2019-2020Benefits Enrollment Guide

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Welcome to your new Benefits Enrollment Guide. This guide is your summary of the benefitoptions that are available to eligible employees of the Dawson County. Each benefit isdesigned to protect your health and well-being as well as provide valuable financialprotection.

Each section of the Benefits Enrollment Guide is structured to provide you with planhighlights as well as detailed, descriptive instructions to assist you in navigating through theweb-based enrollment portal.

While the Benefits Enrollment Guide is an important component in the benefitcommunication process, your dedicated ShawHankins service team continues to provideannual enrollment meetings in addition to being available for questions and concernsregarding benefits throughout the plan year.

Please review the plans contained in the Benefits Enrollment Guide and see how these planscan work for you and your eligible dependents. Your participation in the plans is voluntary.The benefit plans have been chosen to provide a continuation of protection thatcomplements Dawson County’s current policies.

The plan year is in effect from July 1, 2019 to June 30, 2020.

This Benefits Enrollment Guide is intended for orientation purposes only. It is an abbreviatedoverview of the plan documents. Please refer to the Certificate Booklet (the contract)available from the plan carriers for complete details. Your Certificate Booklet will providedetailed information regarding copayments, coinsurance, deductibles, exclusions and otherbenefits. The certificate booklet will govern should a conflict arise relating to the informationcontained in this summary. This summary does not establish eligibility to participate in orreceive benefits from any benefit plan.

Benefits are available to fulltime employees working a minimum of 30 hours a week. Benefitcoverage begins on the first of the month following 60 after your date of hire. You are alsoeligible to cover your spouse and dependent children up to age 26 or disabled children.

Upon termination, your life and disability plans will end on the date of your termination. Yourvoluntary life plan can be converted to an individual policy through Lincoln Financial, if youwere enrolled at time of termination and completed the necessary forms. Your medical,dental and vision coverage will end on the last date of the month of termination.

NOTICE: If you (and/or your dependents) have Medicare or will becomeeligible for Medicare in the next 12 months, a Federal law gives youmore choices about your prescription drug coverage. Please see page 17for more details.

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Topic Page

Welcome Letter 2

Before You Enroll 4

How to Enroll 5

Medical 6

Telemedicine 10

Dental 11

Vision 12

Basic Life & Voluntary Life 13

Voluntary Short & LongTerm Disability 14

Employee Assistance Program 15

Medical & Dependent Care Flexible Spending 16

Medicare Disclosures 17

CHIP Notice 19

Why Should I Contact the Service Center 22

Contact Information 23

Table of Contents

This guide describes the benefit plans available to you as an eligible employee of Dawson County. The details ofthese plans are contained in the official Plan Documents, including some insurance contracts. This guide is meantto cover only the major points of each plan. It does not contain all of the details that are included in yourSummary Plan Descriptions (SPD) (as described by the Employee Retirement Income Security Act).

If there is ever a question about one of these plans, or if there is a conflict between the information in this guideand the formal language of the Plan Documents, the formal wording in the Plan Documents will govern.

Please note the benefits described in this guide may be changed at any time and do not represent a contractualobligation on the part of Dawson County and ShawHankins.

You are REQUIRED to provide the following information or documentation for alldependents and beneficiaries:

• Name• Date of birth• Social Security number

• Please go online to make your elections during the New Hire Orientation by the deadlineprovided.

• Please contact ShawHankins at 877-373-0730 to speak with a benefit counselor if youneed assistance with your enrollment.

Failure to enroll within the enrollment time period will result in the forfeiture of youreligibility for enrollment until the next annual enrollment period unless you experiencean eligible qualifying event.

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Before You Enroll – Things to Know

HOW TO ENROLL

Go to www.dawsoncounty.bswift.com.

At this time, make sure to disable your pop up blocker.

At the enrollment website enter your Username and Password.

• Username is the first letter of your first name, your last name, and last 4 digits of your Social Security number (ex. jdoe4567).

• Password is the last 4 digits of your Social Security number (ex. 4567).

You will then be prompted to create a permanent password.

To Begin:1) From the “Home Page” click on the “Enroll Now” link, to begin the election process.2) On the “Personal & Family Page”, verify your information is accurate and “Add” all

eligible dependents you wish to cover under any benefits.

3) To make a plan selection, select the button beside the newly elected plan. If you arecovering dependents, make sure to “Select” them by checking off next to their nameunder “Select who to cover with this plan.” Then press “Next” at the bottom of thescreen.

4) Once you have reviewed and completed your enrollment, click on “I Agree and I amfinished with my enrollment”. Then click on “Save My Enrollment”.

5) You will now be taken to the final confirmation page to either print or email.

Note: The enrollment images within this guide are for illustrative purposes only.

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How To Enroll

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Anthem HMO

Covered Benefits In-Network Only

Calendar Year DeductibleIndividual / Family $1,000 / $3,000

Coinsurance 80% / 20%

Out of Pocket Calendar Year Maximum (Includes deductible and copays)Individual / Family

$2,500 / $7,500

Lifetime Maximum Unlimited

Office Visits:Preventive ServicesPrimary Care Physician/ Retail Health ClinicSpecialty Care PhysicianUrgent Care FacilityEmergency Room

Covered 100%$30 Copay$40 Copay$75 Copay

$300 Copay (waived if admitted)

Inpatient Services:(Facility, physician services, etc.)

$100 Copay, then 20% After Deductible

Outpatient Services:(Facility, physician services, etc.)

$100 Copay, then 20% After Deductible

Prescription Drugs:

Tier 1Tier 2Tier 3Tier 4Mail Order:Tier 1, Tier 2 and Tier 3

$10 Copay$30 Copay$50 Copay

20% to $200

2 x Copay

Per Pay Period Deductions (24)

Employee OnlyEmployee + SpouseEmployee + Child(ren)Employee + 2 or more

$ 78.26$ 131.71$ 131.71$ 188.90

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Anthem POS

Covered Benefits In-Network Out-of-network

Calendar Year DeductibleIndividual / Family $1,500 / $4,500 $3,000 / $9,000

Coinsurance 80% / 20% 60% / 40%

Out of Pocket Calendar Year Maximum(Includes deductible and copays)Individual / Family

$3,500 / $10,500 $7,000 / $21,000

Lifetime Maximum Unlimited

Office Visits:

Preventive ServicesPrimary Care Physician/Retail Health ClinicSpecialty Care PhysicianUrgent Care FacilityEmergency Room

Covered 100%

$35 Copay$45 Copay$75 Copay

$300 Copay (waived if admitted)

40% After Deductible

40% After Deductible40% After Deductible40% After Deductible

$300 Copay (waived if admitted)

Inpatient Services: (Facility, physician services, etc.)

20% After Deductible 40% After Deductible

Outpatient Services:(Facility, physician services, etc.)

20% After Deductible 40% After Deductible

Prescription Drugs:

Tier 1Tier 2Tier 3Tier 4Mail Order:Tier 1, Tier 2 and Tier 3

$10 Copay$30 Copay$50 Copay

20% to $200

2 x Copay

Per Pay Period Deductions (24)

Employee OnlyEmployee + SpouseEmployee + Child(ren)Employee + 2 or more

$ 76.12$ 127.44$ 127.44$ 182.35

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Anthem HDHP POS w/ Lumenos Blue HSA

Covered Benefits In-Network Out-of-network

Calendar Year DeductibleIndividual / Family $2,600 / $5,200 $5,200 / $10,400

Health Savings Account Contribution Maximum

Single - $3,450 / Family - $6,900

Coinsurance 100% / 0% 70% / 30%

Out of Pocket Calendar Year Maximum(Includes deductible and copays) Individual / Family

$3,600 / $7,200 $7,200 / $14,400

Lifetime Maximum Unlimited

Office VisitsPreventive ServicesPrimary Care PhysicianSpecialty Care PhysicianUrgent Care FacilityEmergency Room

Covered 100%0% After Deductible0% After Deductible0% After Deductible

0% After Deductible(waived if admitted)

30% After Deductible30% After Deductible30% After Deductible30% After Deductible

30% After Deductible (waived if admitted)

Inpatient Services(Facility, physician services, etc.)

0% After Deductible 30% After Deductible

Outpatient Services(Facility, physician services, etc.)

0% After Deductible 30% After Deductible

Prescription DrugsIn and Out of Network Subject to Medical Deductible

Tier 1Tier 2Tier 3

Mail Order:Tier 1, Tier 2 and Tier 3

$10 Copay After Deductible$35 Copay After Deductible$60 Copay After Deductible

2 x Copay

Per Pay Period Deductions (24)Employee OnlyEmployee + SpouseEmployee + Child(ren)Employee + 2 or more

$ 70.67$ 116.54$ 116.54$ 165.62

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Medical Plan Information

Deductible – (January 1 – December 31) You must pay all of the costs up to the deductibleamount before this plan begins to pay for covered services you use. The deductible is separatefor prescription drugs and does not apply to in network preventive services. Coinsurance andcopayments do not count towards the deductible.

Coinsurance – Your share of the cost of a covered service, calculated as a percentage of theallowed amount for the service.

Allowed Amount – The amount the plan pays for covered services is based on the allowedamount. If an out of network provider charges more than the allowed amount, you may haveto pay the difference.

Out-of-Pocket Limit – This is the most you could pay during a coverage period (usually oneyear) for your share of the cost of covered services. This limit helps you plan for your healthcare expenses.

Prescription Drugs – To search for your medications, visit https://www11.anthem.com/pharmacyinformation/ and select the Essential Drug List.

Locate a Provider - With Anthem Blue Cross Blue Shield of Georgia, you can choose from a diversenetwork of Primary Care Physicians (PCP) and other medical providers through their nationaldirectory.

Visit www.anthem.com to find a provider near you. Click on “Find a Doctor” to begin your search.Be sure to choose Blue Open Access HMO (or POS) as the “Plan /Network”.

Member/Patient Services:(855) 397-9269

For all Employees of Dawson County, Flexcare offers non-emergency medical assistance toyou and your immediate family at no cost. Using Flexcare’s national network, you canreceive a consultation by phone, video or mobile app. The membership is simple to use, visitwww.flexcare.com.

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Telemedicine – Administered through Flexcare

FlexCare

When can it be used: • When you cannot see the physician due to availability or time

• Cannot take time off work• On vacation or business trip• For a refill of a recurring prescription (short

term only)• Geographical barrier such as distance from

your provider• Pediatric care of any age

Top 10 Diagnoses: • Sinus Issues / Nasal Congestion• Urinary Tract Infection• Pink Eye• Bronchitis / Upper Respiratory• Allergies• Flu• Cough• Ear Infection• Headaches and Migraines• Stomach Aches

Maintaining our dental health is a large component in our overall health. While brushing andflossing may help us maintain our dental health, routine dental exams and cleanings arenecessary to remove bacteria, plaque and tartar and detect early signs of gum disease. Inaddition, regular dental visits may actually help reveal other previously unknown healthissues. To locate a provider, visit www.metlife.com and select the PDP Plus network.

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Dental Benefits – Administered through MetLife

Preferred Dentist Program Benefit

Calendar Year Deductible$50 Individual$150 Family

Out of Network Reimbursement 99th UCR

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

Preventive ServicesRoutine Exam, X-rays, Cleaning & Sealants 100%

Basic TreatmentFillings, Simple Extractions, Endodontics & Periodontics 80%

Major TreatmentImplants, Crowns , Bridges, Inlays, Onlays, & Dentures 50%

Orthodontia (Up to Age 19) 50%

Lifetime Orthodontia Maximum $1,000

Coverage Tier Per Pay Period (24 Pay Periods)

Employee Only $ 14.01

Employee + Spouse $ 28.46

Employee + Child(ren) $ 35.11

Employee + Family $ 49.50

Good visual health can play an important role in our overall health. For those of us with eyecare needs, having a vision plan available through our Employer can ultimately help offsetsome of those associated costs in preserving our eye health and ongoing wellness. Becominga member in the vision plan available through Dawson County will enable you to takeadvantage of substantial savings on your eye care and eyewear needs. For a list ofparticipating providers in the Blue View Vision network, go to www.anthem.com.

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Vision Benefits – Administered through Anthem

Benefit In Network Out-of-Network Frequency

Vision Exam $20 copay Up to $30 Once a calendar year

Contact Lenses

Elective Conventional

Elective Disposable

Medically Necessary

$130 allowance; 15% off balance

$130 allowance

Covered in Full

Up to $105

Up to $105

Up to $210

Once a calendar year

Lenses (per pair)Standard Plastic

Single VisionBifocal, Trifocal

Covered in Full after $20

Up to $25 Up to $40 Up to $55

Once a calendar year

Frames $130 allowance: 20% off balance Up to $45 Once every other

year

LASIK Discount per EyeLogin in to member services and select discounts, then Vision, Hearing & Dental

Coverage Tier Per Pay Period (24 Pay Periods)

Employee Only $ 2.56

Employee + Spouse $ 4.76

Employee + Child(ren) $ 5.01

Employee + Family $ 7.37

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Basic Term Life and AD&D Insuranceprovides valuable financial protection foryour family. Dawson County is pleased toprovide Basic Life & AD&D Insurance toall full-time employees in the amount of$50,000, at no cost to you.

In addition, Dawson County provides youwith Dependent Life and AD&Dinsurance in the amount of $5,000 for aneligible spouse and $2,500 for eacheligible child.

Dawson County also offers the option foryou to purchase additional Life Insurancecoverage. You may elect coverage on yourspouse and dependents, up to age 26, aslong as you elect coverage on yourself.

Basic Life & Voluntary Life Benefits – Administered through Lincoln Financial

Benefit Coverage

Employee Voluntary Life

Employee elections over $100,000 will require Evidence of Insurability (EOI).

You can purchase coverage in increments

of $10,000 up to a maximum of $500,000,not to exceed 5x your

annual salary.

New Hires: You will have a guarantee issue

5x salary up to $100,000.

Spouse Voluntary Life

Spouse elections over $20,000 will require Evidence of Insurability.

You can purchase coverage in increments

of $5,000 to a maximum of $100,000 not to exceed 50% of your employee coverage

amount.

New Hires: You will have a guarantee issue amount of $20,000 (not

to exceed 50% of EE amount).

Child(ren) Voluntary Life

You can purchase $5,000 or $10,000 in coverage for eligible

child(ren) not to exceed 100% of your employee

coverage amount.

Accelerated Life Benefit

If you are Permanently and Totally Disabled and

are diagnosed with a Terminal Condition, you may apply for payment of the Accelerated Life Benefit. Benefits will be paid in one lump sum to

you.

Annual EnrollmentNew participants can add life benefits up to 2 increments at open enrollment for themselves or their spouse without completing an Evidence of Insurability Form. Current participants can increase up to $20,000 (Employee) or $10,000 (Spouse) to their current coverage amount (including amounts over the Guaranteed Issue Amount), without completing an Evidence of Insurability form.

Voluntary Short-Term DisabilityNo one wants to think he or she might become injured in an off-the-job accident or comedown with an acute or chronic illness. An auto accident, a fall, an unexpected healthproblems, or even an expected maternity leave can impact your financial security. DawsonCounty offers you the protection you may need through the Short-Term Disability plan.

*Note: Premiums will automatically calculate online when you enroll.

Voluntary Long-Term DisabilityA long-term disability is one of the most devastating experiences that can happen to anemployee, impacting both your work and personal life in a major way. Protection for you andyour family is available through the Long-Term Disability insurance offered to you by DawsonCounty. LTD insurance provides the financial protection you may need during the allowableperiod of disability by paying you a monthly benefit.

What is a pre-existing condition? The plan does not cover pre-existing conditions, unlessyour disability begins after you have been covered under the plan for 12 consecutivemonths. A pre-existing condition is a condition for which you, during the 3 months prior toyour effective date, received medical treatment, took prescription medication or hadmedication prescribed, or had symptoms which would cause a reasonably prudent person toseek diagnosis, care, or treatment.

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Voluntary Short- and Long-Term Disability Benefits – Administered through Lincoln Financial

Short Term Disability(Employee Paid)

Benefit Amount 60% of weekly salary

Maximum Benefits $1,150 Per week

Benefits Begin After

(*Elimination Period)

0 Days – Accident

7 Days – Injury

Maximum Benefit Duration Up to 26 weeks

Pre-Existing Condition Exclusion 3/12

Long Term Disability(Employee Paid)

Benefit Amount 60% of monthly salary

Maximum Benefits $5,000 Per month

Benefits Begin After

(*Elimination Period)180 days

Maximum Benefit Duration Up to your Social Security Normal Retirement Age

Pre-Existing Condition Exclusion 3/12

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Life has its share of ups and downs — and sometimes you may need a little guidancethrough the “downs.” EmployeeConnectSM services included with your employer’s long-term disability insurance offer an array of confidential services to help you and your lovedones meet the challenges that life, work, and relationships can bring.

Unlimited 24/7 assistanceYou can access the following services anytime, online or with a toll-free call:• Information, resources, and referrals on family matters, such as child and elder care;

kennels and pet care; event and vacation planning; moving and relocation; car buying;college planning; and more

• Legal information and referrals for situations requiring expertise in family law, estateplanning, landlord/tenant relations, consumer and civil law, and more

• Guidance with financial matters, including household budgeting, and short-and long-term planning

In-person guidanceSome matters are best resolved by meeting with a professional in person. WithEmployeeConnect, you get:• In-person help for short-term issues (up to four sessions with a counselor per person, per

issue, per year)• In-person consultations with network lawyers, including one free 30-minute in-person

consultation per legal issue, and subsequent meetings at a reduced fee.

To take advantage of the EmployeeConnectSM program, or for more information. Visitwww.GuidanceResources.com or call 888-628-4824.

Employee Assistance Program (EAP)– Lincoln Financial

Participating in the Flexible Spending Account (FSA) available through your Employer canincrease your take-home pay by reducing your taxable income. It allows you to potentiallysave up to 30% on your eligible healthcare and/or dependent care expenses every year byusing pre-tax dollars instead of post-tax dollars to pay for those expenses.

We recommend that, prior to making an election, you consider and derive a conservativeestimate of how much you spend on healthcare and/or dependent care expenses for you andyour qualified dependents in one year. For example, you may want to consider yourestimated cost for prescription drugs, medical and dental office visit copays and/ordeductibles, as well as vision related needs including exams and prescription glasses/lenses.

Most FSAs require you use the funds you contribute within the plan year or you lose them.However, through the FSA available through Dawson County, you can now roll over up to$500 of unused contributions in your Healthcare Reimbursement FSA only.

This account has a Mastercard® debit card. This benefits has a $500 rollover provision.

The Internal Revenue Code does not allow you to enroll and contribute to the medical FSA ifyou are currently enrolled in the Anthem HDHP Plan with the Lumenos Health SavingsAccount.

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Flexible Spending – Administered through TASC

Highlights

Healthcare Reimbursements FSAMaximum Employee Contribution: $2,650 Annually

Dependent Care FSAMaximum Employee Contribution:$5,000 Annually (or $2,500 if married and filing separately)

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Important Notice from the Dawson 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 drugcoverage with Dawson County and about your options under Medicare’s prescription drug coverage. This information can help youdecide 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 coveragein your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of thisnotice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join aMedicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. AllMedicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for ahigher monthly premium.

2. Dawson County has determined that the prescription drug coverage offered by the BlueCross BlueShield HMO and Choice POS plansare, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and istherefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and notpay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

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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 Dawson County coverage will not be affected.

If you drop your current prescription drug coverage and enroll in Medicare prescription drug coverage, you may enroll back into theDawson County benefit plan during an open enrollment period under the Dawson County benefit plan.

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 the Dawson County and don’t join a Medicare drug plan within63 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% ofthe Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteenmonths 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 haveto wait until the following October to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage…

Contact the person listed below for further information NOTE: You’ll get this notice each year. You will also get it before the next periodyou can join a Medicare drug plan, and if this coverage through Dawson County changes. You also may request a copy of this notice at anytime.

For More Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get acopy 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 theirtelephone 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 aboutthis 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).

From: July 1, 2019 to June 30, 2020

Name of Entity/Sender: Dawson County

Contact Department: Human Resources

Disclosure Notice – Prescription Drug and Medicare Notice

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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Important Notice from the Dawson 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 drugcoverage with the Dawson County and about your options under Medicare’s prescription drug coverage. This information can help youdecide whether or not you want to join a Medicare drug plan. Information about where you can get help to make decisions about yourprescription drug coverage is at the end of this notice.

There are three important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join aMedicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. AllMedicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for ahigher monthly premium.

2. Dawson County has determined that the prescription drug coverage offered by the BCBSGA QHDHP POS Plan is, on average for allplan participants, NOT expected to pay out as much as standard Medicare prescription drug coverage pays. Therefore, your coverage isconsidered Non-Creditable Coverage. This is important because, most likely, you will get more help with your drug costs if you join aMedicare drug plan, than if you only have prescription drug coverage from the [Insert Name of Plan]. This also is important because itmay mean that you may pay a higher premium (a penalty) if you do not join a Medicare drug plan when you first become eligible.

3. You can keep your current coverage with BlueCross BlueShield’s QHDHP POS. However, because your coverage is non-creditable, youhave decisions to make about Medicare prescription drug coverage that may affect how much you pay for that coverage, depending onif and when you join a drug plan. When you make your decision, you should compare your current coverage, including what drugs arecovered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. Read this notice carefully - itexplains your options.

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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 Dawson County coverage will not be affected.

If you drop your current prescription drug coverage and enroll in Medicare prescription drug coverage, you may enroll back into theDawson County benefit plan during an open enrollment period under the Dawson County benefit plan.

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 the Dawson County and don’t join a Medicare drug plan within63 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% ofthe Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteenmonths 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 haveto wait until the following October to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage…

Contact the person listed below for further information NOTE: You’ll get this notice each year. You will also get it before the next periodyou can join a Medicare drug plan, and if this coverage through Dawson County changes. You also may request a copy of this notice at anytime.

For More Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get acopy 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 theirtelephone 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 aboutthis 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).

From: July 1, 2019 to June 30, 2020

Name of Entity/Sender: Dawson County

Contact Department: Human Resources

Disclosure Notice – Prescription Drug and Medicare Notice

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).

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your statemay have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. Ifyou or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but youmay be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visitwww.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your StateMedicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents mightbe eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877- KIDS NOW orwww.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay thepremiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employerplan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “specialenrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance.If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. Thefollowing list of states is current as of January 31, 2019. Contact your State for more information on eligibility –

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Disclosure Notice – CHIP

ALABAMA – Medicaid FLORIDA – MedicaidWebsite: http://myalhipp.com/Phone: 1-855-692-5447

Website: http://flmedicaidtplrecovery.com/hipp/Phone: 1-877-357-3268

ALASKA – Medicaid GEORGIA – MedicaidThe AK Health Insurance Premium Payment Program Website: http://myakhipp.com/Phone: 1-866-251-4861Email: CustomerService@MyAKHIPP.comMedicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: http://dch.georgia.gov/medicaid

- Click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507

ARKANSAS – Medicaid INDIANA – MedicaidWebsite: http://myarhipp.com/

Phone: 1-855-MyARHIPP (855-692-7447)

Healthy Indiana Planfor low-income adults 19-64 Website: http://www.in.gov/fssa/hip/Phone: 1-877-438-4479All other MedicaidWebsite: http://www.indianamedicaid.comPhone 1-800-403-0864

COLORADO – Health First Colorado (Colorado’s

Medicaid Program) & Child Health Plan Plus (CHP+)IOWA – Medicaid

Health First Colorado Website: https://www.healthfirstcolorado.com/

Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus CHP+ Customer Service: 1-800-359-1991/

State Relay 711

Website:

http://dhs.iowa.gov/ime/members/medicaid-a-to-z/hippPhone: 1-888-346-9562

KANSAS – Medicaid NEW HAMPSHIRE – Medicaid

Website: http://www.kdheks.gov/hcf/Phone: 1-785-296-3512

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdfPhone: 603-271-5218

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP

Website: http://chfs.ky.gov/dms/default.htmPhone: 1-800-635-2570

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/MedicaidMedicaid Phone: 609-631-239

CHIP Website: http://www.njfamilycare.org/index.html

CHIP Phone: 1-800-701-0710

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LOUISIANA – Medicaid NEW YORK – MedicaidWebsite: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331Phone: 1-888-695-2447

Website: https://www.health.ny.gov/health_care/medicaid/Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – MedicaidWebsite: http://www.maine.gov/dhhs/ofi/public-assistance/index.html

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

Website: https://dma.ncdhhs.gov/Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – MedicaidWebsite: http://www.mass.gov/eohhs/gov/departments/masshealth/

Phone: 1-800-462-1120

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/

Phone: 1-844-854-4825

MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIPWebsite: http://mn.gov/dhs/people-we- serve/seniors/health-care/health-care-programs/programs- and-services/medical-assistance.jsp Phone: 1-800-657-3739

Website: http://www.insureoklahoma.orgPhone: 1-888-365-3742

MISSOURI – Medicaid OREGON – MedicaidWebsite: http://www.dss.mo.gov/mhd/participants/pages/hipp.htmPhone: 573-751-2005

Website: http://healthcare.oregon.gov/Pages/index.aspxhttp://www.oregonhealthcare.gov/index-es.htmlPhone: 1-800-699-9075

MONTANA – Medicaid PENNSYLVANIA – MedicaidWebsite: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPPPhone: 1-800-694-3084

Website:http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htmPhone: 1-800-692-7462

NEBRASKA – Medicaid RHODE ISLAND – MedicaidWebsite: http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/accessnebraska_index.aspx

Phone: 1-855-632-7633

Website: http://www.eohhs.ri.gov/Phone: 401-462-5300

NEVADA – Medicaid SOUTH CAROLINA – Medicaid

Medicaid Website: https://dwss.nv.gov/

Medicaid Phone: 1-800-992-0900

Website: https://www.scdhhs.govPhone: 1-888-549-0820

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid

Website: http://dss.sd.govPhone: 1-888-828-0059

Website: http://www.hca.wa.gov/free-or-low-cost- health-care/program-administration/premium-payment- program

Phone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid WEST VIRGINIA – Medicaid

Website: http://gethipptexas.com/Phone: 1-800-440-0493

Website: http://mywvhipp.com/

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

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP

Medicaid Website: https://medicaid.utah.gov/CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.p df

Phone: 1-800-362-3002

VERMONT– Medicaid WYOMING – Medicaid

Website: http://www.greenmountaincare.org/Phone: 1-800-250-8427

Website: https://wyequalitycare.acs-inc.com/Phone: 307-777-7531

VIRGINIA – Medicaid and CHIP

Medicaid Website: http://www.coverva.org/programs_premium_assistance. cfmMedicaid Phone: 1-800-432-5924 CHIP Website:http://www.coverva.org/programs_premium_assistance. cfm

CHIP Phone: 1-855-242-8282

To see if any more States have added a premium assistance program since January 31, 2019, or for more information on special enrollment rights, you can contact either:

U.S. Department of Labor U.S. Department of Health and Human ServicesEmployee Benefits Security Administration Centers for Medicare & Medicaid Services

www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565

OMB Control Number 1210-0137 (expires 12/31/2019)

Unless otherwise noted, a paper copy is available, free of charge, by calling ShawHankins at 877-373-0730.

NOTICE OF YOUR HIPAA SPECIAL ENROLLMENT RIGHTS:If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance orgroup health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents loseeligibility for that other coverage (or if the employer stops contributing towards you or your dependents’ other coverage).However, you must request enrollment within 30 days after you or your dependents’ other coverage ends (or after theemployer stops contribution 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 or your dependents. However, you must requestenrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

SECTION 125 PRE-TAX BENEFIT AUTHORIZATION NOTICE:Before-tax deductions will lower the amount of income reported to the federal government. This may result in slightly reducedSocial Security benefits. If you do not enroll eligible dependents at this time, you may not enroll them until the next openenrollment period. You may not drop the coverage you elected until the next open enrollment period. You may only make achange or drop coverage elections before the next open enrollment period under the following circumstances:A change in marital status, orA change in the number of dependents due to birth, adoption, placement for adoption or death of a dependent, orA change in employment status for myself or my spouse, orOpen enrollment elections for my spouse, orA change in dependents eligibility, orA change in residence or worksite.Any change being made must be appropriate and consistent with the event and must be made within 30 days of when theevent occurred. All changes are subject to approval by your Employer/Plan.

WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998 ANNUAL NOTICE:The Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including all stages ofreconstruction and surgery to achieve symmetry between the breast, prostheses, and complications resulting from amastectomy, including lymph edema.

NEWBORNS’ ACT DISCLOSURE:Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length ofstay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attendingprovider after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours asapplicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from theplan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96) hours.

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION: This Notice describes how the Plan(s) may use anddisclose your protected health information ("PHI”) and how you can get access to your information. The privacy of yourprotected health information that is created, received, used or disclosed by the Plan(s) is protected by the Health InsurancePortability and Accountability Act of 1996 ("HIPAA"). This Notice is available on the web at: www dawsoncounty.bswift.com. Apaper copy is also available, free of charge, by calling your Employer or ShawHankins at 877-373-0730. Please note theparticipant is responsible for providing a copy to their dependents covered under the group health plan."

GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS: On April 7, 1986, a federal law was enacted (Public Law99272, Title X) requiring that most employers sponsoring group health plans offer employees and their families the opportunityfor a temporary extension of health coverage (called "continuation coverage") at group rates in certain instances wherecoverage under the plan would otherwise end. If you or your eligible dependents enroll in the group health benefits availablethrough your Employer you may have access to COBRA continuation coverage under certain circumstances. Therefore, yourplan makes available to you and your dependents the General Notice Of COBRA Continuation Coverage Rights. This noticecontains important information about your right to COBRA continuation coverage, which is a temporary extension of coverageunder the Plan. This notice generally explains COBRA continuation coverage, when it may become available to you and yourfamily, and what you need to do to protect the right to receive it. The full Notice is available on the webat: www.dawsoncounty.bswift.com . A paper copy is also available, free of charge, by calling your Employer or ShawHankins at877-373-0730. Please note the participant is responsible for providing a copy to their spouse/dependents covered under thegroup health plan.

SUMMARY OF BENEFITS AND COVERAGE (SBC): As an employee, the group health (medical) benefits available to you representa significant component of your compensation package. They also provide important protection for you and your family in thecase of illness or injury. Your plan offers a series of health coverage options. Choosing a health coverage option is an importantdecision. To help you make an informed choice, your plan makes available a Summary of Benefits and Coverage (SBC) whichsummarizes important information about any health coverage option in a standard format to help you compare across options.The SBC is available on the web at www.dawsoncounty.bswift.com. A paper copy is also available, free of charge, by callingyour Employer or ShawHankins at 877-373-0730. Please note the participant is responsible for providing a copy to theirdependents covered under the group health plan.

HEALTH INSURANCE MARKETPLACE NOTICE (a.k.a. Exchange Notice): When key parts of the health care law took effect in2014, a new way to buy health insurance became available through the Health Insurance Marketplace. To assist you as youevaluate options for you and your family, the Marketplace notice provides some basic information about the Marketplace andemployment-based health coverage offered by your employer. This notice is available on the web atwww.dawsoncounty.bswift.com. A paper copy is also available, free of charge, by calling your Employer.

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Disclosure Notice – Continued

Why Would I Contact the ShawHankins Service Center?

Order ID Cards: We can contact the insurance carrier directly and have yourreplacement card in ten to fifteen business days.

Claim Resolution and Research: We can help you understand your Explanation ofBenefits (EOB) as well as contact the insurance carriers on your behalf. We can assistin appealing a denied claim or help you request a Prior Authorization (PA) from yourphysician as may be required by your medical carrier. We can also help you file out-of-network claims and assist with reimbursement if you require medical assistance whiletraveling outside of the United States.

Locate In-Network Providers: Staying in network saves everyone money. Our ServiceCenter can help you locate in-network providers for medical, dental and visioncoverage whether you are at home or away.

Request Copies of Any Necessary Forms: Medical claim forms, out-of-network claimforms, evidence of insurability forms, short and long term disability claim forms andany other applicable forms are always available if the need should arise.

Understanding Your Benefits: We can assist you with questions regarding deductibles,copayments and coinsurance. We can explain waiting periods, elimination periods andeligibility rules.

Explain Qualifying Events: Most benefit plans require that you have a Qualifying Event(like marriage, birth of a child or other life event) to make a change in your electionanytime other than during open enrollment. We work with your employer to ensurethat your change follows the rules of the plan, that your request is allowed within theappropriate timeframes, and that your give proper documentation of the event.

Annual Enrollment Information: We can provide details about when open enrollmentbegins and ends and if your plan designs or payroll deductions are changing.

Enrollment Assistance: The Service Center representative can walk you through everystep of the enrollment process. Whether it’s an online enrollment or paper enrollmentform, your Service Center representative is available to help.

Confirmation Statements: We can provide copies of your online enrollmentconfirmation statement or a copy of your paper enrollment form at any time.

The Service Center is available from 8:30 a.m. to 5:00 p.m. Monday through Friday toassist you. We have an after-hours voice mailbox and your call will be returned thenext business day.

877-373-0730customerservice@shawhankins.com

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Contact Information

Plan Administrator Website Phone Number

Benefit / Enrollment Questions

ShawHankins www.shawhankins.com (877) 373-0730

Medical, and Vision

Anthem www.anthem.com (855) 397-9267

Dental MetLife www.metlife.com (800) 942-0854

Basis Life AD&D, Voluntary Life, STD and LTD

Lincoln Financial

www.lfg.com (877) 275-5462

Telemedicine FlexCare www.flexcare.com (404) 846-4100

Health Savings account (HSA)

Health Equity www.healthequity.com (866) 346-5800

Employee Assistance Program (ComPsych)

Lincoln Financial

www.guidanceresources.com (888) 628-4824

Flexible Spending Account (FSA)

TASC www.tasconline.com (800) 422-4661

COBRA TASC www.tasconline.com (800) 422-4661

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shawhankins.com1-877-373-0730