email: service@myameriflex.comChat: myameriflex.com

myameriflex.com/participants61

Getting real about your healthcare savings starts hereYou made a great decision by enrolling in a flexible spending account (FSA)! Now that you’ve gotten the difficult decisions out of the way, use this packet to learn how to best take advantage of your account. Let’s get started!

HOW YOUR FSA WORKS

Your FSA is a spending account that can be used to pay for a variety of healthcare expenses.

TWO GREAT PERKS COME WITH YOUR FSA:

You will have access to your entire election on the first day of the plan year.

The funds are taken out of your paycheck “pre-tax” (meaning they are subtracted from your gross earnings before taxes) throughout the course of the year. That means you are increasing your take-home pay simply by participating!

WHAT CAN I SPEND MY FSA FUNDS ON?

The IRS determines what expenses are eligible under an FSA. Below are some examples of common eligible expenses.

GETTING STARTED CHECKLIST

Use this checklist to take full advantage of all the great resources made available to you through your FSA.

Set up your MyAmeriflex account MyAmeriflex is where you’ll have real-time access to all of your account information, including your current balance, transaction history, payment status, and more. To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

Enroll in MyPlanConnectThere are instances when you may be asked to submit documentation to Ameriflex to verify the eligibility of an expense. MyPlanConnect does the heavy lifting for you by automatically detecting when you swipe your MyAmeriflex Debit Mastercard and matching the purchase with your insurance plan. After enrolling, all of your expenses moving forward will be processed through MyPlanConnect. To enroll, log into your MyAmeriflex account and select “MyPlanConnect.” If you aren't sure if your employer offers MyPlanConnect, please check with your HR department or call our Participant Services department at 888.868.FLEX (3539).

Download mobile app The MyAmeriflex App lets you access and manage your account anywhere you go, 24/7. It puts all of the great features of the MyAmeriflex Portal right at your fingertips. You can download the app on the Apple App Store and Google Play.

Register for complimentary ID theft protection Ameriflex is pleased to offer our cardholders complimentary access to Mastercard’s comprehensive Identity Theft Protection program*, powered by CSID®. You can rest assured knowing that if your MyAmeriflex Debit Mastercard (or any other debit/credit cards you choose to register!) gets misplaced or stolen, you can utilize Mastercard’s industry-leading ID theft protection and restoration services for everything you may need. To register, visit myameriflex.com/IDtheftprotection.

Use your cardYou will receive a MyAmeriflex Debit Mastercard that can be used to make eligible purchases. Your card will be mailed within 7-10 business days after your enrollment is processed by Ameriflex.

Enroll for direct depositBy enrolling for direct deposit, getting reimbursed is easier and faster anytime you need to pay for an eligible expenses out of pocket. Login to MyAmeriflex to set up direct deposit.

Start spendingYou’re ready to make purchases! Be sure to hang on to your receipts anytime you make a purchase. Login to MyAmeriflex for a full list of eligible expenses.

HOW TO GET REIMBURSED FOR OUT-OF-POCKET EXPENSES

As you begin to use your account, it’s important to understand how to submit a request for reimbursement or payment to a provider.

Two most common reasons for requesting a reimbursement or payment:

You paid an eligible expense out of pocket.

To request a payment be made directly to a provider

Your MyAmeriflex Debit Mastercard is the quickest and easiest way to access your account funds. But if you can’t use your card, getting reimbursed is quick and painless.

STEP 1: Login in to your MyAmeriflex account online or through the MyAmeriflex App

STEP 2: Click the Submit Claim button

STEP 3: Fill out all of the required fields and attach documentation

STEP 4: If requesting to pay a provider, enter the provider’s information, including address, and select “Pay Provider.” Once processed, the reimbursement will be sent directly to the provider. You can also save the provider for any future

reimbursements.

STEP 5: Click submit

You can view the status of a pending reimbursement anytime through MyAmeriflex or the MyAmeriflex App. If any further action is needed before the reimbursement is processed, you will receive a message through your account.

REQUEST FOR ADDITIONAL DOCUMENTATION

Due to the tax-advantaged nature of your account, the IRS has guidelines in place to ensure that purchases made with the account are for eligible medical, dental, or vision expenses. There are instances when additional documentation—like itemized receipts–are needed to verify the eligibility of your expenses.

HERE’S HOW IT WORKS:

STEP 1: You make a payment with your MyAmeriflex Debit Mastercard. This could be a copay for a doctor’s visit, prescription, etc. It’s important to note that when you

swipe your card, the provider is paid.

STEP 2: We will attempt to auto-verify the transaction instantly using stored copays, stored recurring expense values, electronic data feeds, or Inventory Information Approval Systems (IIAS).

STEP 3: If the transaction can’t be auto-verified at the point of purchase, this is normally because the merchant’s (e.g. hospital) payment terminal can’t distinguish if the transaction was for surgery (eligible) or flowers from the hospital gift store (not eligible). You’ll receive a notification if we need more information about the expense, such as an itemized receipt or insurance explanation of benefits (EOB). In some cases, a letter of medical necessity may be required for certain eligible expenses (e.g. therapy).

STEP 4: You can login to MyAmeriflex or use the MyAmeriflex App to upload the itemized receipt or EOB. You can also mail, fax, or email a manual claim form, documentation, and the request for documentation letter to:

Email: claims@myameriflex.com Fax: 888.631.1038 (Attention: Claims Department) Mail: Ameriflex Claims Department P.O. Box 269009 Plano, TX 75026

Please do not send original documents. If damaged or lost during processing.

FREQUENTLY ASKED QUESTIONS

How do I check my account balance?You can check your real-time balance online by logging into MyAmeriflex or through the MyAmeriflex Mobile App. Ameriflex also provides 24/7 access to automated account information via telephone. Call 888.868.FLEX (3539) and follow the prompts to listen to balance and transaction information for your account.

How do I access my account?If you’re a new user, setting up your account is easy! To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your MyAmeriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

What expenses are eligible? The IRS, and sometimes your employer, determine what goods and services are eligible. This will vary based on what type of account you have. For more information about your account and expenses eligibility, visit myameriflex.com/participants. Login to MyAmeriflex for a full list of eligible expenses.

How do I order a new card?You can request a free replacement card online through your Ameriflex account or through the MyAmeriflex Mobile App.

What happens if I don’t use my FSA account balance by the end the year?Employers may offer a $500 roll over or 2.5-month grace period to help employees use their unused money at the end of the plan year. If your employer offers a roll over, up to $500 of unused money will carry over to the next plan year. If your employer offers a 2.5-month grace period, you can continue using your unused money 2.5 months into the new plan year. Please refer to your plan documents or contact Ameriflex to verify the specific rules and features associated with your company's plan.

Can I have an FSA and an HSA?You can’t contribute to an FSA and HSA within the same plan year. However, you can contribute to an HSA and a limited purpose FSA, which only covers dental and vision expenses.

How do these programs save me money on taxes?Since the accounts are tax-advantaged, you get to leverage pre-tax payroll deductions -- increasing your take-home pay and saving you money on everyday expenses. In many cases, you can experience savings of up to 40% on expenses eligible under your employer-sponsored plan.

If I leave my employer, can I still use my funds?No, your funds are forfeited if you leave your employer.

What does pre-tax dollars mean and why is this important?Essentially, “pre-taxing,” which can be used for life insurance, disability insurance, health FSA contributions, dependent care contributions, health savings account contributions and commuter account contributions, means taking income that would otherwise be taxable and diverting it to something else before (so: “pre”) is becomes taxable.

By making pre-tax contributions to an FSA, HSA, HRA, you are lowering the amount your income is taxed, which results in taking home a bigger paycheck.

Can I change my annual election amount?FSA elections are irrevocable and cannot be changed during the period of coverage unless there is a permitted change in election event, such as a change in marital status, birth or adoption of a child, change in an employment status, etc. The event and contribution change must coincide.

How can I get more information about my account?There are several options to get more information about your account. For an overview of account features, visit myameriflex.com/participants.

You can manage your account, check your balance, file and claim anytime online through MyAmeriflex or through the MyAmeriflex App.

How can I change my reimbursement setting to add direct deposit?To set up direct deposit, simply login to MyAmeriflex, select reimbursement settings under the my account tab, then enter your banking information. We also offer a paper direct deposit form that can be mailed, faxed, or emailed to Ameriflex.

If you have any questions you can contact the Ameriflex Participant Services team Monday - Friday, 8:30 a.m. - 8:00 p.m. (ET).

Phone: 888.868.FLEX (3539)Email: service@myameriflex.comChat: myameriflex.com

myameriflex.com/participants62

Getting real about your healthcare savings starts hereYou made a great decision by enrolling in a dependent care account (DCA)! Now that you’ve gotten the difficult decisions out of the way, use this packet to learn how to best take advantage of your account. Let’s get started!

HOW YOUR DCA WORKS

Your DCA is a spending account that can be used to pay for services like daycare, nurs-ery school, and elder care. By simply participating in a DCA, you get to experience benefits like:

A higher take-home pay thanks to your pre-tax payroll deductions

Savings on daycare and other dependent care services you’re already paying for

Easy-to-use MyAmeriflex Debit Mastercard to make purchases

WHAT CAN I SPEND MY DCA FUNDS ON?IThe IRS determines what expenses are eligible under a DCA. Here are some examples of common eligible expenses

GETTING STARTED CHECKLIST

Use this checklist to take full advantage of all the great resources made available to you through your DCA.

Set up your MyAmeriflex account MyAmeriflex is where you’ll have real-time access to all of your account information, including your current balance, transaction history, payment status, and more. To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

Download mobile app The MyAmeriflex App lets you access and manage your account anywhere you go, 24/7. It puts all of the great features of the MyAmeriflex Portal right at your fingertips. You can download the app on the Apple App Store and Google Play.

Register for complimentary ID theft protection Ameriflex is pleased to offer our cardholders complimentary access to Mastercard’s comprehensive Identity Theft Protection program*, powered by CSID®. You can rest assured knowing that if your MyAmeriflex Debit Mastercard (or any other debit/credit cards you choose to register!) gets misplaced or stolen, you can utilize Mastercard’s industry-leading ID theft protection and restoration services for everything you may need. To register, visit myameriflex.com/IDtheftprotection.

Use your cardYou will receive a MyAmeriflex Debit Mastercard that can be used to make eligible purchases. Your card will be mailed within 7-10 business days after your enrollment is processed by Ameriflex.

Enroll for direct depositBy enrolling for direct deposit, getting reimbursed is easier and faster anytime you need to pay for an eligible expenses out of pocket. Login to MyAmeriflex to set up direct deposit.

Start spendingYou’re ready to make purchases as funds become available! Your account will be funded each pay period. Be sure to hang on to your receipts anytime you make a purchase. Login to MyAmeriflex for a full list of eligible expenses.

HOW TO GET REIMBURSED FOR OUT-OF-POCKET EXPENSES

As you begin to use your account, it’s important to understand how to submit a request for reimbursement or payment to a provider.

Two most common reasons for requesting a reimbursement or payment:

You paid an eligible expense out of pocket

To request a payment be made directly to a provider

Your MyAmeriflex Debit Mastercard is the quickest and easiest way to access your account funds. But if you can’t use your card, getting reimbursed is quick and painless.

Step 1: Login in to your MyAmeriflex account online or through the MyAmeriflex App

Step 2: Click the Submit Claim button

Step 3: Fill out all of the required fields and attach documentation

Step 4: If requesting to pay a provider, enter the provider’s information, including address, and select “Pay Provider.” Once processed, the reimbursement will be sent directly to the provider. You can also save the provider for any future reimbursements.

Step 5: Click submit

You can view the status of a pending reimbursement anytime through MyAmeriflex or the MyAmeriflex App. If any further action is needed before the reimbursement is processed, you will receive a message through your account.

ONE-TIME CLAIM FOR DEPENDENT CARE SERVICES

Ameriflex makes it easy to get reimbursed automatically from your account as your funds build up during the year. If you’re paying for childcare or elderly care each month, you can avoid submitting a manual claim every month to get reimbursed for expenses you paid out of pocket. All you have to do is submit one Claim Form for the entire year that shows the date range for which childcare/eldercare services will be provided, along with a signature from the service provider on the designated line of the form. As long as the form is signed by the provider, no receipt is needed. Once the recurring claim has been processed, Ameriflex will automatically reimburse you every month with a check or direct deposit as funds in your Dependent Care Account become available.

FREQUENTLY ASKED QUESTIONS

How do I check my account balance?You can check your real-time balance online by logging into MyAmeriflex or through the MyAmeriflex Mobile App. Ameriflex also provides 24/7 access to automated account information via telephone. Call 888.868.FLEX (3539) and follow the prompts to listen to balance and transaction information for your account.

How do I access my account?If you’re a new user, setting up your account is easy! To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Mastercard debit card number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

What expenses are eligible? The IRS, and sometimes your employer, determine what goods and services are eligible. This will vary based on what type of account you have. Login to MyAmeriflex for a full list of eligible expenses.

How do I order a new card?You can request a free replacement card online through your Ameriflex account or through the MyAmeriflex Mobile App.

What happens if I don’t use my DCA account balance by the end the year?Employers may offer a 2.5-month grace period to help employees use their unused money at the end of the plan year. If your employer offers a 2.5-month grace period, you can continue using your unused money 2.5 months into the new plan year. Please refer to your plan documents or contact Ameriflex to verify the specific rules and features associat-ed with your company's plan.

How do these programs save me money on taxes?Since the accounts are tax-advantaged, you get to leverage pre-tax payroll deductions -- increasing your take-home pay and saving you money on everyday expenses. In many cases, you can experience savings of up to 40% on expenses eligible under your employer-sponsored plan.

Dependent Care Account

If I leave my employer, can I still use my funds?No, your funds are forfeited if you leave your employer.

What does pre-tax dollars mean and why is this important?Essentially, “pre-taxing,” which can be used for life insurance, disability insurance, HSA contributions, dependent care contributions, health savings account contributions and commuter account contributions, means taking income that would otherwise be taxable and diverting it to something else before (so: “pre”) is becomes taxable.

By making pre-tax contributions to an HSA, you are lowering the amount your income is taxed, which results in taking home a bigger paycheck.

Can I change my annual election amount?DCA elections can be changed if the cost of the services received changes (i.e. daycare increases fees), or if the dependent no longer goes to daycare.

How can I get more information about my account?For an overview of account features, visit myameriflex.com/participants.

You can manage your account, check your balance, file and claim anytime online through MyAmeriflex or through the Ameriflex App.

How can I change my reimbursement setting to add direct deposit?To set up direct deposit, simply login to MyAmeriflex, select reimbursement settings under the my account tab, then enter your banking information.

If you have any questions you can contact the Ameriflex Participant Services team Monday - Friday, 8:30 a.m. - 8:00 p.m. (ET).

Phone: 888.868.FLEX (3539)Email: service@myameriflex.comChat: myameriflex.com

63

Getting real about your healthcare savings starts hereYou made a great decision by enrolling in a dependent care account (DCA)! Now that you’ve gotten the difficult decisions out of the way, use this packet to learn how to best take advantage of your account. Let’s get started!

HOW YOUR DCA WORKS

Your DCA is a spending account that can be used to pay for services like daycare, nurs-ery school, and elder care. By simply participating in a DCA, you get to experience benefits like:

A higher take-home pay thanks to your pre-tax payroll deductions

Savings on daycare and other dependent care services you’re already paying for

Easy-to-use MyAmeriflex Debit Mastercard to make purchases

WHAT CAN I SPEND MY DCA FUNDS ON?IThe IRS determines what expenses are eligible under a DCA. Here are some examples of common eligible expenses

GETTING STARTED CHECKLIST

Use this checklist to take full advantage of all the great resources made available to you through your DCA.

Set up your MyAmeriflex account MyAmeriflex is where you’ll have real-time access to all of your account information, including your current balance, transaction history, payment status, and more. To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

Download mobile app The MyAmeriflex App lets you access and manage your account anywhere you go, 24/7. It puts all of the great features of the MyAmeriflex Portal right at your fingertips. You can download the app on the Apple App Store and Google Play.

Register for complimentary ID theft protection Ameriflex is pleased to offer our cardholders complimentary access to Mastercard’s comprehensive Identity Theft Protection program*, powered by CSID®. You can rest assured knowing that if your MyAmeriflex Debit Mastercard (or any other debit/credit cards you choose to register!) gets misplaced or stolen, you can utilize Mastercard’s industry-leading ID theft protection and restoration services for everything you may need. To register, visit myameriflex.com/IDtheftprotection.

Use your cardYou will receive a MyAmeriflex Debit Mastercard that can be used to make eligible purchases. Your card will be mailed within 7-10 business days after your enrollment is processed by Ameriflex.

Enroll for direct depositBy enrolling for direct deposit, getting reimbursed is easier and faster anytime you need to pay for an eligible expenses out of pocket. Login to MyAmeriflex to set up direct deposit.

Start spendingYou’re ready to make purchases as funds become available! Your account will be funded each pay period. Be sure to hang on to your receipts anytime you make a purchase. Login to MyAmeriflex for a full list of eligible expenses.

HOW TO GET REIMBURSED FOR OUT-OF-POCKET EXPENSES

As you begin to use your account, it’s important to understand how to submit a request for reimbursement or payment to a provider.

Two most common reasons for requesting a reimbursement or payment:

You paid an eligible expense out of pocket

To request a payment be made directly to a provider

Your MyAmeriflex Debit Mastercard is the quickest and easiest way to access your account funds. But if you can’t use your card, getting reimbursed is quick and painless.

Step 1: Login in to your MyAmeriflex account online or through the MyAmeriflex App

Step 2: Click the Submit Claim button

Step 3: Fill out all of the required fields and attach documentation

Step 4: If requesting to pay a provider, enter the provider’s information, including address, and select “Pay Provider.” Once processed, the reimbursement will be sent directly to the provider. You can also save the provider for any future reimbursements.

Step 5: Click submit

You can view the status of a pending reimbursement anytime through MyAmeriflex or the MyAmeriflex App. If any further action is needed before the reimbursement is processed, you will receive a message through your account.

ONE-TIME CLAIM FOR DEPENDENT CARE SERVICES

Ameriflex makes it easy to get reimbursed automatically from your account as your funds build up during the year. If you’re paying for childcare or elderly care each month, you can avoid submitting a manual claim every month to get reimbursed for expenses you paid out of pocket. All you have to do is submit one Claim Form for the entire year that shows the date range for which childcare/eldercare services will be provided, along with a signature from the service provider on the designated line of the form. As long as the form is signed by the provider, no receipt is needed. Once the recurring claim has been processed, Ameriflex will automatically reimburse you every month with a check or direct deposit as funds in your Dependent Care Account become available.

FREQUENTLY ASKED QUESTIONS

How do I check my account balance?You can check your real-time balance online by logging into MyAmeriflex or through the MyAmeriflex Mobile App. Ameriflex also provides 24/7 access to automated account information via telephone. Call 888.868.FLEX (3539) and follow the prompts to listen to balance and transaction information for your account.

How do I access my account?If you’re a new user, setting up your account is easy! To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Mastercard debit card number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

What expenses are eligible? The IRS, and sometimes your employer, determine what goods and services are eligible. This will vary based on what type of account you have. Login to MyAmeriflex for a full list of eligible expenses.

How do I order a new card?You can request a free replacement card online through your Ameriflex account or through the MyAmeriflex Mobile App.

What happens if I don’t use my DCA account balance by the end the year?Employers may offer a 2.5-month grace period to help employees use their unused money at the end of the plan year. If your employer offers a 2.5-month grace period, you can continue using your unused money 2.5 months into the new plan year. Please refer to your plan documents or contact Ameriflex to verify the specific rules and features associat-ed with your company's plan.

How do these programs save me money on taxes?Since the accounts are tax-advantaged, you get to leverage pre-tax payroll deductions -- increasing your take-home pay and saving you money on everyday expenses. In many cases, you can experience savings of up to 40% on expenses eligible under your employer-sponsored plan.

myameriflex.com/participants

1

2

3

Pre-schoolNanny serviceCustodial care fordependent adults

Nursery school

Daycare Summer day camp Before and afterschool programs

Private sitter

If I leave my employer, can I still use my funds?No, your funds are forfeited if you leave your employer.

What does pre-tax dollars mean and why is this important?Essentially, “pre-taxing,” which can be used for life insurance, disability insurance, HSA contributions, dependent care contributions, health savings account contributions and commuter account contributions, means taking income that would otherwise be taxable and diverting it to something else before (so: “pre”) is becomes taxable.

By making pre-tax contributions to an HSA, you are lowering the amount your income is taxed, which results in taking home a bigger paycheck.

Can I change my annual election amount?DCA elections can be changed if the cost of the services received changes (i.e. daycare increases fees), or if the dependent no longer goes to daycare.

How can I get more information about my account?For an overview of account features, visit myameriflex.com/participants.

You can manage your account, check your balance, file and claim anytime online through MyAmeriflex or through the Ameriflex App.

How can I change my reimbursement setting to add direct deposit?To set up direct deposit, simply login to MyAmeriflex, select reimbursement settings under the my account tab, then enter your banking information.

If you have any questions you can contact the Ameriflex Participant Services team Monday - Friday, 8:30 a.m. - 8:00 p.m. (ET).

Phone: 888.868.FLEX (3539)Email: service@myameriflex.comChat: myameriflex.com

64

Getting real about your healthcare savings starts hereYou made a great decision by enrolling in a dependent care account (DCA)! Now that you’ve gotten the difficult decisions out of the way, use this packet to learn how to best take advantage of your account. Let’s get started!

HOW YOUR DCA WORKS

Your DCA is a spending account that can be used to pay for services like daycare, nurs-ery school, and elder care. By simply participating in a DCA, you get to experience benefits like:

A higher take-home pay thanks to your pre-tax payroll deductions

Savings on daycare and other dependent care services you’re already paying for

Easy-to-use MyAmeriflex Debit Mastercard to make purchases

WHAT CAN I SPEND MY DCA FUNDS ON?IThe IRS determines what expenses are eligible under a DCA. Here are some examples of common eligible expenses

GETTING STARTED CHECKLIST

Use this checklist to take full advantage of all the great resources made available to you through your DCA.

Set up your MyAmeriflex account MyAmeriflex is where you’ll have real-time access to all of your account information, including your current balance, transaction history, payment status, and more. To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

Download mobile app The MyAmeriflex App lets you access and manage your account anywhere you go, 24/7. It puts all of the great features of the MyAmeriflex Portal right at your fingertips. You can download the app on the Apple App Store and Google Play.

Register for complimentary ID theft protection Ameriflex is pleased to offer our cardholders complimentary access to Mastercard’s comprehensive Identity Theft Protection program*, powered by CSID®. You can rest assured knowing that if your MyAmeriflex Debit Mastercard (or any other debit/credit cards you choose to register!) gets misplaced or stolen, you can utilize Mastercard’s industry-leading ID theft protection and restoration services for everything you may need. To register, visit myameriflex.com/IDtheftprotection.

Use your cardYou will receive a MyAmeriflex Debit Mastercard that can be used to make eligible purchases. Your card will be mailed within 7-10 business days after your enrollment is processed by Ameriflex.

Enroll for direct depositBy enrolling for direct deposit, getting reimbursed is easier and faster anytime you need to pay for an eligible expenses out of pocket. Login to MyAmeriflex to set up direct deposit.

Start spendingYou’re ready to make purchases as funds become available! Your account will be funded each pay period. Be sure to hang on to your receipts anytime you make a purchase. Login to MyAmeriflex for a full list of eligible expenses.

HOW TO GET REIMBURSED FOR OUT-OF-POCKET EXPENSES

As you begin to use your account, it’s important to understand how to submit a request for reimbursement or payment to a provider.

Two most common reasons for requesting a reimbursement or payment:

You paid an eligible expense out of pocket

To request a payment be made directly to a provider

Your MyAmeriflex Debit Mastercard is the quickest and easiest way to access your account funds. But if you can’t use your card, getting reimbursed is quick and painless.

Step 1: Login in to your MyAmeriflex account online or through the MyAmeriflex App

Step 2: Click the Submit Claim button

Step 3: Fill out all of the required fields and attach documentation

Step 4: If requesting to pay a provider, enter the provider’s information, including address, and select “Pay Provider.” Once processed, the reimbursement will be sent directly to the provider. You can also save the provider for any future reimbursements.

Step 5: Click submit

You can view the status of a pending reimbursement anytime through MyAmeriflex or the MyAmeriflex App. If any further action is needed before the reimbursement is processed, you will receive a message through your account.

ONE-TIME CLAIM FOR DEPENDENT CARE SERVICES

Ameriflex makes it easy to get reimbursed automatically from your account as your funds build up during the year. If you’re paying for childcare or elderly care each month, you can avoid submitting a manual claim every month to get reimbursed for expenses you paid out of pocket. All you have to do is submit one Claim Form for the entire year that shows the date range for which childcare/eldercare services will be provided, along with a signature from the service provider on the designated line of the form. As long as the form is signed by the provider, no receipt is needed. Once the recurring claim has been processed, Ameriflex will automatically reimburse you every month with a check or direct deposit as funds in your Dependent Care Account become available.

FREQUENTLY ASKED QUESTIONS

How do I check my account balance?You can check your real-time balance online by logging into MyAmeriflex or through the MyAmeriflex Mobile App. Ameriflex also provides 24/7 access to automated account information via telephone. Call 888.868.FLEX (3539) and follow the prompts to listen to balance and transaction information for your account.

How do I access my account?If you’re a new user, setting up your account is easy! To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Mastercard debit card number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

What expenses are eligible? The IRS, and sometimes your employer, determine what goods and services are eligible. This will vary based on what type of account you have. Login to MyAmeriflex for a full list of eligible expenses.

How do I order a new card?You can request a free replacement card online through your Ameriflex account or through the MyAmeriflex Mobile App.

What happens if I don’t use my DCA account balance by the end the year?Employers may offer a 2.5-month grace period to help employees use their unused money at the end of the plan year. If your employer offers a 2.5-month grace period, you can continue using your unused money 2.5 months into the new plan year. Please refer to your plan documents or contact Ameriflex to verify the specific rules and features associat-ed with your company's plan.

How do these programs save me money on taxes?Since the accounts are tax-advantaged, you get to leverage pre-tax payroll deductions -- increasing your take-home pay and saving you money on everyday expenses. In many cases, you can experience savings of up to 40% on expenses eligible under your employer-sponsored plan.

1

2

3

4

5

6

myameriflex.com/participants

If I leave my employer, can I still use my funds?No, your funds are forfeited if you leave your employer.

What does pre-tax dollars mean and why is this important?Essentially, “pre-taxing,” which can be used for life insurance, disability insurance, HSA contributions, dependent care contributions, health savings account contributions and commuter account contributions, means taking income that would otherwise be taxable and diverting it to something else before (so: “pre”) is becomes taxable.

By making pre-tax contributions to an HSA, you are lowering the amount your income is taxed, which results in taking home a bigger paycheck.

Can I change my annual election amount?DCA elections can be changed if the cost of the services received changes (i.e. daycare increases fees), or if the dependent no longer goes to daycare.

How can I get more information about my account?For an overview of account features, visit myameriflex.com/participants.

You can manage your account, check your balance, file and claim anytime online through MyAmeriflex or through the Ameriflex App.

How can I change my reimbursement setting to add direct deposit?To set up direct deposit, simply login to MyAmeriflex, select reimbursement settings under the my account tab, then enter your banking information.

If you have any questions you can contact the Ameriflex Participant Services team Monday - Friday, 8:30 a.m. - 8:00 p.m. (ET).

Phone: 888.868.FLEX (3539)Email: service@myameriflex.comChat: myameriflex.com

65

Getting real about your healthcare savings starts hereYou made a great decision by enrolling in a dependent care account (DCA)! Now that you’ve gotten the difficult decisions out of the way, use this packet to learn how to best take advantage of your account. Let’s get started!

HOW YOUR DCA WORKS

Your DCA is a spending account that can be used to pay for services like daycare, nurs-ery school, and elder care. By simply participating in a DCA, you get to experience benefits like:

A higher take-home pay thanks to your pre-tax payroll deductions

Savings on daycare and other dependent care services you’re already paying for

Easy-to-use MyAmeriflex Debit Mastercard to make purchases

WHAT CAN I SPEND MY DCA FUNDS ON?IThe IRS determines what expenses are eligible under a DCA. Here are some examples of common eligible expenses

GETTING STARTED CHECKLIST

Use this checklist to take full advantage of all the great resources made available to you through your DCA.

Set up your MyAmeriflex account MyAmeriflex is where you’ll have real-time access to all of your account information, including your current balance, transaction history, payment status, and more. To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

Download mobile app The MyAmeriflex App lets you access and manage your account anywhere you go, 24/7. It puts all of the great features of the MyAmeriflex Portal right at your fingertips. You can download the app on the Apple App Store and Google Play.

Register for complimentary ID theft protection Ameriflex is pleased to offer our cardholders complimentary access to Mastercard’s comprehensive Identity Theft Protection program*, powered by CSID®. You can rest assured knowing that if your MyAmeriflex Debit Mastercard (or any other debit/credit cards you choose to register!) gets misplaced or stolen, you can utilize Mastercard’s industry-leading ID theft protection and restoration services for everything you may need. To register, visit myameriflex.com/IDtheftprotection.

Use your cardYou will receive a MyAmeriflex Debit Mastercard that can be used to make eligible purchases. Your card will be mailed within 7-10 business days after your enrollment is processed by Ameriflex.

Enroll for direct depositBy enrolling for direct deposit, getting reimbursed is easier and faster anytime you need to pay for an eligible expenses out of pocket. Login to MyAmeriflex to set up direct deposit.

Start spendingYou’re ready to make purchases as funds become available! Your account will be funded each pay period. Be sure to hang on to your receipts anytime you make a purchase. Login to MyAmeriflex for a full list of eligible expenses.

HOW TO GET REIMBURSED FOR OUT-OF-POCKET EXPENSES

As you begin to use your account, it’s important to understand how to submit a request for reimbursement or payment to a provider.

Two most common reasons for requesting a reimbursement or payment:

You paid an eligible expense out of pocket

To request a payment be made directly to a provider

Your MyAmeriflex Debit Mastercard is the quickest and easiest way to access your account funds. But if you can’t use your card, getting reimbursed is quick and painless.

Step 1: Login in to your MyAmeriflex account online or through the MyAmeriflex App

Step 2: Click the Submit Claim button

Step 3: Fill out all of the required fields and attach documentation

Step 4: If requesting to pay a provider, enter the provider’s information, including address, and select “Pay Provider.” Once processed, the reimbursement will be sent directly to the provider. You can also save the provider for any future reimbursements.

Step 5: Click submit

You can view the status of a pending reimbursement anytime through MyAmeriflex or the MyAmeriflex App. If any further action is needed before the reimbursement is processed, you will receive a message through your account.

ONE-TIME CLAIM FOR DEPENDENT CARE SERVICES

Ameriflex makes it easy to get reimbursed automatically from your account as your funds build up during the year. If you’re paying for childcare or elderly care each month, you can avoid submitting a manual claim every month to get reimbursed for expenses you paid out of pocket. All you have to do is submit one Claim Form for the entire year that shows the date range for which childcare/eldercare services will be provided, along with a signature from the service provider on the designated line of the form. As long as the form is signed by the provider, no receipt is needed. Once the recurring claim has been processed, Ameriflex will automatically reimburse you every month with a check or direct deposit as funds in your Dependent Care Account become available.

FREQUENTLY ASKED QUESTIONS

How do I check my account balance?You can check your real-time balance online by logging into MyAmeriflex or through the MyAmeriflex Mobile App. Ameriflex also provides 24/7 access to automated account information via telephone. Call 888.868.FLEX (3539) and follow the prompts to listen to balance and transaction information for your account.

How do I access my account?If you’re a new user, setting up your account is easy! To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Mastercard debit card number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

What expenses are eligible? The IRS, and sometimes your employer, determine what goods and services are eligible. This will vary based on what type of account you have. Login to MyAmeriflex for a full list of eligible expenses.

How do I order a new card?You can request a free replacement card online through your Ameriflex account or through the MyAmeriflex Mobile App.

What happens if I don’t use my DCA account balance by the end the year?Employers may offer a 2.5-month grace period to help employees use their unused money at the end of the plan year. If your employer offers a 2.5-month grace period, you can continue using your unused money 2.5 months into the new plan year. Please refer to your plan documents or contact Ameriflex to verify the specific rules and features associat-ed with your company's plan.

How do these programs save me money on taxes?Since the accounts are tax-advantaged, you get to leverage pre-tax payroll deductions -- increasing your take-home pay and saving you money on everyday expenses. In many cases, you can experience savings of up to 40% on expenses eligible under your employer-sponsored plan.

myameriflex.com/participants

If I leave my employer, can I still use my funds?No, your funds are forfeited if you leave your employer.

What does pre-tax dollars mean and why is this important?Essentially, “pre-taxing,” which can be used for life insurance, disability insurance, HSA contributions, dependent care contributions, health savings account contributions and commuter account contributions, means taking income that would otherwise be taxable and diverting it to something else before (so: “pre”) is becomes taxable.

By making pre-tax contributions to an HSA, you are lowering the amount your income is taxed, which results in taking home a bigger paycheck.

Can I change my annual election amount?DCA elections can be changed if the cost of the services received changes (i.e. daycare increases fees), or if the dependent no longer goes to daycare.

How can I get more information about my account?For an overview of account features, visit myameriflex.com/participants.

You can manage your account, check your balance, file and claim anytime online through MyAmeriflex or through the Ameriflex App.

How can I change my reimbursement setting to add direct deposit?To set up direct deposit, simply login to MyAmeriflex, select reimbursement settings under the my account tab, then enter your banking information.

If you have any questions you can contact the Ameriflex Participant Services team Monday - Friday, 8:30 a.m. - 8:00 p.m. (ET).

Phone: 888.868.FLEX (3539)Email: service@myameriflex.comChat: myameriflex.com

1

2

66

Getting real about your healthcare savings starts hereYou made a great decision by enrolling in a dependent care account (DCA)! Now that you’ve gotten the difficult decisions out of the way, use this packet to learn how to best take advantage of your account. Let’s get started!

HOW YOUR DCA WORKS

Your DCA is a spending account that can be used to pay for services like daycare, nurs-ery school, and elder care. By simply participating in a DCA, you get to experience benefits like:

A higher take-home pay thanks to your pre-tax payroll deductions

Savings on daycare and other dependent care services you’re already paying for

Easy-to-use MyAmeriflex Debit Mastercard to make purchases

WHAT CAN I SPEND MY DCA FUNDS ON?IThe IRS determines what expenses are eligible under a DCA. Here are some examples of common eligible expenses

GETTING STARTED CHECKLIST

Use this checklist to take full advantage of all the great resources made available to you through your DCA.

Set up your MyAmeriflex account MyAmeriflex is where you’ll have real-time access to all of your account information, including your current balance, transaction history, payment status, and more. To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

Download mobile app The MyAmeriflex App lets you access and manage your account anywhere you go, 24/7. It puts all of the great features of the MyAmeriflex Portal right at your fingertips. You can download the app on the Apple App Store and Google Play.

Register for complimentary ID theft protection Ameriflex is pleased to offer our cardholders complimentary access to Mastercard’s comprehensive Identity Theft Protection program*, powered by CSID®. You can rest assured knowing that if your MyAmeriflex Debit Mastercard (or any other debit/credit cards you choose to register!) gets misplaced or stolen, you can utilize Mastercard’s industry-leading ID theft protection and restoration services for everything you may need. To register, visit myameriflex.com/IDtheftprotection.

Use your cardYou will receive a MyAmeriflex Debit Mastercard that can be used to make eligible purchases. Your card will be mailed within 7-10 business days after your enrollment is processed by Ameriflex.

Enroll for direct depositBy enrolling for direct deposit, getting reimbursed is easier and faster anytime you need to pay for an eligible expenses out of pocket. Login to MyAmeriflex to set up direct deposit.

Start spendingYou’re ready to make purchases as funds become available! Your account will be funded each pay period. Be sure to hang on to your receipts anytime you make a purchase. Login to MyAmeriflex for a full list of eligible expenses.

HOW TO GET REIMBURSED FOR OUT-OF-POCKET EXPENSES

As you begin to use your account, it’s important to understand how to submit a request for reimbursement or payment to a provider.

Two most common reasons for requesting a reimbursement or payment:

You paid an eligible expense out of pocket

To request a payment be made directly to a provider

Your MyAmeriflex Debit Mastercard is the quickest and easiest way to access your account funds. But if you can’t use your card, getting reimbursed is quick and painless.

Step 1: Login in to your MyAmeriflex account online or through the MyAmeriflex App

Step 2: Click the Submit Claim button

Step 3: Fill out all of the required fields and attach documentation

Step 4: If requesting to pay a provider, enter the provider’s information, including address, and select “Pay Provider.” Once processed, the reimbursement will be sent directly to the provider. You can also save the provider for any future reimbursements.

Step 5: Click submit

You can view the status of a pending reimbursement anytime through MyAmeriflex or the MyAmeriflex App. If any further action is needed before the reimbursement is processed, you will receive a message through your account.

ONE-TIME CLAIM FOR DEPENDENT CARE SERVICES

Ameriflex makes it easy to get reimbursed automatically from your account as your funds build up during the year. If you’re paying for childcare or elderly care each month, you can avoid submitting a manual claim every month to get reimbursed for expenses you paid out of pocket. All you have to do is submit one Claim Form for the entire year that shows the date range for which childcare/eldercare services will be provided, along with a signature from the service provider on the designated line of the form. As long as the form is signed by the provider, no receipt is needed. Once the recurring claim has been processed, Ameriflex will automatically reimburse you every month with a check or direct deposit as funds in your Dependent Care Account become available.

FREQUENTLY ASKED QUESTIONS

How do I check my account balance?You can check your real-time balance online by logging into MyAmeriflex or through the MyAmeriflex Mobile App. Ameriflex also provides 24/7 access to automated account information via telephone. Call 888.868.FLEX (3539) and follow the prompts to listen to balance and transaction information for your account.

How do I access my account?If you’re a new user, setting up your account is easy! To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Mastercard debit card number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

What expenses are eligible? The IRS, and sometimes your employer, determine what goods and services are eligible. This will vary based on what type of account you have. Login to MyAmeriflex for a full list of eligible expenses.

How do I order a new card?You can request a free replacement card online through your Ameriflex account or through the MyAmeriflex Mobile App.

What happens if I don’t use my DCA account balance by the end the year?Employers may offer a 2.5-month grace period to help employees use their unused money at the end of the plan year. If your employer offers a 2.5-month grace period, you can continue using your unused money 2.5 months into the new plan year. Please refer to your plan documents or contact Ameriflex to verify the specific rules and features associat-ed with your company's plan.

How do these programs save me money on taxes?Since the accounts are tax-advantaged, you get to leverage pre-tax payroll deductions -- increasing your take-home pay and saving you money on everyday expenses. In many cases, you can experience savings of up to 40% on expenses eligible under your employer-sponsored plan.

myameriflex.com/participants

If I leave my employer, can I still use my funds?No, your funds are forfeited if you leave your employer.

What does pre-tax dollars mean and why is this important?Essentially, “pre-taxing,” which can be used for life insurance, disability insurance, HSA contributions, dependent care contributions, health savings account contributions and commuter account contributions, means taking income that would otherwise be taxable and diverting it to something else before (so: “pre”) is becomes taxable.

By making pre-tax contributions to an HSA, you are lowering the amount your income is taxed, which results in taking home a bigger paycheck.

Can I change my annual election amount?DCA elections can be changed if the cost of the services received changes (i.e. daycare increases fees), or if the dependent no longer goes to daycare.

How can I get more information about my account?For an overview of account features, visit myameriflex.com/participants.

You can manage your account, check your balance, file and claim anytime online through MyAmeriflex or through the Ameriflex App.

How can I change my reimbursement setting to add direct deposit?To set up direct deposit, simply login to MyAmeriflex, select reimbursement settings under the my account tab, then enter your banking information.

If you have any questions you can contact the Ameriflex Participant Services team Monday - Friday, 8:30 a.m. - 8:00 p.m. (ET).

Phone: 888.868.FLEX (3539)Email: service@myameriflex.comChat: myameriflex.com

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Getting real about your healthcare savings starts hereYou made a great decision by enrolling in a dependent care account (DCA)! Now that you’ve gotten the difficult decisions out of the way, use this packet to learn how to best take advantage of your account. Let’s get started!

HOW YOUR DCA WORKS

Your DCA is a spending account that can be used to pay for services like daycare, nurs-ery school, and elder care. By simply participating in a DCA, you get to experience benefits like:

A higher take-home pay thanks to your pre-tax payroll deductions

Savings on daycare and other dependent care services you’re already paying for

Easy-to-use MyAmeriflex Debit Mastercard to make purchases

WHAT CAN I SPEND MY DCA FUNDS ON?IThe IRS determines what expenses are eligible under a DCA. Here are some examples of common eligible expenses

GETTING STARTED CHECKLIST

Use this checklist to take full advantage of all the great resources made available to you through your DCA.

Set up your MyAmeriflex account MyAmeriflex is where you’ll have real-time access to all of your account information, including your current balance, transaction history, payment status, and more. To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

Download mobile app The MyAmeriflex App lets you access and manage your account anywhere you go, 24/7. It puts all of the great features of the MyAmeriflex Portal right at your fingertips. You can download the app on the Apple App Store and Google Play.

Register for complimentary ID theft protection Ameriflex is pleased to offer our cardholders complimentary access to Mastercard’s comprehensive Identity Theft Protection program*, powered by CSID®. You can rest assured knowing that if your MyAmeriflex Debit Mastercard (or any other debit/credit cards you choose to register!) gets misplaced or stolen, you can utilize Mastercard’s industry-leading ID theft protection and restoration services for everything you may need. To register, visit myameriflex.com/IDtheftprotection.

Use your cardYou will receive a MyAmeriflex Debit Mastercard that can be used to make eligible purchases. Your card will be mailed within 7-10 business days after your enrollment is processed by Ameriflex.

Enroll for direct depositBy enrolling for direct deposit, getting reimbursed is easier and faster anytime you need to pay for an eligible expenses out of pocket. Login to MyAmeriflex to set up direct deposit.

Start spendingYou’re ready to make purchases as funds become available! Your account will be funded each pay period. Be sure to hang on to your receipts anytime you make a purchase. Login to MyAmeriflex for a full list of eligible expenses.

HOW TO GET REIMBURSED FOR OUT-OF-POCKET EXPENSES

As you begin to use your account, it’s important to understand how to submit a request for reimbursement or payment to a provider.

Two most common reasons for requesting a reimbursement or payment:

You paid an eligible expense out of pocket

To request a payment be made directly to a provider

Your MyAmeriflex Debit Mastercard is the quickest and easiest way to access your account funds. But if you can’t use your card, getting reimbursed is quick and painless.

Step 1: Login in to your MyAmeriflex account online or through the MyAmeriflex App

Step 2: Click the Submit Claim button

Step 3: Fill out all of the required fields and attach documentation

Step 4: If requesting to pay a provider, enter the provider’s information, including address, and select “Pay Provider.” Once processed, the reimbursement will be sent directly to the provider. You can also save the provider for any future reimbursements.

Step 5: Click submit

You can view the status of a pending reimbursement anytime through MyAmeriflex or the MyAmeriflex App. If any further action is needed before the reimbursement is processed, you will receive a message through your account.

ONE-TIME CLAIM FOR DEPENDENT CARE SERVICES

Ameriflex makes it easy to get reimbursed automatically from your account as your funds build up during the year. If you’re paying for childcare or elderly care each month, you can avoid submitting a manual claim every month to get reimbursed for expenses you paid out of pocket. All you have to do is submit one Claim Form for the entire year that shows the date range for which childcare/eldercare services will be provided, along with a signature from the service provider on the designated line of the form. As long as the form is signed by the provider, no receipt is needed. Once the recurring claim has been processed, Ameriflex will automatically reimburse you every month with a check or direct deposit as funds in your Dependent Care Account become available.

FREQUENTLY ASKED QUESTIONS

How do I check my account balance?You can check your real-time balance online by logging into MyAmeriflex or through the MyAmeriflex Mobile App. Ameriflex also provides 24/7 access to automated account information via telephone. Call 888.868.FLEX (3539) and follow the prompts to listen to balance and transaction information for your account.

How do I access my account?If you’re a new user, setting up your account is easy! To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Mastercard debit card number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

What expenses are eligible? The IRS, and sometimes your employer, determine what goods and services are eligible. This will vary based on what type of account you have. Login to MyAmeriflex for a full list of eligible expenses.

How do I order a new card?You can request a free replacement card online through your Ameriflex account or through the MyAmeriflex Mobile App.

What happens if I don’t use my DCA account balance by the end the year?Employers may offer a 2.5-month grace period to help employees use their unused money at the end of the plan year. If your employer offers a 2.5-month grace period, you can continue using your unused money 2.5 months into the new plan year. Please refer to your plan documents or contact Ameriflex to verify the specific rules and features associat-ed with your company's plan.

How do these programs save me money on taxes?Since the accounts are tax-advantaged, you get to leverage pre-tax payroll deductions -- increasing your take-home pay and saving you money on everyday expenses. In many cases, you can experience savings of up to 40% on expenses eligible under your employer-sponsored plan.

myameriflex.com/participants

If I leave my employer, can I still use my funds?No, your funds are forfeited if you leave your employer.

What does pre-tax dollars mean and why is this important?Essentially, “pre-taxing,” which can be used for life insurance, disability insurance, HSA contributions, dependent care contributions, health savings account contributions and commuter account contributions, means taking income that would otherwise be taxable and diverting it to something else before (so: “pre”) is becomes taxable.

By making pre-tax contributions to an HSA, you are lowering the amount your income is taxed, which results in taking home a bigger paycheck.

Can I change my annual election amount?DCA elections can be changed if the cost of the services received changes (i.e. daycare increases fees), or if the dependent no longer goes to daycare.

How can I get more information about my account?For an overview of account features, visit myameriflex.com/participants.

You can manage your account, check your balance, file and claim anytime online through MyAmeriflex or through the Ameriflex App.

How can I change my reimbursement setting to add direct deposit?To set up direct deposit, simply login to MyAmeriflex, select reimbursement settings under the my account tab, then enter your banking information.

If you have any questions you can contact the Ameriflex Participant Services team Monday - Friday, 8:30 a.m. - 8:00 p.m. (ET).

Phone: 888.868.FLEX (3539)Email: service@myameriflex.comChat: myameriflex.com

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Learning CenterGet daily money-saving info

Did you know you could use your FSA to save money on everyday health essentials like baby health items, health trackers, pain relief products and more?Use your FSA funds or risk forfeiting your money.

Visit FSAstore.com/FlyerAMERI for the largest selection ofguaranteed FSA-eligible products with zero guesswork.

Get $5 off with code, FCAMERI5. One use per customer.

Don’t knowwhat to use yourFSA money on?

Use your FSA cardor any major credit card

Need an Rx?We’ll work with you tomake getting one easier

Are your healthneeds eligible?Easily check with ourexpansive Eligibility List

24/7 support,FREE shipping on ordersover $50

The largest selectionof guaranteed FSA-eligibleproducts

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Accident Insurance Accidents can happen anytime, anywhere.Accidents are usually followed by a series of bills. Even if you have good insurance, you may still have to cover out-of-pocket costs, such as:

� Doctor bills � Ambulance fees � Hospital expenses

Accident insurance from Colonial Life & Accident Insurance Company can help protect you, your spouse and your dependent children from the unexpected expenses of an accident.

Features of Colonial Life’s Accident Insurance: � You are paid benefits to help you with the care and treatment of a covered accidental injury. � Your benefits are paid directly to you (unless you specify otherwise). � You are paid benefits regardless of any other insurance you may have with other insurance companies. � You can take your coverage with you if you change jobs or retire.

Disability InsuranceIf you got sick or hurt and couldn’t work, how long could you go without a paycheck? In today’s economy, it’d be difficult losing just one paycheck. But a disability could have you out of work for days, weeks, months or even a year:

Disability insurance from Colonial Life & Accident Insurance Company can help protect your income, so you can maintain your way of life.

Features of Colonial Life’s Accident Insurance: � You’re paid regardless of any other insurance you may have with other insurance companies. � Benefits are paid directly to you, unless you specify otherwise. � You may choose the amount of your disability benefits to meet your needs, subject to income. � You can take your coverage with you if you change jobs or leave your employer.

Colonial LifeVoluntary Insurance

Coverage is subject to policy exclusions and limitations that may affect benefits payable. Products may vary by state and may not be available in all states. For cost and complete details, see a Colonial Life benefits counselor.

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Hospital Confinement Indemnity Insurance You may have health insurance, but are you really covered? Health insurance may cover:

� Hospital fees � Outpatient surgery � Doctor/ER visits � Prescriptions

It may not cover: � Deductibles � Co-payments � Coinsurance

Hospital confinement indemnity insurance from Colonial Life & Accident Insurance Company can help you with unexpected health care expenses that your medical insurance may not cover. It pays an indemnity benefit for each covered hospital confinement. Plans also include a wellness testing benefit, which helps reimburse you for a portion of the tests you would normally have each year.

Features of Colonial Life’s Hospital Confinement Indemnity Insurance: � Benefits are paid directly to you, unless you specify otherwise. � Benefits are paid regardless of any other insurance you may have with other insurance companies. � You can take your coverage with you if you change jobs or leave your employer. � Coverage is guaranteed renewable as long as premiums are paid when they are due. � Coverage is available for you, your spouse and your dependent children.

Term Life InsuranceLife insurance protection when you need it most? Life insurance needs change as life circumstances change. You may need different coverage if you’re:

� Getting married � Buying a home � Having a child � Taking on additional debt

Term life insurance from Colonial Life & Accident Insurance Company provides protection for a specified period of time, typically offering the greatest amount of coverage for the lowest initial premium. This fact makes term life insurance a good choice for supplementing cash value coverage during life stages where obligations are higher, such as while children are young. It’s also a good option for families on a tight budget – especially since you can convert it to a permanent cash value plan later.

Benefits of Colonial Life’s Term Life Insurance: � Provides a benefit for the beneficiary that is typically free from income tax. � The policy’s Accelerated Death Benefit can pay a percentage of the death benefit if the insured is diagnosed with

a terminal illness. � You can take it with you if you change jobs or retire. � Convert to a Colonial Life cash value life insurance plan, with no proof of good health, to age 75. � Spouse and dependent children coverage is available.

Coverage is subject to policy exclusions and limitations that may affect benefits payable. Products may vary by state and may not be available in all states. For cost and complete details, see a Colonial Life benefits counselor.

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Whole Life InsuranceLife insurance that comes with guarantees … because life doesn’tWhole life insurance from Colonial Life & Accident Insurance Company provides guaranteed features – cash value accumulation, premium rates and death benefit (minus any loans and loan interest) – that help ensure those benefits will be there to help protect your family’s way of life.

Guaranteed protection: Offers lifetime protection with a guaranteed death benefit that will not change as long as premiums are paid when due.

Guaranteed premiums: Promises a level premium that stays the same from the day you purchase the policy.

Guaranteed cash value: Guarantees the cash value amount – which accumulates on a tax-deferred basis.

Features of Colonial Life’s Whole Life Insurance: � Provides a benefit for the beneficiary that is typically free from income tax. � Three option dates to purchase additional coverage with no proof of good health required if you are age 55 or younger

at the time of purchase. � The policy’s Accelerated Death Benefit can provide a percentage of the death benefit if the insured is diagnosed with

a terminal illness. � $3,000 immediate claim payment as an advance of the death benefit, paid to the designated beneficiary.

Coverage is subject to policy exclusions and limitations that may affect benefits payable. Products may vary by state and may not be available in all states. For cost and complete details, see a Colonial Life benefits counselor.

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Getting startedThe easiest way to manage your business with us is through ColonialLife.com. To sign up for the website, click Register at the top right of the home page and follow the instructions.

Consider your optionsAt Colonial Life, our goal is to give you an excellent customer experience that is simple, modern and personal. For your convenience, you can choose how you interact with us. For the quickest service, we recommend using our website, which lets you do the following:

� Review, print or download a copy of your policy/certificate by clicking on the My Correspondence tab.

� Update contact information or add family member profile information for use when filing online claims.

� Access service forms to make changes to your policy, such as a beneficiary change.

� Submit your claim using our eClaims system.

� Check the status of your claim and view claims correspondence.

� Access claim forms.

Customer Service Guide

eClaims are quick and easyWith the eClaims feature on ColonialLife.com, you can file most claims online by simply answering a few questions and uploading your supporting documentation. You’re able to spend less time on paperwork, and we’re able to process your claim faster.

� From ColonialLife.com, file claims from any device. It’s fast, easyand available 24/7.

� Select direct deposit to receive your benefit payment faster.

� Easily submit additional documents.

Paper claims � If you don’t want to file online, download the form you need byvisiting the File a Claim page on ColonialLife.com and clicking onclaim and service forms.

� You may fax your claim to 1-800-880-9325.

� Follow the instructions, tips and videos to complete and submityour claim.

ColonialLife.com

Contact us Online ColonialLife.com Log in and click on Contact Us

Telephone 1-800-325-4368

Hearing-impaired customers Please contact the National Relay service at 711 for assistance.

7-19 | 43233-40

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

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3

Medicare D Notice

Important Notice from Bell 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 Bell 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 getthis coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like anHMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least astandard level of coverage set by Medicare. Some plans may also offer more coverage for a highermonthly premium.

2. Bell County has determined that the prescription drug coverage offered by the Bell County MedicalPlan is, on average for all plan participants, expected to pay out as much as standard Medicareprescription drug coverage pays and is therefore considered Creditable Coverage. Because yourexisting coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (apenalty) if you later decide to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

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 Bell County coverage will not be affected. Your current coverage pays for other health expenses in addition to prescription drug. Please see the Medical Benefit Plan in this book for specific details about the prescription drug coverage.

If you enroll in a Medicare prescription drug plan, you and your eligible dependents will be eligible to receive all of your current health and prescription drug benefits and your coverage will coordinate with Medicare.

If you do decide to join a Medicare drug plan and drop your current Bell County coverage, be aware that you and your dependents may not be able to get this coverage back.

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 infor-mation collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data re-sources, 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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4

Medicare D Notice

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 Bell 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. For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information. NOTE: You will 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 Bell 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).

Date: November 2020 Name of Entity/Sender: Bell County Contact Office: Human Resources Address: 101 E. Central Avenue, 3rd Floor Belton, TX 76513 Phone Number: 254-933-5111

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 infor-mation collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data re-sources, 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.

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).

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We may use and share your information as we:

• Help manage the health care treatment you receive• Run our organization• Pay for your health services• Administer your health plan• Help with public health and safety issues• Do research• Comply with the law• Respond to organ and tissue donation requests and

work with a medical examiner or funeral director• Address workers’ compensation, law enforcement,

and other government requests• Respond to lawsuits and legal actions

➤ See pages 3 and 4 for more information on these uses and disclosures

You have the right to: • Get a copy of your health and claims records• Correct your health and claims records• Request confidential communication• Ask us to limit the information we share• Get a list of those with whom we’ve shared

your information• Get a copy of this privacy notice• Choose someone to act for you• File a complaint if you believe your privacy

rights have been violated

➤ See page 2 for more information on these rights and how to exercise them

Our Uses and

Disclosures

Your Rights

➤ See page 3 for more information on these choices and how to exercise them

You have some choices in the way that we use and share information as we:

• Answer coverage questions from your family and friends• Provide disaster relief• Market our services and sell your information

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.

Your Information. Your Rights.Our Responsibilities.

Your Choices

Notice of Privacy Practices • Page 1

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Notice of Privacy Practices • Page 2

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Your Rights

Get a copy of your health and claims records

• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct health and claims records

• You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations.

• We are not required to agree to your request, and we may say “no” if it would affect your care.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on page 1.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

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Notice of Privacy Practices • Page 3

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in payment for your care

• Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

Your Choices

Help manage the health care treatment you receive

• We can use your health information and share it with professionals who are treating you.

Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.

Run our organization

• We can use and disclose your information to run our organization and contact you when necessary.

• We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.

Example: We use health information about you to develop better services for you.

Pay for your health services

• We can use and disclose your health information as we pay for your health services.

Example: We share information about you with your dental plan to coordinate payment for your dental work.

Administer your plan

• We may disclose your health information to your health plan sponsor for plan administration.

Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Our Uses and

Disclosures

continued on next page

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Notice of Privacy Practices • Page 4

Help with public health and safety issues

• We can share health information about you for certain situations such as: • Preventing disease• Helping with product recalls• Reporting adverse reactions to medications• Reporting suspected abuse, neglect, or domestic violence• Preventing or reducing a serious threat to anyone’s health or safety

Do research • We can use or share your information for health research.

Comply with the law • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests and work with a medical examiner or funeral director

• We can share health information about you with organ procurement organizations.

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

• We can use or share health information about you:• For workers’ compensation claims• For law enforcement purposes or with a law enforcement official• With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

• We can share health information about you in response to a court or administrative order, or in response to a subpoena.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

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Notice of Privacy Practices • Page 5

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this NoticeWe can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.

This Notice of Privacy Practices applies to the following organizations.

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CHIPRA Notice

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Important Information

The Women’s Health and Cancer Rights Act The Women’s Health and Cancer Rights Act of 1998 requires group health plans that provide coverage for a mastectomy to provide coverage for certain reconstructive services. This law also requires that written notice of the availability of the coverage be delivered to all plan participants upon enrollment and annually thereafter. This language serves to fulfill that requirement for this year. These services include:

Reconstruction of the breast upon which the

mastectomy has been performed;

Surgery / reconstruction of the other breast to

produce a symmetrical appearance;

Prostheses; and

Treatment for physical complications during all stages

of mastectomy, including lymphedemas.

In addition, the plan may not:

Interfere with a participant’s rights under the plan to

avoid these requirements; or

Offer inducements to the healthcare provider, or

assess penalties against the provider, in an attempt to interfere with the requirements of the law.

However, the plan may apply deductibles, coinsurance, and co-payments consistent with other coverage provided by the plan.

Newborns Act Disclosure 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.

Summary of Material Modification This Summary of Material Modification (SMM) describes changes to the Bell County Plan and supplements the Summary Plan Description (SPD) for the plan. The effective date of each of these changes is November 1st, 2020. You should read this SMM very carefully and retain this document with your copy of the SPD for future reference.

This book highlights some of the main features of your benefit programs, but does not include all plan rules, features, limitations or exclusions. The terms of your benefit plans are governed by legal documents, including insurance contracts. Should there be any inconsistencies between this book and the legal plan documents, the plan documents are the final authority. Bell County reserves the right to change or discontinue its benefit plans at any time.

Special Enrollment Notice If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself or you dependents in this plan if your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request and complete enrollment within 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request and complete enrollment within 31 days after the marriage, birth, adoption, or placement for adoption. Special enrollment rights also may exist in the following circumstances:

If you or your dependents experience a loss of

eligibility for Medicaid or a state Children’s Health Insurance Program (CHIP) coverage and you request enrollment within 60 days after that coverage ends; or

If you or your dependents become eligible for a state

premium assistance subsidy through Medicaid or a state CHIP with respect to coverage under this plan and you request enrollment within 60 days after the determination of eligibility for such assistance.

Note: The 60 day period for requesting enrollment applies only in these last two listed circumstances relating to Medicaid and state CHIP. As described above, a 31 days period applies to most special enrollments. To request special enrollment or obtain more information, contact Human Resources at Bell County.

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