2020 - 2021

EMPLOYEE NEWHIRE GUIDE

1. Self enroll via EMB’s secure website

2. Using the EMB Mobile App

YOUR BENEFITS AT A GLANCE

As a benefiteligible employee, now is thetime to make your annualplan elections for theupcoming plan year.Following yourinitial enrollment period,annual enrollment is youronce‐a‐ year‐opportunity toenroll in the various benefitofferings or make changes toyour current benefit elections,such as adding orremoving dependents(outside of a life‐ changingevent). Benefit elections canonly be made when firsteligible and/or at annualenrollment. No changes inelections can be madeduring the plan year unlessthere is a qualifying event(birth, adoption, divorce,death, changein employment status, lossof other coverage,etc.) Qualifying eventchanges requested duringthe plan year must be madewithin 30 days of the actualqualifying event. Pleasecontact Lakeisha Hauglandat the Business Office if youhave questions aboutqualifying events.

Under the medicalinsurance plans, deductiblesand out of pocket maximumscontinue to accumulate on acalendar year basis (Jan. 1 –Dec. 31), but our plan yearruns from July 1 – June 30th.This means any deductibleamount(s) you may havesatisfied between Jan. 1 –June 30, 2020 will continueto accumulate until Dec.31, 2020 and then start overon Jan. 1, 2021

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Welcome to Fort Dodge!YOU HAVE 3 OPTIONS TO ENROLL IN BENEFITS

As always, we value you as a member of the FDCSD family and look forward to a healthy and safe year.

Even if you are waiving coverage, you must still complete the enrollment process. This organizer will help you gather the information needed for your enrollment. THIS DOCUMENT IS NOT CONFIRMATION OF YOUR ENROLLMENT ELECTIONS, BUT SIMPLY A TOOL FOR YOUR USE IN PREPERATION OF YOUR ENROLLMENT SESSION. YOU WILL NOT TURN THIS FORM IN.

NOT SURE HOW TO GET STARTED? DON’T WORRY!

Prior to open enrollment, you will receivestep-by-step enrollment instructions by email from our team.

Until then, now is the perfect time to prepare by doing the following:

Checking that your personal information is accurate at www.explainmybenefits.com/FDCSD

Reviewing the benefits in which you are currently enrolled

Checking out the plans being offered for the coming year

Providing meaningful healthcare‐related benefits to you and your family remains a high priority of the Fort Dodge Community School District (FDCSD). Our comprehensive benefits package includes medical, dental, vision, employer paid life and accidental life and disability (AD&D), voluntary life, long term disability, and voluntary benefits, such as accident,critical illness, short term disability, and medical bridge (hospital confinement) coverages.

https://www.explainmybenefits.com/FDCSD

ACCESSINGEMB NROLLe

GETTING STARTEDAccess your company’s Benefits Resource Website and select

“Log Into Your Benefit System”

A

B C

A

B

Access the system using your Username and Password

Forgot username• Enter your 9-digit ID (SSN without dashes)• Answer your three security questions•Your username will be emailed to your email address on file (watch for an email fromautobenestatus@autobene.com)

C Forgot password• Enter your username• Answer your three security questions• Enter and confirm your new password• Confirm your email address; you will receive a confirmation of the change

CREATE NEW ACCOUNT

AB

C

A • Hover over the question mark next to each field for specific instructions

B • Enter the required Employee ID and PIN as instructedC • Click “Create New Account”

In the event the system advises that an account already exists, return to the “Log In” steps above.

USERNAME AND PASSWORD CRITERIA

Username:• At least one (1) letter and one (1) number• Between 8 - 32 characters• Not the same as your password• No more than three sequential characters(abc, cba, 123, 321)• No more than three repeating characters(aaa, 111)• Permitted special characters: @ . - _ *• Your username must be unique

Password:•At least one (1) uppercase letter and one (1) lowercase letter• At least one (1) number• Between 8 - 20 characters• Not the same as your username• No more than three sequential characters(abc, cba, 123, 321)• No more than three repeating characters(aaa, 111)• Permitted special characters: @ . - _ *•Password cannot be the same as your previous 10 passwords on this system

Referencing the criteria to the left:

• Create your Username and Password

• Choose your Security Questions and Answers• Click Continue.

Three (3) SecurityQuestions with Answersand a valid email address are required to validate

identity.

NEW HIRE EMPLOYEES ANDFIRST TIME USERS ARE REQUIRED

TO CREATEANEW ACCOUNT

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Welcome..................................................................................2

Contact Information & Table of Contents.........................4

Understanding Medical Plan Options ................................5

Care Options and When to Use Them .............................6

Medical Insurance Plan Options and Costs....................7

2020/2021 Medical Plan Contributions.............................8

Understanding Health Savings Account (HSA)...............9

Dental Insurance ................................................................11

Vision Insurance……………………………………………..12

Basic Life and AD&D ..........................................................13

Supplemental Life...............................................................14

Disability Insurance.............................................................17

Voluntary Coverage..........................................................18

Section 125 Flexible Savings Account ...........................19

Important Notices…………………………………………...27

Glossary………………………………………………………..37

CONTACT INFORMATIONAs Fort Dodge Community School District’s benefits broker/ consultant, CBIZ Benefits & Insurance Services is committed to providing legendary service. Due to this dedication, we provide a customer service department that specifically handles your claims and expedites resolution. This department works on a variety of claim administrative tasks but does not actually process claim payment. FDCSD contacts in the Business Office can also be reached as follows: Lakeisha Haugland at (515)-574–5646 (lhaugland@fdschools.org) or Anna Toohey at (515) 574-5649 (atoohey@fdschools.org).

The majority of claim problems can be resolved by a simple phone call directly to the carrier. We request that you contact your carrier first when you have questions regarding your benefits or claim determination.

MedicalUMRwww.umr.com 1-800-826-9781

PharmacyRx Benefits www.rxbenefits.com 1-866-769-5987

DentalDelta Dental of Iowa www.deltadentalia.com 1-800-544-0718

VisionAvesis www.avesis.com 1-800-828-9341

Life AD&D, Supplemental Life/AD&D, and Long Term Disability (LTD)

One America www.oneamerica.com 1-800-553-5318LTD Claims—1-800-553-3522Life/AD&D Claims—1-855-517-6365

Flexible Spending AccountsUMRwww.umr.com 1-800-826-9781

Pharmacy Advocate Program Tria Health www.triahealth.com1-888-799-8742

TABLE OF CONTENTS

CBIZ Representative(s)

Natasia Peterson, Account Manager 816-841-3470natasia.peterson@cbiz.com

Jennifer McKee, Senior Account Executive 816-945-5205jmckee@cbiz.com

mailto:lhaugland@fdschools.orgmailto:atoohey@fdschools.orghttps://www.umr.com/https://www.rxbenefits.com/https://www.deltadentalia.com/https://www.avesis.com/https://www.oneamerica.com/https://www.umr.com/https://www.triahealth.com/mailto:natasia.peterson@cbiz.commailto:jmckee@cbiz.com

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FDCSD IS EXCITED TO ANNOUNCETHAT UMR WILL CONTINUE AS OURMEDICAL INSURANCE PROVIDER

UMR MEDICAL PLANFDCSD is pleased to continue to offer two medical plan choices. You have the option of enrolling in a traditional PPO plan or the Qualified High Deductible Health plan(QHDHP). If you elect the QHDHP, you will also have access to a Health Savings Account (HSA). You can choose from these plans based on your specific needs.

A general summary of benefits and 2020/2021 premiums are detailed on the following pages. A more detailed summary from UMR is found on the EMB Portal by selecting the Summary link on www.explainmybenefits.com/FDCSD.It outlines the 2020/2021 benefits available for your review and consideration.Both medical plans utilize the same network of providers ‐ UnitedHealthcare Options PPO network. You are not restricted to choosing one doctor to administer all your care; you can see any provider in the network without a referral. It is your responsibility to verify your physician’s participation in the network prior to services. You can find the most recent and accurate list of providers on the UMR website or by calling customer service at 1-800‐826‐9781.

To find helpful benefit information and tools, log on towww.umr.com and register as a member.Through www.umr.com, you will have the ability to:• Find Doctors & Hospitals• Check ClaimStatus• Order New ID Card• Print Temporary ID Card• View Benefits• Access Health and Wellness Ideaswww.umr.comUMR Customer Service 1-800‐826‐9781

Express Scripts administered through RxBenefits is the pharmacy administrator for the FDCSD. As a reminder, medications under the prescription drug program continue to be subject to one or more of the following changes during any given plan year: prior authorization, quantity limits, level changes, and/or safety edits. Please be mindful of this when obtaining prescriptions from your physician and/or when filling your medication. It’s always a good practice to ask for a generic equivalent, if available.

Don’t forget about the 100% paid preventive generic drugs that are available under the QHDHP Plan (Option 1). This program includes coverage for certain generic preventive medications for a $0 copay (you don’t have to satisfy a deductible first). The drugs on this list help protect against or manage a medical condition. Preventive drugs are intended to maintain your quality of life and keep you from developing other conditions. Be sure to review the partial list of medications that will be included in your enrollment materials. If you don’t see a particular medication, contact RxBenefits at 866-769-5987 to see if it’s available under this program.

Preferred Drug List, Exclusion List and Medication List are available at Express-Scripts.com

MEDICAL INSURANCE

Did you know you have a mail order prescription drug benefit for maintenance medications? You can receive up to a 90‐day supply of medication for only two months’ worth of copays or costs! This is a savings in dollars and time – your prescription drugs are mailed to you at your home address through Express Scripts which is administeredbyRxBenefits.

https://www.explainmybenefits.com/FDCSDhttps://www.umr.com/https://www.umr.com/https://www.umr.com/

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● Sprains● Small cuts● Strains● Sore throats

● Minorinfections

● Vaccinations● Screenings

● Routine, primary/ preventive care

● Non-urgent treatment

● Common infections(Ear infections, pink eye, strep throat)

● Flu shots● Pregnancy tests

PRIMARY CARE

For routine, primary/ preventive care or non-urgent treatment, we recommend going to your doctor’s office. Your doctor knows you and your health history and has access to your medical records. You may also pay the least amount out of pocket.

CONVENIENCE CARE

These providers are a good alternative when you are not able to get to your doctor’s office and your condition is not urgent or an emergency.

They are often located in malls or retail stores (such as CVS Caremark, Walgreens, Wal-Mart and Target), and generally serve patients 18 months of age or older without an appointment. Services may be provided at a lower out-of-pocket cost than an urgent care center.

URGENT CARE

Sometimes you need medical care fast, but a trip to the emergency room may not be necessary.

During office hours, you may be able to go to your doctor’s office. Outside regular office hours—or if you can’t be seen by your doctor immediately—you may consider going to an Urgent Care Center where you can generally be treated for many minor medical problems faster than at an emergency room.

EMERGENCY ROOM

An emergency medical condition is any condition (including severe pain) which you believe that, without immediate medical care, may result in serious injury or is life threatening.

Emergency services are always considered in-network. If you receive treatment for anemergency in a non-network facility, you may be transferred to an in-network facility once yourcondition has been stabilized.

URGENT CARE

PRIMARY CARE

CONVENIENCE CARE

EMERGENCY ROOM

If you believe you are experiencing a medical emergency, go to the nearest emergency room or call 911, even if your symptoms are not described here.

CALL 9-1-1

Care OptionsWhile we recommend that you seek routine medical care from your primary care physician whenever possible, there are alternatives available to you. Services may vary, so it’s a good idea to visit the care provider’s website. Be sure to check that the facility is in-network by calling the toll-free number on the back of your medical ID card, or by visiting www.umr.com

● Heavy bleeding

● Large open wounds

● Chest pain

● Spinal injuries● Difficulty

breathing

● Major burns

https://www.umr.com/

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A non-embedded/aggregate deductible means if you have family coverage, the entire family deductible must be satisfied before eligible benefits are paid (exception: preventive care is covered at 100% in-network and not subject to the deductible). Once the family deductible is satisfied, then covered services will be paid at the applicable coinsurance level.

The above information is a summary of benefits only and is not intended to be inclusive of all benefits, limitations, and/or exclusions. In all cases, the carrier’s contract will govern at all times.

Medical Insurance Plan Options and Costs

UMR

Option 1 Option 2

$2,500/$5,000 Ded. QHDHP Plan/HSA Eligible $500/$1,000 Ded./$20 Copay Plan

Calendar Year Deductible

IndividualFamily

In Network Non-Network Non-Embedded/Aggregate Deductible*

$2,500$5,000

In Network Non-Network

$500$1,000

In-Network Out-of-Network In-Network Out-of-Network

Calendar Year Out of Pocket Max (Includes Deductible)Individual / Family

$2,500/$5,000 $1,500/$3,000

Health Savings Account (HSA)? Yes No

Member Coinsurance 0% 20% 10% 30%

Office Visits Deductible then 0% Deductible then 20% $20 Copay Deductible then 30%

Preventive CareCovered at100%

(Deductible Waived) Deductible then 20%Covered at100%

(Deductible Waived) Deductible then 30%

Inpatient Hospital Services Deductible then 0% Deductible then 20% Deductible then 10% Deductible then 30%Prescription Drug

RetailTier 1Tier 2Tier 3Specialty Drugs

Mail Order (via OrchardPharmaceutical Service)

Medical Deductible then 0% for all tiers

Deductible then 0% for a 90 day supply

Medical Deductible then 20% for all tiers

Deductible then 0% for a 90 day supply

No Rx Deductible$10$20$30$85

2x retail co-pay for 90 day supply

Dependent Age Limit Up to age 26 (terminates on the last day of the birthday month) or the month they are no longer an eligible dependent, whichever is first

Tria Health is our voluntary pharmacy advocate program. You qualify for this program if you have one of the identified chronic conditions (high blood pressure, diabetes, asthma, osteoporosis, heart conditions, and/or depression) and are taking at least 4 medications. The plan is designed to (1) ensure your medications are safe based on your unique individual situation, (2) are affordable to you, and (3) are the most effective at treating your condition(s). Since not all medications are prescribed by the same provider, is it important to monitor drug interactions, contradictions, and safe dosage levels. Your Tria Heath advocate, a licensed pharmacist, will review your medications and provide you with an action plan to be shared with your provider(s). If you enroll and stay active in the program, you may be eligible for reduced pharmacy copays. If you are eligible, why not join and get started with this valuable benefit! Tria will also identity eligible members from pharmacy claims. Tria will reach out directly to those members via mailers, email, postcards and outbound phone calls.

To Enroll, visit: https://triahealth.com/enroll

https://triahealth.com/enroll

Option 1$2,500/$5,000 Ded.QHDHP MONTHLY Rates—Effective July 1, 2020

Plan

Total Cost District Pays You Pay

Employee Only $572.86 $572.86 $0.00

Employee + Family $1,432.18 $859.32 $572.86

Option 2

$500/$1,000 Ded./$20 Copay Plan

MONTHLY Rates—Effective July 1, 2020

Total Cost District Pays You Pay

Employee Only $745.06 $745.06 $0.00

Employee + Family $1,862.64 $1,117.58 $745.06

Premiums will be deducted on pre-tax basis unless specifically requested otherwise.

2020/2021 Medical Plan Contributions

*Premiums are deducted on a pre-tax basis. Please note that premiums reflected are shown as monthly costs and annualized for 12 months of coverage. If you are an 18 paycheck employee or starting work after the beginning of the plan year please confirm with the Business Office to determine your final premium cost as it may be more than is shown on your benefits confirmation form during enrollment.

· The 2020/2021 medical premiums will remain the same as the rates in effect for the2019/2020 plan year (this includes both the District’s portion as well as your portion). The District will continue to pay 100% of the employee only rate, regardless of plan enrolled in, and it will continue to be your responsibility to pay for any additional premiums for family/dependent coverage.

· Spouses who both work for the District, with no eligible dependents, and want to enroll in coverage, will each elect single employee medical coverage. The employee monthly contribution will be $0 per enrolled employee.

· Spouses who both work for the District, and have eligible dependents to cover, will enroll as a family unit for medical coverage. Couples in this situation will designate one spouse as the “employee” to elect the coverage for the family, and then the other spouse will “waive” their coverage and be listed as a dependent spouse on the family plan. The employee monthly contribution will be $0 for the family. Please be sure to coordinate your enrollment with your spouse. Spouses who both work for the district and do not have any eligible dependents should each enroll in single coverage.

· Dependent coverage ends the last day of the month that the dependent turns 26 or is no longer eligible.

· IMPORTANT NOTE: If you and/or your spouse are close to or over age 65, you may want to evaluate your medical insurance needs through Medicare to help manage your insurance costs. As long as you are a full-time employee, you and your spouse may continue on the District’s group plan up to and past age65. However, if you choose to pursue Medicare coverage, please be aware that the Federal government imposes strict guidelines and timelines for which you can apply for Medicare coverage. You are encouraged to evaluate any and all options to determine the best coverage for your needs. If you should wish to make changes, you must notify Lakeisha Haugland within 30 days of any requested changes.

· By reviewing all your options, you get to decide the plan that is best suited for you both in coverage and in price!

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HEALTH SAVINGSACCOUNT (HSA)

UNDERSTANDING A HEALTH SAVINGS ACCOUNT (HSA)What is an HSA?•An HSA combines a lower medical premium with anemployee‐directed, tax‐advantaged savings account.Why should I choose an HSA?•You pay a lower premium rate for a HighDeductible Health Plan (HDHP). The savings youaccumulate in monthly premiums can be placedinto a Health Savings Account that rolls over fromyear to year. These funds can be used toward yourdeductible. Remember that the deductible runs on a calendar year basis!•An out‐of‐pocket maximum provides a built‐in capon annual health care expenses. You know exactlywhat the maximum amount due for in‐network plan benefits.•Preventative care is always covered at 100% and is not subject to the deductible.•Contributions and investment earnings are tax‐free,as are disbursements from the account to pay forqualified expenses. Funds withdrawn for non‐qualified expenses will be assessed a 20% penalty inaddition to normal taxation. The penalty is waived inthe event of death, disability, or attainment of Medicare eligible age.•An HSA works much like an IRA. The money is yoursand rolls over year to year, accumulating as youage, and from one qualified HDHP to another. FortDodge Community School District utilizes Great Western Bank as the H.S.A plan administrator.•Besides your health plan deductible, HSA qualifiedmedical expenses include the same type ofexpenses covered by a Section 125 flexible spendingaccount (e.g. dental, vision, and prescription drugout‐of‐pocket costs), and some expenses notallowed under Section 125: such as COBRA premium,post‐age 65 retiree health insurance premium otherthan Medicare supplement policies, some Long TermCare insurance premiums, and health insurance premiums if you are receiving unemployment.•Flexible Spending Account (FSA), whether it belongsto the employee or a spouse, is considered “firstdollar” coverage and therefore you cannotcontribute to an HSA if you are eligible for an FSA. Ifyour spouse is enrolled in a flexible spendingaccount, you by default are eligible for his/herflexible spending account plan and cannot contribute to an HSA.

NOTE: If you are newly eligible to participate in an HSA, it is YOUR responsibility to visit Great Western Bank and open an HSA Bank account within 30 days prior to your first July check. You can go to either branch of Great Western Bank in Fort Dodge. You will need to provide your driver’s license to the teller and request to open an HSA with the Fort Dodge Community School District. After the account has been established, you must provide your new account number to Lakeisha Haugland at the Business Office so that the District can fund your account. If you fail to do this, no funds will be deposited. Funds must be deposited within 30 days or the account will be closed.

HSA and High Deductible Health Plan important points:

•Obtain care from your provider as you normally would. Always present your UMR ID card.

•You should not need to make payment at the time of service, since covered services are subject to your deductible and coinsurance.

•Your network provider will file a claim on your behalf.

•You will receive an Explanation of Benefits (EOB) showing the patient responsibility after contracted discounts. Make payment to your provider at this time.

•Prescription drug costs are subject to the annual deductible. At the point of sale, you will be responsible for the full negotiated cost of the prescription medication.

•You are responsible for ensuring your HSA dollars are used for qualifying healthcare expenses. You are encouraged to keep receipts and documentation of HSA expenses with your tax records

HSA Eligibility Requirements:

· A person must enroll in a qualified high deductible health plan (QHDHP)

• A person is not eligible to participate in an HSA if: Enrolled in Medicare (Part A, B, or D)

• Can be claimed as a dependent on someone else’s tax return

• Covered by a non‐QHDHP such as TRICARE or covered by VA benefits and have used VA medical services within the 3 months prior to enrolling in an QHDHP

• Covered by another health plan that is not a QHDHP

• If you have dual medical coverage (through a spouse, for example) and your other coverage is considered “first dollar” (i.e. there are copays for an office visit or prescription drug), then you are NOT eligible to contribute to an HSA. However, if yourspouse has a QHDHP medical plan and you are also enrolled in it, then you are still eligible to contribute to an HSA so long as there are no first dollar benefits.

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Frequently Asked Questions about HSAs

·

· If you choose option 1, the $2,500/$5,000 QHDHP medical plan, you are eligible to participate in an HSA.

· For employees that choose to participate in the QHDHP, the Fort Dodge Community School District will make a contribution of $1,500 for those enrolled in employee only medical coverage and $3,000 for those enrolled in family medical coverage into the HSA! Not only will you be saving in premium dollars by enrolling in the QHDHP, but you also will be receiving a monetary contribution from the District to be used on future eligible healthcare expenses! Employer funds will be deposited into the HSA as follows: half up front and then the other half divided equally each month over the next 5 months of the policy year (i.e. for individual coverage, $750 up front and then the balance paid in monthly installments by December 31, 2020). In order to receive this contribution, you must have an HSA bank account at Great Western.

· For the 2020 tax year, maximum contributions to your HSA are $3,550/individual or $7,100/family. The maximum includes both employer and employee contributions. A catch-up contribution for individuals aged 55 and over is allowed in addition to the maximums noted above. The catch-up contribution for the 2020 tax year is an additional$1,000.Please note, you can make contributions to your HSA account in addition to the amount that FortDodge Community School District contributes to your account. However, the combination of FortDodge’s contribution and your contribution cannot be more than the 2020 tax year maximum.The district contribution coincides with the plan year (July to June), but the legally mandatedmaximums are per calendar year (January to December). Therefore, it is important to consult withthe Business Office when contemplating changes to YOUR contribution.

REVIEW YOUR DENTALPLAN

DENTAL INSURANCE

The District will continue to offer dental insurance through Delta Dental of Iowa for the upcoming plan year.

You may see any dentist of your choice; however, there will be an increase in payment if that dentist is not part of the Delta Dental network. If you receive services from an Out‐of‐Network dentist, your out‐of‐pocket expenses will increase. You are the one responsible for verifying if your dentist(s) participate in the network.

Spouses who both work for the District, with no eligible dependents, and want to enroll in coverage, will each elect single employee dental coverage. The employee monthly contribution will be $0 per enrolled employee.

Spouses who both work for the District and have eligible dependents to cover, will enroll as a family unit for dental coverage. Couples in this situation will designate one spouse as the “employee” to elect coverage for the family. The other spouse will “waive” his/her coverage and be listed as a dependent spouse on the family plan. The employee monthly contribution for the family coverage in this situation will be $53.40 per month, which is $116.88 ‐ $63.48 ($63.48 = 2 x $31.74 employee premium). Spouses who work for the district and do not have any eligible dependents should each enroll in single coverage.

Who to contact with dental‐related questions? Delta Dental of Iowa Customer Service at 1-800‐544‐0718.

Also, you can visit www.deltadentalia.com for secure access to personal claims, to find a participating provider in the Delta Dental PREMIER network, or to download the mobile app to view and show your ID card to providers.

Dental MONTHLY Rates—Effective July 1, 2020

Plan Total Cost District Pays You Pay

Employee Only $31.74 $31.74 $0.00

Employee + Family $116.88 $31.74 $85.14

Delta Dental of IowaIn-Network

Premier Network Out-Of-Network

Calendar Year Deductible (Ded.) $25 indiv./$75 family (waived for Preventive), combined in and out of network

Calendar Year Max. Benefit $1,000 per person, combined in and out of network

Lifetime Orthodontia Max. Benefit $1,000 per person, combined in and out of network

Preventive -(exam, cleanings, periodic x-rays etc.)

You pay 0% (plan pays 100%)

Preventive care does not apply to your calendar year maximum

You pay 0%(plan pays 100%

Basic -(fillings, oral surgery, general anesthesia, root canal, etc.)

Ded. Then you pay 20% (plan pays 80%)

Ded. Then you pay 20% (plan pays 80%)

Major - (bridges, dentures, crowns, etc.)Ded. Then you pay 50%

(plan pays 50%)Ded. Then you pay 50%

(plan pays 50%)

Orthodontia—(braces)

Ded. Then you pay 50% (plan pays 50%)

For children under age 19

Ded. Then you pay 50% (plan pays 50%)

For children under age 19

Dependent Age Limit Up to age 26 (at the end of the birthday month) or the month they are no longer dependent eligible, whichever is first

Premiums will be deducted on pre‐tax basis unless specifically requested otherwise. Rates did not change from last year.

Remember, with out‐of‐network providers, you may have additional out of pocket expenses. The above comparison is for illustrative purposes only and doesnot include all benefits, plan limitations, and/or exclusions. Please refer to the actual Delta Dental benefit summary/Summary Plan Description (SPD) for detailed information. In the event there is a discrepancy in benefits, the carrier benefit summary/SPD will always govern.

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https://www.deltadentalia.com/

REVIEW YOUR VISIONPLAN

Key Highlights of the plan:

•Access the PPO network of providers, including private practice and retail chains

• Copay for exam is $10

• Copay for materials is $25

•$150 allowance per lifetime PLUS up to 25% discounted pricing for Lasik surgery

•Allowances for frames is equivalent to $150 retail, plus 20% off any amount over the allowance

• Extra discounts and savings up to 20% on all non‐covered items/upgrades

•Remember, with out‐of‐network providers, you may have additional out of pocket costs. It is your responsibility to determine if your provider is part of the network.

Avesis Vision PPO Plan

VISION INSURANCE

In-Network Out-of-Network

Examination CopayExamsMaterials

$10$25

Frequency of Service

12Months12Months24Months

ExamLenses (contact lenses or lenses for glasses)Frames

Reimbursement Schedule (carrier pays)100%

100%100%100%100%

$130 Allowance$150 Allowance

Up to $35

Up to $25Up to $40Up to $50Up to $80

Up to $110Up to $50

ExamsGlass Lenses

Single VisionBifocalTrifocalLenticular

Contact Lenses (in lieu of glasses)Frames

Dependent Age LimitUp to age 26 (at the end of the birthday month), or the month

they are no longer dependent eligible, whichever is first.Must reside in Iowa.

The above comparison is for illustrative purposes only and does not include all benefits, plan limitations, and/or exclusions. Pleaserefer to the actual benefit summary/Summary Plan Description (SPD) for detailed information. In the event there is a discrepancyin benefits, the carrier benefit summary/SPD will always govern.

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Vision Plan

MONTHLY Rates—Effective July 1, 2020

Total Cost District Pays You Pay

Employee Only $8.30 $0.00 $8.30

Employee+ Spouse

$16.25 $0.00 $16.25

Employee + Children

$17.71 $0.00 $17.71

Employee+ Family

$22.77 $0.00 $22.77

Premiums will be deducted on pre‐tax basis unless specifically requested otherwise. Rates did not change from last year.

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BASIC LIFE ANDAD&D

BASIC LIFE AND AD&D INSURANCEAs a benefit eligible employee, Fort Dodge

Community School District provides you with a

life and accidental death and dismemberment

(AD&D) benefit based on your job classification.

One America will be the provider of these

benefits for the upcoming plan year. All basic life

insurance programs are paid 100% by Fort

Dodge Community School District, and

coverage terminates at retirement. The life

insurance policy has an age reduction schedule

whereby benefit amounts reduce to 65% at age

70 and 50% at age 75.

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SUPPLEMENTAL LIFE ANDAD&D

REVIEW YOURLIFE INSURANCEPOLICY

Add your spouseAdd your dependents Increase your coverage

SUPPLEMENTAL LIFE AND AD&D INSURANCE

A Supplemental Life and A&D Insurance program is available to all employees and their eligible dependents –this is in addition to the basic plan provided by the District. OneAmerica will be the provider of these benefits for the upcoming plan year.

Employee Benefit:The Voluntary Life and AD&D Plan allows for an employee to elect coverage from $10,000 to $250,000 up to 5x your annual salary in voluntary life and AD&D insurance in increments of $10,000. If you currently have Voluntary Life coverage, you can increase coverage $10,000 up to $100,000 without completing an Evidence of Insurability (EOI) form. If you would like to elect more than a $10,000 increment, you will need to complete an Evidence of Insurability form and OneAmerica will need to approve the additional coverage. If you did not elect Voluntary Life coverage at open enrollment last year or during your new hire enrollment, you will need to complete an Evidence of Insurability (EOI) form for any amount that you choose to elect. If this is your first time enrolling, you can elect up to $100,000 or 5x your annual salary whichever is less without completing an Evidence of Insurability form. If you choose to elect more than $100,000 you will need to complete an Evidence of Insurability for OneAmerica to approve the amount over $100,000.

Spouse Benefit:You may also elect Voluntary Life and AD&D Insurance for your spouse if you enroll in the coverage as an employee. You can apply for dependent spouse life and AD&D insurance from $5,000 to $50,000 in $5,000 increments (not to exceed 50% of the employee’s amount). If you currently have Voluntary Spouse Life coverage and would like to increase your spouse’s benefit, you will need to complete an Evidence of Insurability form and OneAmerica will need to approve the additional coverage. If you did not elect spouse Voluntary Life coverage at open enrollment last year or during your new hire enrollment, you will need to complete an Evidence of Insurability (EOI) form for any amount that you choose to elect. If this is your first time enrolling you can elect up to $30,000(Not to exceed 50% of the employee’s amount without completing an Evidence of Insurability form. If you choose to elect more than $30,000 you will need to complete an Evidence of Insurability for OneAmerica to approve the amount over $30,000.

Spouse rates are based on employee’s age.

Dependent child(ren) benefit:If you enroll as an employee, you may also elect Voluntary Life and AD&D Insurance for dependent children, from birth to age 26. Regardless of the number of dependent children enrolled, the employee pays a flat premium of $1.53 per month for $10,000 of coverage per dependent.

Important note ‐ Spouses who both work for the District, and have eligible dependents, can only enroll in this program as one family unit: an employee, the spouse, and dependent child/ren. Each employee cannot independently enroll and cover the spouse and the dependent child/ren. This is considered double coverage and is not allowed.

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SUPPLEMENTAL LIFE(CONTINUED)

How do I calculate my premium?Example 1 = Employee age 35 requesting $100,000 in life and AD&D coverage would pay $12.00 a month in premium ($100,000 / 1,000 x $0.12 = $12.00).

Example 2 = Employee age 50 requesting $100,000 in life and AD&D coverage+ $30,000 in spouse life coverage would pay $41.60 a month in premium.$41.60 = $32.00 + $9.60 = ($100,000 / 1,000 x ($0.32)) + ($30,000 / 1,000 x $.32).

Example 3 = Employee age 35 requesting $50,000 in life and AD&D coverage+ $10,000 in dependent child life coverage for 3 children would pay $7.53 amonth in premium. $7.53 = $6.00 + $1.53 = ($50,000 / 1,000 x ($0.12)) + $1.53.

New Hires: Get up to the guarantee issue amounts listed, with no questionsasked.

Employee & Spouse Life and A&D rates Monthly Rates (per $1,000 of benefit)

Age Rated: Under 30 $0.09

30‐34 $0.11

35‐39 $0.12

40‐44 $0.15

45‐49 $0.20

50‐54 $0.32

55‐59 $0.54

60‐64 $0.83

65‐69 $1.35

70 and older $3.68

Rates are subject to change as you move from one age bracket

to the next, but will not be adjusted until the next anniversary

period, July 1st 2021.

Please note: rates illustrated for the voluntary life coverage may be slightly different when calculating payroll deductions due to rounding.

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Employee ‐ Late Entrants: If you do not apply for coverage within 31 days of first becoming eligible under the program, you are considered a “late en-trant”. During annual enrollment, you can apply for supplemental life insur-ance, but you will have to complete an “Evidence of Insurability” (EOI) form.

Note: any changes requested in benefit amounts outside the annual enroll-ment period will always require an “Evidence of Insurability” (EOI) form be completed.

Beneficiaries ‐ You are automatically the beneficiary for any dependent life coverage elected (for spouse and child/ren). However, you have the oppor-tunity to designate or update beneficiaries for your life insurance on the elec-tion form. The same beneficiaries will apply to both your Basic Life/AD&D cov-erage as well as any Supplemental Life/AD&D coverage you elect for yourself (unless you designate different beneficiaries for each line of coverage). You can update your beneficiaries at any time by contacting Lakeisha Haugland in the Business Office.

Benefit reduction based on age ‐ The same age reduction schedule applies to the Supplemental Life/AD&D policy as under the Basic employer paid Life/ AD&D policy. Benefit amounts reduce to 65% at age 70 and 50% at age 75.Coverage terminates at retirement.

EXAMPLE:

· Employee is age 69 and has $100,000 in Supplemental Life insurance and ispaying $135.00 a month in premium ($100,000 / 1,000 * $1.35 = $135.00).

· On Dec 1, the employee attains age 70. The coverage reduces to $65,000 (65% of $100,000) but the rate stays the same. The employee continues to pay $135.00 a month in premium ($100,000 / 1,000 * $1.35 = $135.00).

· On July 1 (the anniversary date), the employee moves to the new age bracket so the rate goes up but their coverage stays the same. They are now paying $237.62 a month ($65,000 / 1,000 * $3.68 = $239.20).

SUPPLEMENTAL LIFE(CONTINUED)

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DISABILITY INSURANCE

REVIEW YOURDISABILITY COVERAGELong-Term Disability

Nearly 70% of workers that apply to Social Security Disability Insuranceare denied.

Many workers think these events are more likely than becoming disabled during their careers. But here are the actual odds:

.0000004% .02% 3%1%

25%Becoming

Disabled

Winning Mega Millions

Being struck by lightening

IRSAudit

Having Twins

In fact, nearly 40 million American adults live with a disability

Fort Dodge Community School District provides Long Term Disability insurance for all eligible employees. Disability insurance provides financial protection by paying you a portion of your income while you are disabled.OneAmerica is also the administrator of this benefit.The Long Term Disability (LTD) insurance is equal to 66 2/3% of your pre‐disability monthly earnings up to a maximum of $9,445 per month. There is a 90 day elimination period, and benefits will continue to at least your normal Social Security retirement age or until you are no longer deemed disabled according to the contract.What’s more likely?

LONG-TERM DISABILITY INSURANCE

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INDIVIDUAL VOLUNTARY INSURANCEFort Dodge Community School District is pleased to partner with EMB to offer you the opportunity to purchase individual products via payroll deduction to help protect against medical related financial losses.

The following products are available to you through Trustmark:

• Accident Coverage

• Critical Illness Coverage

• Short Term Disability‐ (STD)

The following products are available to you through TransAmerica:

• Medical Bridge (hospital confinement)Coverage

Information on specific benefits and rates are available on the EMB website. www.explainmybenefits.com/FDCSD

PROTECT YOURFINANCESElect Critical Illness coverage Elect Accident insurance

Short Term Disability

Hospitalization

VOLUNTARY COVERAGE

https://www.explainmybenefits.com/FDCSD

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SECTION 125 FLEXIBLE SPENDINGACCOUNT(FSA)

FOR MEDICAL EXPENSES:This program allows each eligible employee the opportunity to voluntarily redirect a portion of his/her gross pay to a Flexible Spending Account (FSA), and these contributions will be deducted on a pre‐tax basis. These dollars can then be used during the plan year (July 1, 2020 to June 30, 2021) to pay for eligible unreimbursed medical, dental, and vision expenses as you incur them. You can view a complete list of eligible expenses at www.umr.com or by viewing IRS publication 502.

1.IF YOU ELECT THE PPO MEDICAL PLAN: you have access to the FULL Flexible Spending Account (FSA). This plan allows for reimbursement of medical, dental, and vision expenses. You cannot participate in this account if you are participating in the QHDHP medical plan, as the FDCSD is automatically providing a contribution to the HSA. Eligible expenses include deductibles and coinsurance, office visits, prescription drugs, eye glasses, contact lenses, orthodontia, and amounts over plan maximums.

2.IF YOU ELECT THE QHDHP: you have access to the LIMITED FSA. This plan only allows for reimbursement of dental and vision expenses. Your eligible medical expenses are reimbursed through your HSA account.

Health Care Reimbursement Account: $2,750 Maximum / $300 Minimum per calendar year.

FOR DEPENDENT CARE EXPENSES:This program allows working employees to pay for adult and child day care, as well as before/after school expenses, with pre‐tax dollars.

Qualifying expenses include:

· Child care for children under the age of 13 by babysitters, nursery schools, preschools, or day care centers

· In‐home services performed by a full‐time, live‐in housekeeper who cares for qualifiedindividuals

· Services for members of a family who are unable to care for themselves and who are dependent for more than one‐half of their support. (If care is provided outside the home, the dependent must spend at least eight hours per day in the home.)

Expenses for kindergarten fees, elementary school expenses for a child in first grade or higher, and expenses paid to a housekeeper, maid, cook, etc. are NOT eligible (except where incidental to child or dependent adult care).

Dependent Care Assistance Account: $5,000 Maximum (for single or married filing jointly statuses) / $300 Minimum per calendar year.

https://www.umr.com/

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You can participate in the Section 125 Dependent Care account and have an HSA at the same time.

Here’s how the Flexible Spending Accounts work:1.You decide how much you will spend on unreimbursed health, dental, and vision expenses and/or dependent care costs for the plan year (July 1 – June 30). Plan conservatively – you will lose anyunclaimed dollars in your account(s).

2.You elect to redirect part of your paycheck into a pre‐tax account (Flexible Spending Account).This amount can only be changed at open enrollment or if you have a qualifying event.

3.Qualifying events include marriage, divorce, birth, adoption, a change in you or your spouse’s employment status (change in eligibility due to, i.e. reduced hours or termination), or a significant change in the amount of daycare you are required (or no longer are obligated) to pay.

4.You pay expenses as they are incurred. Then you will complete a claim form and submit it with valid receipts to UMR for reimbursement.

5.Your reimbursement will be in the form of a check or direct deposit and will be made from your Flexible Spending Account.

6. Excess contributions cannot be rolled over to the next plan year or transferred between accounts– this is the IRS mandated “use it or lose it” provision. These excess amounts are forfeited back to the plan if not incurred by September 15, 2020 and claimed by October 31, 2020.

For the 2020/2021 plan year, should you wish to participate in either the Health Care Reimbursement Account and/or the Dependent Care Assistance Account, you will be charged a monthly maintenance fee of $4.88 per month.

Go to www.umr.com for additional plan information or to check your account balance(s).

SECTION 125 FLEXIBLESPENDINGACCOUNT (FSA) CONTINUED

https://www.umr.com/

Everyone MUST enroll OR waive coverage – NO EXCEPTIONS! If you fail to enroll incoverage, you will miss your opportunity to enroll in benefits for the 2020/2021 plan year.· After your enrollment session, you will NOT be required to sign or fill out a form. Any other

requested documents (i.e. “Dependent Verification” form for new dependents,“Evidence of Insurability (EOI)” form for Voluntary Life insurance, etc.), must be submittedto Lakeisha Haugland in order to ensure coverage.

· If you are adding dependents to your benefits for the first time, you must provide copiesof the appropriate dependent documentation (see page 23). If you have provided this documentation in the past, you need NOT provide it again, unless there arechanges.

· Qualifying event changes requested during the plan year must be made within 30 daysof the actual qualifying event. It is your responsibility to contact Lakeisha Haugland if youhave questions about or experience a qualifying event that impacts your insurancecoverage. If you fail to make any timely requests and turn in the appropriate paperwork,you cannot make changes to your benefits election until the next annual enrollment period, unless there is another qualifying event.

· Eligible dependent child/ren is/are covered until the age of 26. Coverage terminates theearlier of the end of the month in which the child turns 26 years of age or the date theyare no longer eligible. It is your responsibility to notify Lakeisha Haugland within 30 daysof this qualifying event so the dependent can be removed from the insurance program(s) and premiums adjusted, as applicable. Please note, this is a qualifying event for thedependent to be removed from the insurance plan(s) and is NOT an opportunity for any other coverage changes.

· Remember if you are eligible to participate in an HSA, it is YOUR responsibility to visit oneof the Great Western Bank locations in Fort Dodge to open an account. Once youraccount is open, you must report back to Lakeisha Haugland with your new accountnumber. Failure to notify Lakeisha of the account number means no deposits will bemade on your behalf and your bank account will be closed due to inactivity.

During the enrollment process, you will be asked if you or your family members haveother medical insurance coverage with another company or through Medicare. Thisquestion is required by UMR and must be answered by you every 12 months. In an effortto collect this information globally, we are asking this question on behalf of UMR duringannual enrollment. Simply answer “Yes” or “No”. If you answer “Yes,” UMR will contactyou in order to gather the necessary Coordination of Benefits (COB) information. If youreceive this questionnaire from UMR, please don’t ignore it. Your claims will not be paid until this data is updated.

Please contact Lakeisha Haugland in the Business Office with any benefit or HSA related questions at 515-574-5646 or at lhaugland@fdschools.org

ENROLLMENTREQUIREMENTS AND CLOSING STATEMENTS

CONTINUED

22

mailto:lhaugland@fdschools.org

23

Eligible Dependent RequirementsAccording to the UMR plan document, eligible dependents are defined as:

•your legal Spouse to whom you are legally married by ceremony, provided he or she is not covered as an Employee under this Plan

•you or your Spouse’s child who is under age 26, including a natural biological child, step child, a legally adopted child, a child placed for adoption, a child for whom you or your Spouse are the legal guardian, or a foster child

•a child for whom health care coverage is required through a Qualified Medical Child Support Order or other court or administrative order

Important note: All enrolled eligible children will continue to be covered until the end of the month in which the child attains age 26

If your dependent(s) meet(s) the definition outlined above and as described in your plan document, you must certify his/her eligibility by providing the appropriate information listed below:

For a Spouse or Domestic Partner

• Marriage certificate or religious certificate; and

• Signed, notarized affidavit indicating you are currently married to your spouse

For a Dependent Child

• Birth or hospital certificate, with both parents listed

• Adoption decree including date of birth

• Legal guardianship documentation including date of birth

• Qualified Medical Child Support Order, if applicable

For an Over‐age Dependent Child

• Appropriate documents for Dependent Child listed above; and

•If the dependent is over the age of 26 and disabled, you will also need to provide written certification by a physician, including the date the disability was first diagnosed

·· All benefit documents and required notices can be found on EMB’s Benefit Resource Portal at

www.explainmybenefits.com/FDCSD

Please scroll down to the ‘Summaries/Forms/Contacts’ section of the page to find this valuable information.

All necessary documentation must be returned to Lakeisha Haugland within 30 days of your effective date or Qualifying Life Event.

http://www.explainmybenefits.com/FDCSD

2020 – 2021 FDCSD ANNUAL ENROLLMENT EMPLOYEE ORGANIZEREven if you are waiving coverage, you must still complete the enrollment process. This

organizer will help you gather the information needed for your enrollment.THIS FORM IS NOT CONFIRMATION OF YOUR ENROLLMENT ELECTIONS, BUT SIMPLY A FORM FOR YOUR USE IN PREPERATION OF YOUR ENROLLMENT SESSION. YOU WILL NOT TURN THIS FORM

IN.Legal Spouse and Dependent Children: Legal spouse and unmarried legally dependent children (does not include grandchildren).If you enroll a dependent child in medical, dental, vision and/or voluntary life insurance coverages, please be advised coverage terminates the end of the month in which the child turns 26 years of age. It is your responsibility to notify Lakeisha Haugland in the Business Office within 30 days of this qualifying event so the dependent can be removed from the insurance program(s) accordingly and premiums adjusted, as necessary. Please note, this is a qualifying event for only the dependent to be removed from the insurance plans and is NOT an opportunity for any other changes to the coverages.

Dependents Legal Name

Social Security Number

Relationship(spouse or child)

Gender Date of Birth

Medical Yes / No

Dental Yes/No

Vision Yes/No

Vol. Life Yes / No

If you are enrolling your spouse and/or your child/ren under your insurance programs for the first time, you must bring a COPY of thebirth certificate, marriage certificate, or affidavit of marriage. You must submit a copy to Lakeisha Haugland in the Business Office. Please note,due to the Affordable Care Act (ACA), you are REQUIRED to provide valid Social Security numbers for all enrollees. If you do not, you willnot be extended coverage.

All premium deductions are taken on a pre-tax basis unless otherwise noted or designated. Changes can only be made if you have aqualifying life event (QLE).

UMR Medical: Check the plan that you want (cost shown is per month), or check “Waive” if you are not enrolling. If you have additional orsecondary medical insurance on yourself and/or any of your dependents that you are insuring, please bring this information (insuranceprovider name, identification number, group number, etc.) to your enrollment session so UMR’s systems can be updated.

Opt. 1 – QHDHP Opt. 2 - $20 Copay Wavier(HSA Eligible)

EE OnlyEE + Family

$0.00$572.86

$0.00$745.06

I elect to waive medical benefits

Great Western Health Savings Account (HSA): (Only available with the QHDHP plan) Please remember the eligibility rules as outlined in the “Annual Enrollment Benefits Newsletter” in order to make contributions to an HSA.

It is your responsibility to ensure you meet all eligibility requirements. Yes – Employee Contribution Amount $ /paycheck - 2020 tax year limits: $3,550/individual or $7,100/family. This is the combination of

any employer + employee contributions. This election amount can be changed as often as monthly, but you must contact Lakeisha Haugland in the Business Office to make that change. FDCSD will contribute $1,500 for EE Only plans or $3,000 for EE + Family plans. Contributions will be made within the first 6 months of the plan year (i.e. for single contribution, half the $1,500 will be contributed immediately, $750 in July, and then $150 per month for August, September, October, November and December). No additional contributions will be made for the balance of the plan year. Late entrants to this plan will have a pro-rated HSA contribution from the District. Remember it is YOUR responsibility to open the HSA bank account with Great Western Bank, no sooner than June 16th, and then notify Lakeisha in the Business Office with the account number so deposits can be made. Open your account after June 20th and before your first paycheck in July2020.

No

Under the following three Flexible Spending Account programs, the plan year is the same as with all benefits: July 1, 2020 – June 30, 2021. All eligible expenses need to be incurred by September 15, 2021 and claimed by October 31, 2021. You have a 2 ½ month extension at the end of the plan year in which to incur claims to be reimbursed from the 2020/2021 plan year that ends June 30, 2021. Any remaining balances will be forfeited and are not refundable back to the employee.

FULL Healthcare Flexible Spending Account (FSA): (Not available if you are enrolled in the medical QHDHP plan) Yes – Plan Year Contribution Amount $ ($2,750 plan year max. / $300 plan year min.) No

LIMITED Healthcare Flexible Spending Account (FSA): (Available only if you participate in the QHDHP medical plan – this FSA can be used for dental and vision eligible expenses only. Your HSA is available for reimbursement of medical expenses.)

Yes – Plan Year Contribution Amount $ ($2,750 plan year max. / $300 plan year min.) No

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Dependent Care Flexible Spending Account (FSA): (Day Care Expenses only – Available with or without a Health Savings Account- HSA) Yes - Plan Year ContributionAmount $ ($5,000 plan year max. / $300 plan year min.) No

Delta Dental: Check the plan that you want (cost shown is per month), or check “Waive” if you are not enrolling.When both spouses work for the District, the premium contribution will be $0.00 for EE only coverage or $53.40 per month for EE + Family coverage.

WaiverI elect to waive dental benefitsEE Only

EE + Family

Dental$0.00$85.14

Avesis Vision: Check the plan that you want (cost shown is per month), or check “Waive” if you are not enrolling.

One America Supplemental Group Term Life/AD&D: You have the opportunity to enroll in Voluntary Life and Accidental Death &Dismemberment (AD&D) insurance.

EE

Spouse

Child/ren

Waiver

$10,000 Increments/$10,000 Minimum/$250,000 Maximum - Please see page 14 for Evidence of Insurability rules.

$5,000 increments, $5,000 Minimum up to $50,000 Maximum – $30,000 Guarantee. All enrollments and/ or increases will be subject to evidence of insurability.

Birth to age 26 = $10,000 benefit. All Guarantee Issue. You must enroll in supplemental group term life inorder to elect child/ren coverage.

I elect to waive all enrollment

Beneficiary Legal Name Relationship SSN Date of Birth Primary or Contingent Percent (must add up to100%)

Trust or Individual

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Age BandLife RateEmployee or Spouse

< age30 $0.0930-34 $0.1135-39 $0.1240-44 $0.1545-49 $0.2050-54 $0.3255-59 $0.5460-64 $0.8365-69 $1.35

70 and over $3.68

Vision WaiverEE Only $8.30 I elect to waive vision benefitsEE + Spouse $16.25EE + Child/ren $17.71EE + Family $22.77

One America Supplemental Life/AD&D Rates (employee and spouse increments shown are per $1,000 of coverage). These will be deducted post–tax on a monthly basis.

Child/ren Life

Life rate = $1.53 for$10,000 of coverage

NOTE: The premiumpaid for child coverage isbased on the cost ofcoverage for one child,regardless of how manychildren you have.

Insurance Age Employee/spouse rate is based on employee’s insurance age. The premium is based on your age at the beginning ofthe plan/policy year, which is July 1, 2020. That is the age you use to calculate your premiums until July 1, 2021. At thattime, your rates will be based on your current age.

Voluntary Benefits: Voluntary Accident, Critical Illness, AND Medical Bridge (hospital confinement) plans will continue to be offered on a pre-tax basis. Likewise, the Voluntary Short Term Disability (STD) will continue to be offered on a post-tax basis. Trustmark and TransAmerica’s portfolio of supplemental policies help pay for out of pocket medical and non-medical expenses. Benefits are paid directly to you. These benefit payments are in addition to any other benefit plans. All plans can be customized based on your needs, and you can continue the plans if you leave employment at the District.

2020 – 2021 FDCSD ANNUAL ENROLLMENT KEY POINTS

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Please carefully review each statement on this page. As a benefit eligible employee, you are responsible for understanding this very importantinformation.

As a benefit eligible employee, now is the time to make your annual plan elections for the plan year. Following your initialenrollment period, annual enrollment will be your once-a-year-opportunity to enroll in the various benefit offerings or make changesto your current benefit elections, such as adding or removing dependents (outside of a life-changing event). Benefit elections can only bemade when first eligible and/or at annual enrollment. No changes in elections can be made during the plan year unless there is aqualifying event (birth, adoption, divorce, death, change in employment status, loss of other coverage, etc.). Please review your benefitconfirmation to verify that your elections are correct. FDCSD will not let you make changes after open enrollment unless youhave a Qualified LifeEvent.Qualifying event changes requested during the plan year must be made within 30 days of the actual qualifying event. It is yourresponsibility to contact Lakeisha Haugland at the Business Office if you have questions or experience a qualifying event that impacts yourinsurance and you wish to make changes. If you fail to make any timely requests and turn in the appropriate paperwork, you cannot makechanges to your benefits election until the next annual enrollment period, unless there is another qualifying event.

Eligible dependent child/ren is/are covered until the age of 26. Coverage terminates at either the earlier of the end of the month in whichthe child turns 26 years of age, or the date he/she is no longer eligible. It is your responsibility to notify Lakeisha Haugland in theBusiness Office within 30 days of this qualifying event so the dependent(s) can be taken off the insurance program(s) accordingly andpremiums adjusted, as necessary. Please note, this is a qualifying event for the dependent only to be removed from the insurance plansand is NOT an opportunity for any other changes to the coverages. The qualifying event only applies to the dependent triggering thequalifying event.

All applicable UMR Medical, Delta Dental, Avesis Vision, Trustmark Accident, Trustmark Critical Illness and Transamerica HospitalIndemnity premiums will automatically be deducted on a pre-tax basis. All flexible spending account and HSA contributions will likewisebe deducted on a pre-tax basis. By allowing your premiums to be deducted from your paycheck on pre-tax basis, it reduces your taxableincome (i.e. you pay less in taxes), and it locks you in the plan for the full plan year (unless there is a qualifying event). Accordingly, yourW-2 income will differ from the total wages reported on your pay stub.

If electing the high deductible health plan, it is YOUR responsibility to open an HSA bank account at Great Western Bank.You can go to either branch of Great Western Bank in Fort Dodge. You will need to provide your driver’s license to the teller and request toopen an HSA with the Fort Dodge Community School District. After the account has been established, you must also provide LakeishaHaugland in the Business Office with the new account number so that the District can fund your account. If you fail to do this, no fundswill be deposited, and your account will be closed. Please open your account 30 days prior to your first check.

Please note that premiums reflected are shown as monthly costs and annualized for 12 months of coverage. If you are an 18 paycheck employee or starting work after the beginning of the plan year please confirm with the Business Office to determine your final premium cost as it may be more than is shown on your benefits confirmation form during enrollment.

Any and all outstanding forms (i.e. Dependent Verification form for new dependents, Evidence of Insurability from for Voluntary Life insurance above the guarantee issue, etc.), must be returned to Lakeisha Haugland in the Business Office within 30 days of the insurance effective date.

Your enrollment session will include the following 4 options: 1. Self-Enroll via EMB Secure Website 2. Using the EMB Mobile App

If you fail to complete your enrollment, you will not be eligible to re-enroll until July 1, 2021, unless a qualifying event occurs.

At the time of enrollment it is your responsibility to carefully review each selection before you certify your benefits elections. You are responsible for understanding all of the information presented in this benefit guide.

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SPECIAL ENROLLMENT NOTICE

During the open enrollment period, eligible employees are given the opportunity to enroll themselves and dependents into our group health plans.

If you elect to decline coverage because you are covered under an individual health plan or a group health plan through your parent’s or spouse’s employer, you may be able to enroll yourself and your dependents in this plan if you and/or your dependents lose eligibility for that other coverage. You must request enrollment within 30 days after the other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may enroll any new dependent within 30 days of the event. To request special enrollment or obtain more information, contact Lakeisha Haugland. Two additional special enrollment events are available to you and your eligible dependents. They are:

1.Becoming ineligible for Medicaid or the Children’s Health Insurance Program (CHIP). If you or your dependents become ineligible for Medicaid or CHIP, you may be able to enroll yourself and your dependents in the UMR Medical Plan. You must request enrollment within 60 days.

2.Becoming eligible for Premium Assistance through Medicaid or CHIP. If you or your dependents become eligible for premium assistance from Medicaid or CHIP, you may be able to enroll yourself and your dependents in the UMR Medical Plan. You must request enrollment within 60 days.

NOTICE OF PRIVACY PRACTICES: Fort Dodge Community School District is subject to the HIPAA privacy rules. In compliance with these rules, it maintains a Notice of Privacy Practices. You have the right to request a copy of the Notice of Privacy Practices by contacting Human Resources.

WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998

As a requirement of the Women’s Health and Cancer Rights Act of 1998, your plan provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses and complications resulting from a mastectomy, including lymphedema. The benefits must be provided and are subject to the health plan’s regular copays, deductibles and co-insurance. Contact UMR at the phone number on the back of your ID card for additional benefit information.

NOTICE OF MATERIAL CHANGE (ALSO MATERIAL REDUCTION IN BENEFITS)

FDCSD has amended the Medical, Dental and Vision benefit plans. This benefit guide contains a summary of the modifications that were made. It should be read in conjunction with the Summary Plan Description or Certificate of Coverage, which is available to you once it has been updated by the carriers. If you would like a copy, please submit your request to Human Resources.

IMPORTANT INFORMATION REGARDING 1095 FORMS

As an employer with 50 or more eligible employees, we are required to provide 1095-C forms to all employees who were eligible for coverage under our group health plan in 2020. If you were eligible for coverage under our group plan, you’ll receive a personalized 1095-C form before January 31, 2021. We are also required to send a copy of your 1095-C form to the IRS.

The information reported on Form 1095-C is used in determining whether an employer owes a payment under the employer shared responsibility provisions under section 4980H. Form 1095-C is also used by you and the IRS to determine eligibility for the premium tax credit.

You’ll need 1095 form to complete your Federal tax return.

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MEDICAID CHIP NOTICE

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1- 877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

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

ALABAMA − Medicaid FLORIDA − Medicaid

Website: myalhipp.comPhone: 855.692.5447

Website: flmedicaidtplrecovery.com/hippPhone: 877.357.3268

ALASKA − Medicaid GEORGIA − Medicaid

The AK Health Insurance Premium Payment Program Website: myakhipp.comPhone: 866.251.4861Email: customerservice@myakhipp.com Medicaid Eligibility:dhss.alaska.gov/dpa/pages/medicaid/default.aspx

Website: medicaid.georgia.gov/health-insurance-premium-payment-program-hippPhone: 678.564.1162, ext 2131

ARKANSAS − Medicaid INDIANA − MedicaidWebsite: myarhipp.comPhone: 1.855.MyARHIPP (855.692.7447)

Healthy Indiana Plan for Low-Income Adults 19-64 Website: www.in.gov/fssa/hipPhone: 877.438.4479All Other Medicaid Website: www.indianamedicaid.comPhone: 800.403.0864

COLORADO − Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) IOWA − Medicaid

Health First Colorado Website: www.healthfirstcolorado.comHealth First Colorado Member Contact Center: 800.221.3943, state relay 711CHP+: www.colorado.gov/pacific/hcpf/child-health-plan-plusCHP+ Customer Service: 800.359.1991, state relay 711

Website: dhs.iowa.gov/hawki Phone: 800.257.8563

KANSAS − Medicaid NEW HAMPSHIRE − MedicaidWebsite: www.kdheks.gov/hcf Phone: 785.296.3512

Website: www.dhhs.nh.gov/oii/hipp.htm Phone: 603.271.5218HIPP Phone: 800.852.3345, ext 5218

KENTUCKY −Medicaid NEW JERSEY − Medicaid and CHIPWebsite: chfs.ky.gov Phone: 800.635.2570

Medicaid Website:www.state.nj.us/humanservices/dmahs/clients/medicaidMedicaid Phone: 609.631.2392CHIP Website: www.njfamilycare.org/index.html CHIP Phone: 800.701.0710

https://www.healthcare.gov/https://www.insurekidsnow.gov/https://www.askebsa.dol.gov/http://myalhipp.com/http://flmedicaidtplrecovery.com/hipp/http://myakhipp.com/mailto:customerservice@myakhipp.commailto:CustomerService@myakhipp.comhttp://dhss.alaska.gov/dpa/Pages/medicaid/default.aspxhttps://medicaid.georgia.gov/health-insurance-premium-payment-program-hipphttps://gcc01.safelinks.protection.outlook.com/?url=https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp&data=02|01|stashlaw@dch.ga.gov|98b18a96ce1b49d087f708d709449652|512da10d071b4b948abc9ec4044d1516|0|0|636https://gcc01.safelinks.protection.outlook.com/?url=https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp&data=02|01|stashlaw@dch.ga.gov|98b18a96ce1b49d087f708d709449652|512da10d071b4b948abc9ec4044d1516|0|0|636http://myarhipp.com/http://www.in.gov/fssa/hip/http://www.indianamedicaid.com/https://www.healthfirstcolorado.com/https://www.colorado.gov/pacific/hcpf/child-health-plan-plushttp://dhs.iowa.gov/Hawkihttp://www.kdheks.gov/hcf/https://www.dhhs.nh.gov/oii/hipp.htmhttps://chfs.ky.gov/http://www.state.nj.us/humanservices/dmahs/clients/medicaid/http://www.njfamilycare.org/index.html

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LOUISIANA − Medicaid NEW YORK − MedicaidWebsite: dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 888.695.2447

Website: www.health.ny.gov/health_care/medicaid Phone: 800.541.2831

MAINE − Medicaid NORTH CAROLINA − Medicaid

Website: www.maine.gov/dhhs/ofi/public-assistance/index.htmlPhone: 800.442.6003TTY: Maine relay 711

Website: medicaid.ncdhhs.govPhone: 919.855.4100

MASSACHUSETTS − Medicaid and CHIP NORTH DAKOTA − MedicaidWebsite:www.mass.gov/eohhs/gov/departments/masshealthPhone: 800.862.4840

Website: www.nd.gov/dhs/services/medicalserv/medicaidPhone: 844.854.4825

MINNESOTA − Medicaid OKLAHOMA − Medicaid and CHIPWebsite: mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/other-insurance.jspPhone: 800.657.3739

Website: www.insureoklahoma.org Phone: 888.365.3742

MISSOURI − Medicaid OREGON − MedicaidWebsite:www.dss.mo.gov/mhd/participants/pages/hipp. htmPhone: 573.751.2005

Website: healthcare.oregon.gov/pages/index.aspxwww.oregonhealthcare.gov/index-es.htmlPhone: 800.699.9075

MONTANA − Medicaid PENNSYLVANIA − MedicaidWebsite: dphhs.mt.gov/montanahealthcareprograms/hipp Phone: 800.694.3084

Website: www.dhs.pa.gov/provider/medicalassistance/he althin-surancepremiumpaymenthippprogram/index.htmPhone: 800.692.7462

NEBRASKA − Medicaid RHODE ISLAND − Medicaid and CHIP

Website: www.accessnebraska.ne.govPhone: 855.632.7633Lincoln: 402.473.7000Omaha: 402.595.1178

Website: www.eohhs.ri.govPhone: 855.697.4347, or 401.462.0311 (Direct RIte Share Line)

NEVADA − Medicaid SOUTH CAROLINA −MedicaidMedicaid Website: dhcfp.nv.gov Medicaid Phone: 800.992.0900

Website: www.scdhhs.gov Phone: 888.549.0820

SOUTH DAKOTA − Medicaid WASHINGTON − MedicaidWebsite: dss.sd.gov Phone: 888.828.0059

Website: www.hca.wa.govPhone: 800.562.3022, ext 15473

TEXAS − Medicaid WEST VIRGINIA −MedicaidWebsite: gethipptexas.comPhone: 800.440.0493

Website: mywvhipp.comToll-Free Phone: 1.855.MyWVHIPP (855.699.8447)

UTAH − Medicaid and CHIP WISCONSIN − Medicaid and CHIPMedicaid Website: medicaid.utah.gov CHIP Website: health.utah.gov/chip Phone: 877.543.7669

Website:www.dhs.wisconsin.gov/publications/p1/p10095.pdfPhone: 800.362.3002

VERMONT − Medicaid WYOMING − MedicaidWebsite: www.greenmountaincare.org Phone: 800.250.8427

Website: wyequalitycare.acs-inc.com Phone: 307.777.7531

VIRGINIA − Medicaid andCHIPMedicaid Website:www.coverva.org/programs_premium_assistance.cfmMedicaid Phone: 800.432.5924 CHIP Website:www.coverva.org/programs_premium_assistance.cfmCHIP Phone: 855.242.8282

http://dhh.louisiana.gov/index.cfm/subhome/1/n/331https://www.health.ny.gov/health_care/medicaid/http://www.maine.gov/dhhs/ofi/public-assistance/index.htmlhttps://medicaid.ncdhhs.gov/http://www.mass.gov/eohhs/gov/departments/masshealthhttp://www.nd.gov/dhs/services/medicalserv/medicaidhttps://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/other-insurance.jsphttps://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/other-insurance.jsphttp://www.insureoklahoma.org/http://www.dss.mo.gov/mhd/participants/pages/hipp.%20htmhttp://www.oregonhealthcare.gov/index-es.htmlhttps://dphhs.mt.gov/MontanaHealthcarePrograms/HIPPhttp://www.dhs.pa.gov/provider/medicalassistance/he%20althinsurancepremiumpaymenthippprogram/index.htmhttp://www.dhs.pa.gov/provider/medicalassistance/he%20althinsurancepremiumpaymenthippprogram/index.htmhttp://www.accessnebraska.ne.gov/http://www.eohhs.ri.gov/https://dhcfp.nv.gov/https://www.scdhhs.gov/http://dss.sd.gov/https://www.hca.wa.gov/http://gethipptexas.com/http://mywvhipp.com/https://medicaid.utah.gov/http://health.utah.gov/chiphttps://www.dhs.wisconsin.gov/publications/p1/p10095.pdfhttp://www.greenmountaincare.org/https://wyequalitycare.acs-inc.com/http://www.coverva.org/programs_premium_assistance.cfmhttp://www.coverva.org/programs_premium_assistance.cfm

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MEDICAID CHIP NOTICE

Premium Assistance under Medicaid and the Children'sHealth Insurance Program (CHIP)

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

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

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

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

For the latest form and states where you may be eligible for assistance paying your employer health premiums, go to https://www.dol.gov/sites/default/files/ebsa/laws-and-regulations/laws/chipra/model-notice.pdf

For more information on special enrollment rights, you can contact either:U.S. Department of Labor

Employee Benefits Security Administration dol.gov/agencies/ebsa866.444.3272

U.S. Department of Health and Human ServicesCenters for Medicare and Medicaid Servicescms.hhs.gov877.267.2323, Menu option 4, ext 61565

This notice is intended as a brief outline; please see HR for more information.

USERRA UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA)

The Uniformed Services Employment and Reemployment Rights Act (USERRA) was signed on October 13, 1994. The Act applies to persons who perform duty, voluntarily or involuntarily, in the "uniformed services," which include the Army, Navy, Marine Corps, Air Force, Coast Guard, and Public Health Service commissioned corps, as well as the reserve components of each of these services. Federal training or service in the Army National Guard and Air National Guard also gives rise to rights under USERRA. In addition, under the Public Health Security and Bioterrorism Response Act of 2002, certain disaster response work (and authorized training for such work) is considered “service in the uniformed services” as well.

Uniformed service includes active duty, active duty for training, inactive duty training (such as drills), initial active duty training, and funeral honors duty performed by National Guard and reserve members, as well as the period for which a person is absent from a position of employment for the purpose of an examination to determine fitness to perform any such duty. USERRA covers nearly all employees, including part-time and probationary employees. USERRA applies to virtually allU.S. employers, regardless of size.

The U.S. Department of Labor, Veterans Employment and Training Service (VETS) are authorized to investigate and resolve complaints of USERRA violations.

· For assistance in filing a complaint, or for any other information on USERRA, contact VETS at 1-866-4-USA-DOL or visit its website at www.dol.gov/vets.

· If you file a complaint with VETS and VETS is unable to resolve it, you may request that your case be referred to the Department of Justice or the Office of Special Counsel, depending on the employer, for representation.

· You may also bypass the VETS process and bring a civil action against an employer for violations of USERRA.

· The rights listed here may vary depending on the circumstances. The USERRA notice can be viewed on the internet at https://www.dol.gov/vets/programs/ userra/USERRA_Private.pdf

· If you leave your job to perform military service, you have the right to elect to continue your existing employer-based health plan coverage for you and your dependents for up to 24 months while in the military.

· Even if you don’t elect to continue coverage during your military service, you have the right to be reinstated in your employer’s health plan when you are reemployed, generally without any waiting periods or exclusions (e.g. pre-existing condition exclusions) except for service-connected illnesses or injuries.

· Under the terms of USERRA, if the military leave is 31 or fewer days, the employer may not charge a higher premium than would be charged to active employees with similar coverage. If the leave exceeds 31 days, the employer may charge up to 102 percent of the applicable premium.

https://www.healthcare.gov/https://www.insurekidsnow.gov/https://www.askebsa.dol.gov/https://www.dol.gov/sites/default/files/ebsa/laws-https://www.dol.gov/vetshttps://www.dol.gov/vets/programs/

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INITIAL COBRA NOTICE

IntroductionYou’re getting this notice because you recently gained coverage under a group health plan (Fort Dodge Community School District.) This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.

You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

What is COBRA continuation coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.

If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

· Your hours of employment are reduced, or

· Your employment ends for any reason other than your gross misconduct.

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

•Your spouse dies;

•Your spouse’s hours of employment are reduced;

•Your spouse’s employment ends for any reason other than his or her gross misconduct;

•Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or

•You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:

•The parent-employee dies;

•The parent-employee’s hours of employment are reduced;

•The parent-employee’s employment ends for any reason other than his or her gross misconduct;

•The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);

•The parents become divorced or legally separated; or

•The child stops being eligible for coverage under the Plan as a “dependent child.”

When is COBRA continuation coverage available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:

· The end of employment or reduction of hours of employment;

· Death of the employee;

· The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs.

How is COBRA continuation coverage provided?

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses,and parents may elect COBRA continuationcoverage on behalf of their children.

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COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

There are also ways in which this 18-month period of COBRA continuation coverage can be extended:

Disability extension of 18-month period of COBRA continuation coverage

If you or anyone in your family covered under the Plan is de