EMPLOYEE BENEFIT ENROLLMENT SELECTION FORM...EMPLOYEE BENEFIT ENROLLMENT SELECTION FORM NAME (Please...

EMPLOYEE BENEFIT ENROLLMENT SELECTION FORM

NAME (Please print)___________________________________ Employee ID# _________________ (ELIGIBLE EMPLOYEES REGULARLY SCHEDULED FOR 30 HOURS PER WEEK)

I understand that I have been offered the opportunity to sign up for group medical insurance for myself and my eligible dependents. If I decline this coverage at this time, I understand that I will not be eligible to participate until the next open enrollment period.

BLUE CROSS/BLUE SHIELD GROUP _______ ACCEPT ______ DECLINE MEDICAL INSURANCE: A1AH MMH3 48A3 $5,000 $5,000 $2000 Deductible Deductible Deductible Pay Period Deductions: Employee Only: $32.54 ____ $84.46 ____ $220.91 ____ Pre Tax ( ) Post Tax ( ) Employee and Spouse: $197.50 ____ $282.91 ____ $542.82 ____ Employee and Children: $156.15 ____ $233.00 ____ $461.87 ____ Employee and Family $321.26 ____ $431.42 ____ $783.70 ____ BENEFITS ADMIN & INS SERVICES _______ ACCEPT ______ DECLINE MEC COVERAGE: US ONLY US/MEXICO $5,000 $5,000 Annual Maximum Annual Maximum Pay Period Deductions: Employee Only: $31.00 ____ $43.50 ____ Pre Tax ( ) Post Tax ( ) Employee and Spouse: $41.00 ____ $53.50 ____ Employee and Children: $51.00 ____ $63.50 ____ Employee and Family $61.00 ____ $73.50____ METLIFE: Dental Insurance ________ ACCEPT ______ DECLINE

Pay Period Deductions: Employee Only: $13.24____ Employee + Family: $49.43____ Pre-Tax ( ) Post Tax ( ) Employee + Spouse: $26.47____ Employee + Children: $31.90____ METLIFE: Vision Insurance ________ ACCEPT ______ DECLINE

Pay Period Deductions: Employee Only: $3.90____ Employee + Family: $11.48____ Pre-Tax ( ) Post Tax ( ) Employee + Spouse: $7.42____ Employee + Children: $7.81____

(ELIGIBLE EMPLOYEES REGULARLY SCHEDULED FOR OVER 20 HOURS PER WEEK)

METLIFE BASIC TERM LIFE / AD & D: ________ ACCEPT ______ DECLINE YWCA paid life insurance of $5,000 for employee – No Cost

METLIFE SUPPLEMENTAL TERM ________ ACCEPT ______ DECLINE LIFE INSURANCE: Voluntary Term Life Insurance

Pay Period Deductions: Employee: $ __________ Spouse: $ __________ Children: $ __________ __________________________________________________________________________________ COLONIAL SUPPLEMENTAL TERM _________ACCEPT _______DECLINE LIFE INSURANCE: Voluntary Term Life Insurance Pay Period Deductions: Employee: $ __________ Spouse: $ __________ Children: $ __________ COLONIAL SHORT-TERM DISABILITY ________ ACCEPT ______ DECLINE Disability for accident, sickness, pregnancy

Pay Period Deduction: $ ______________

COLONIAL SUPPLEMENTAL INSURANCE

Accident Coverage: _________ ACCEPT ______ DECLINE

Critical Illness: _________ ACCEPT ______ DECLINE

Pay Period Deduction: Critical Illness $__________ Accident Coverage $__________

I understand that all benefits listed above are post-tax except for those that indicate the option of pretax or post tax. On a separate benefit enrollment form, I have enrolled for certain benefit or insurance coverage(s) and understand that my required contribution will be deducted from my paycheck by my employer. In the event of a rate change, I authorize a corresponding change in the amount deducted from my pay check without signing a new Selection Form. Amounts corresponded to “NO COST” benefits (if any) will not be deducted from my paycheck. I have elected to participate or not in the company’s Premium-Only-Payment program under Section 125 of the IRS provisions on a separate Form. EMPLOYEE SIGNATURE:_____________________________________________ DATE ______________

2020 - 2021

SUMMARY OF EMPLOYEE BENEFITS

Presented by HUB International Insurance Services

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Employee Benefits Team JIMENA

CENTELLES-PONTE

VICE PRESIDENT/LHIC [email protected]

201 E. Main, Suite 800 El Paso, Texas 79901

hubinternational.com Tel (915) 206-6038 Cell (915) 204-5505 Fax 1-866-399-3972

NANETTE ARRIETA

SR. ACCOUNT MANAGER/LHIC CLAIMS/BENEFITS

[email protected]


hubinternational.com Tel (915) 206-6026 Text (915) 319-4099 Fax 1-866-399-3972

RODOLFO VIADO

ACCOUNT MANAGER CUSTOMER SERVICE

[email protected]


hubinternational.com Tel (915) 206-6094 Fax 1-866-399-3972

ARMANDO ARRIETA

ACCOUNT MANAGER/LHIC [email protected]


hubinternational.com Tel (915) 206-6034 Cell (915) 208-0487 Fax 1-866-399-3972

THERESA LOPEZ

ACCOUNT MANAGER

CUSTOMER SERVICE [email protected]


hubinternational.com Tel (915) 206-6044

Fax 1-866-399-3972

ANEKA OTERO

ACCOUNT MANAGER CUSTOMER SERVICE

[email protected]


hubinternational.com Tel (915) 206-6082

Fax 1-866-399-3972

Dear Employee: This is to confirm that YWCA El Paso Del Norte Region offers full-time employees (who average 30 or more hours per week) the opportunity to enroll in health insurance coverage that offers Minimum Value and/or Minimum Essential Coverage, required under the Patient Protection and Affordable Care Act. For you to become enrolled or make any changes to your current coverage for 2020 – 2021, you have to enroll and make changes via employee navigator at https://harmonyenroll.coloniallife.com/SelfEnrollLogin.Web/Login.aspx by May 15, 2020. Please contact the Human Resource Department at (915) 519-0000 within receipt of this notice. If YWCA El Paso Del Norte Region does not receive either an enrollment form or waiver confirmation and you are currently enrolled on the medical plan, your medical coverage will be defaulted into the new HMO H.S.A. option (Base). Other coverages will rollover based on the current selections you have on file. If you have any questions please call. Sincerely, YWCA El Paso Del Norte Region Human Resource Department (915) 519-0000 ________________________________ Employee Name (Print) ________________________________ Employee Signature _________________ Date

https://harmonyenroll.coloniallife.com/SelfEnrollLogin.Web/Login.aspx

https://www.ywcaelpaso.org/

Colonial Life is pleased to present a new, leading-edge enrollment scheduling tool. It is designed to engage and educate employees, while allowing them to self-schedule their 1-to-1 session with a benefits counselor!

Scheduling made easy for you!

ColonialLife.com7-16 | NS-15215

©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

Employers can select from two options when using the Enrollment Scheduler: 1. SELF-SCHEDULING: Employees visit a customized landing page where they learn about

benefits offered during enrollment and sign up for a 1-to-1 session that is best suits them.

FOR EMPLOYEES � On-demand, educational information regarding their enrollment � A scheduling platform they can engage with any time, on any device � Control over their meeting time � Receive email appointment reminders

FOR PLAN ADMINISTRATORS � Real-time metrics on meeting sign-ups and show rates � Provide their stakeholders with the latest options for enrollment � Post-enrollment reporting

FOR COLONIAL LIFE AND ITS PARTNERS � A differentiated, tech savvy offering available at no cost � A real-time view of signups to drive the enrollment process � The ability to educate enrollees via a new medium � Automated reminders and the ability to reschedule drive engagement rates

2. AUTO-SCHEDULING: Bypass the self-signup and automatically assign a 1-to-1 session to employees. If the assigned time doesn’t work, employees can reschedule their time. *Census information is required for the Auto-Schedule

The Enrollment Scheduling Tool is available for all enrollments.

Follow these steps to get started:1. Identify the need2. Provide case info to coordinator3. Approve the site with client4. Begin scheduling!

Best Practices: � HR sends an email to the

employees with a link to the scheduling tool

� Provide a link of the scheduling tool on enrollment fliers and communications

� Link to the scheduling tool from your custom Youville site

� Have the scheduling tool available 2 weeks prior to enrollment

The Benefits of Virtual Scheduling

82% attendance

rate

BLUE CROSS BLUE SHIELD

PLAN – H.S.A. Blue Essentials HSASM A1AH

https://www.bing.com/images/search?view=detailV2&ccid=Z2SmR17j&id=7A3B406B658A7EF3453A81C6CD93877E454DE6DE&thid=OIP.Z2SmR17jKvli6HDd140GYgHaIl&mediaurl=http://www.clipartbest.com/cliparts/Kin/oEj/KinoEj4RT.png&exph=689&expw=594&q=medical+images+clip+art&simid=608046549379779056&selectedIndex=109

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would sharethe cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is

only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visitwww.bcbstx.com/member/policy-forms/2019 or by calling 1-877-299-2377. For general definitions of common terms, such as allowed amount, balancebilling, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary athttps://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/UG-Glossary-508-MM.pdf or call 1-855-756-4448 to request acopy.

Why This Matters:AnswersImportant QuestionsGenerally, you must pay all of the costs from providers up to the deductible amount beforethis plan begins to pay. If you have other family members on the plan, each family member

$5,000 Individual / $10,000Family

What is the overalldeductible?

must meet their own individual deductible until the total amount of deductible expenses paidby all family members meets the overall family deductible.This plan covers some items and services even if you haven’t yet met the deductible amount.But a copayment or coinsurance may apply. For example, this plan covers certain preventive

Yes. Preventive care services arecovered before you meet yourdeductible.

Are there services coveredbefore you meet yourdeductible? services without cost-sharing and before you meet your deductible. See a list of covered

preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.You don’t have to meet deductibles for specific services.No.Are there other

deductibles for specificservices?

The out-of-pocket limit is the most you could pay in a year for covered services. If you haveother family members in this plan, they have to meet their own out-of-pocket limits until theoverall family out-of-pocket limit has been met.

$5,000 Individual / $10,000Family

What is the out-of-pocketlimit for this plan?

Even though you pay these expenses, they don't count toward the out-of-pocket limit.Premiums, balanced-billedcharges, and health care this plandoesn't cover.

What is not included in theout-of-pocket limit?

This plan uses a provider network. You will pay less if you use a provider in the plan’s network.You will pay the most if you use an out-of-network provider, and you might receive a bill from

Yes. Seewww.bcbstx.com/go/be or call1-877-299-2377 for a list ofParticipating Providers.

Will you pay less if you usea network provider?

a provider for the difference between the provider’s charge and what your plan pays (balancebilling). Be aware your network providermight use an out-of-network provider for some services(such as lab work). Check with your provider before you get services.This plan will pay some or all of the costs to see a specialist for covered services but only ifyou have a referral before you see the specialist.

Yes.Do you need a referral tosee a specialist?

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association1 of 6

Summary of Benefits and Coverage:What this Plan Covers & What You Pay For Covered Services Coverage Period: 06/01/2020-05/31/2021

: MTBEEA1AH Blue Essentials HSASM A1AH Coverage for: Individual/Family Plan Type: HMO

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Limitations, Exceptions, & Other ImportantInformation

What You Will Pay

Services You May NeedCommonMedical Event

Non-ParticipatingProvider (Youwill pay the

most)

Participating Provider(You will pay the least)

Virtual Visits are available. See your benefitbooklet* for details.

Not CoveredNo ChargePrimary care visit to treat aninjury or illness

If you visit a health careprovider’s office orclinic

NoneNot CoveredNo ChargeSpecialist visitYou may have to pay for services that aren'tpreventive. Ask your provider if the services

Not CoveredNo Charge; deductibledoes not apply

Preventive care/screening/immunization

needed are preventive. Then check what yourplan will pay for.

Preauthorization may be required; see yourbenefit booklet* for details.

Not CoveredNo ChargeDiagnostic test (x-ray, bloodwork)If you have a test

Not CoveredNo ChargeImaging (CT/PET scans, MRIs)

Limited to a 30-day supply at retail (or a90-day supply at a network of select retail

Not CoveredNo ChargePreferred generic drugsIf you need drugs totreat your illness orcondition

Not CoveredNo ChargeNon-preferred generic drugs

pharmacies). Up to a 90-day supply at mailNot CoveredNo ChargePreferred brand drugs

order. Specialty drugs limited to a 30-dayMore information aboutprescription drugcoverage is available athttps://www.bcbstx.com/member/prescription-drug-plan-information/drug-lists

Not CoveredNo ChargeNon-preferred brand drugs

supply. Payment of the difference betweenthe cost of a brand name drug and a genericmay also be required if a generic drug isavailable.

Not CoveredNo ChargePreferred specialty drugsNot CoveredNo ChargeNon-preferred specialty drugs

Preauthorization required; failure topreauthorize will result in denial of benefits.

Not CoveredNo ChargeFacility fee (e.g., ambulatorysurgery center)

If you have outpatientsurgery

Abortion is not covered except in limitedcircumstances.For Outpatient Infusion Therapy, see yourbenefit booklet* for details.

Not CoveredNo ChargePhysician/surgeon fees

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2019.2 of 6


What You Will Pay

Services You May NeedCommonMedical Event

Non-ParticipatingProvider (Youwill pay the

most)

Participating Provider(You will pay the least)

None

No ChargeNo ChargeEmergency room careIf you need immediatemedical attention

No ChargeNo ChargeEmergency medicaltransportation

Not CoveredNo ChargeUrgent care


Not CoveredNo ChargeFacility fee (e.g., hospitalroom)If you have a hospital

stayNot CoveredNo ChargePhysician/surgeon fees

Outpatient: Certain services must bepreauthorized; refer to benefit booklet* for

Not CoveredNo ChargeOutpatient servicesIf you need mentalhealth, behavioralhealth, or substanceabuse services

Not CoveredNo ChargeInpatient servicesdetails. Failure to preauthorize will result indenial of benefits.Inpatient: Preauthorization required; failureto preauthorizewill result in denial of benefits.Cost sharing does not apply to certainpreventive services. Depending on the type of

Not CoveredNo ChargeOffice visits

If you are pregnantNot CoveredNo ChargeChildbirth/delivery professional

services services, deductiblemay apply.Maternity caremay include tests and services describedelsewhere in the SBC (i.e. ultrasound).

Not CoveredNo ChargeChildbirth/delivery facilityservices


Not CoveredNo ChargeHome health careIf you need helprecovering or haveother special healthneeds

Not CoveredNo ChargeRehabilitation servicesNot CoveredNo ChargeHabilitation services

60 days/year. Preauthorization required.Not CoveredNo ChargeSkilled nursing careNoneNot CoveredNo ChargeDurable medical equipmentPreauthorization required.Not CoveredNo ChargeHospice servicesEye screenings only. Does not includerefractions. One visit per year for membersages 17 and younger.

Not CoveredNo ChargeChildren’s eye exam

If your child needsdental or eye care

NoneNot CoveredNot CoveredChildren’s glassesNot CoveredNot CoveredChildren’s dental check-up


Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)Non-emergency care when traveling outside theU.S.

Cosmetic surgeryAbortion (Except for a pregnancy that, as certifiedby a physician, places the woman in danger ofdeath or a serious risk of substantial impairmentof a major bodily function unless an abortion isperformed)

Dental care (Adult)Weight loss programsLong-term care

AcupunctureBariatric surgery

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document)Routine eye care (Adult - One visit every two yearsfor members ages 18 and older)

Infertility treatment (Invitro not covered)Chiropractic careHearing aids (Limited to two hearing aids everythree years)

Private-duty nursing (Only when ordered orauthorized by the Primary Care Physician) Routine foot care (Only covered in connectionwith

diabetes, circulatory disorders of the lowerextremities, peripheral vascular disease, peripheralneuropathy, or chronic arterial or venousinsufficiency)

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for thoseagencies is: For group health coverage contact the plan, Blue Cross and Blue Shield of Texas at 1-877-299-2377 or visit www.bcbstx.com. For group healthcoverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. For non-federal governmental group health plans, contact Department of Health and Human Services, Center for Consumer Informationand Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Church plans are not covered by the Federal COBRA continuation coverage rules.If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law.Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For moreinformation about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint iscalled a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plandocuments also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights,this notice, or assistance, contact: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at 1-877-299-2377 or visit www.bcbstx.com, the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, and the TexasDepartment of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. For non-federal governmental group health plans and church plansthat are group health plans, Blue Cross and Blue Shield of Texas at 1-877-299-2377 or www.bcbstx.com or contact the Texas Department of Insurance,Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the TexasDepartment of Insurance’s Consumer Health Assistance Program at 1-800-252-3439 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html.

4 of 6

Does this plan provide Minimum Essential Coverage? YesIf you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemptionfrom the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? YesIf your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-877-299-2377.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-299-2377.Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-877-299-2377.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-299-2377.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

5 of 6

About These Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be differentdepending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs youmight pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby(9 months of in-network pre-natal care and a

hospital delivery)

The plan's overall deductible $5,000Specialist $0Hospital (facility) $0Other $0

This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)

$12,800Total Example Cost

In this example, Peg would pay:Cost Sharing

$5,000Deductibles$0Copayments$0Coinsurance

What isn't covered$60Limits or exclusions

$5,060The total Peg would pay is

Managing Joe’s type 2 Diabetes(a year of routine in-network care of a

well-controlled condition)


This EXAMPLE event includes services like:Primary care physician office visits (includingdisease education)Diagnostic tests (blood work)Prescription drugsDurable medical equipment (glucose meter)


In this example, Joe would pay:Cost Sharing



$5,060The total Joe would pay is

Mia’s Simple Fracture(in-network emergency room visit and follow up

care)


This EXAMPLE event includes services like:Emergency room care (includingmedical supplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)


In this example, Mia would pay:Cost Sharing



$1,900The total Mia would pay is

The plan would be responsible for the other costs of these EXAMPLE covered services. 6 of 6

bcbstx.com

If you, or someone you are helping, have questions, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 855-710-6984.

Español Spanish

Si usted o alguien a quien usted está ayudando tiene preguntas, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame 6984.-710-al 855

العربيةArabic 855-710-6984 مالر ىلع اتصل فوري، مترجم مع للتحدث .تكلفة اية دون من بلغتك الضرورية والمعلومات المساعدة ىلع الحصول في الحق فلديك أسئلة، تساعده شخص لدى أو لديك كان إن.

繁體中文 Chinese 如果您, 或您正在協助的對象, 對此有疑問, 您有權利免費以您的母語獲得幫助和訊息。洽詢一位翻譯員, 請撥電話號碼 855-710-6984。

Français French

Si vous, ou quelqu'un que vous êtes en train d’aider, avez des questions, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 855-710-6984.

Deutsch German

Falls Sie oder jemand, dem Sie helfen, Fragen haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 855-710-6984 an.

ગજુરાતી Gujarati

જો તમને અથવા તમે મદદ કરી રહ્યા હોય એવી કોઈ બીજી વ્યક્તતને એસ.બી.એમ. કાયર્ક્રમ બાબતે પ્રશ્નો હોય, તો તમને વિના ખચેર્, તમારી ભાષામાાં મદદ અને માહિતી મેળવવાનો હક્ક છે. દુભાવિયા સાથે વાત કરવા માટે આ નાંબર 855-710-6984 પર કૉલ કરો.

ह िंदी Hindi

यिद आपके, िा आप जिसकी स ायता कर रहे ैं उैसके, प्रश्न ैं, तो आपके अपनी भाषा म ननिःशुल्क सहािता और जानकारी प्राप्त करन का अधिकार ै। ककसी अनवादक स बात करन क लिए 855-710-6984 पर कॉल करें।.

Italiano Italian

Se tu o qualcuno che stai aiutando avete domande, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare il numero 855-710-6984.

한국어 Korean

만약 귀하 또는 귀하가 돕는 사람이 질문이 있다면 귀하는 무료로 그러한 도움과 정보를 귀하의 언어로 받을 수 있는 권리가 있습니다. 통역사가 필요하시면 855-710-6984 로 전화하십시오.

Diné Navajo

T’áá ni, éí doodago ła’da bíká anánílwo’ígíí, na’ídíłkidgo, ts’ídá bee ná ahóóti’i’ t’áá níík’e níká a’doolwoł dóó bína’ídíłkidígíí bee nił h odoonih. Ata’dahalne’ígíí bich’į’ hodíílnih kwe’é 855-710-6984.

فارسیPersian

شماره با شھافی، مترجم يک با گفتگو جھت .نماييد دريافت اطالعات و کمک رايگان طور به خود، زبان به که داريد را اين حق باشيد، داشته سؤالی کنيد، مي کمک او به شما که کسی يا شما، اگر نماييد حاصل تمسا 855-710-6984 .

Polski Polish

Jeśli Ty lub osoba, której pomagasz, macie jakiekolwiek pytania, macie prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku. Aby porozmawiać z tłumaczem, zadzwoń pod numer 855-710-6984.

Русский Russian

Если у вас или человека, которому вы помогаете, возникли вопросы, у вас есть право на бесплатную помощь и информацию, предоставленную на вашем языке. Чтобы связаться с переводчиком, позвоните по телефону 855-710-6984.

Tagalog Tagalog

Kung ikaw, o ang isang taong iyong tinutulungan ay may mga tanong, may karapatan kang makakuha ng tulong at impormasyon sa iyong wika nang walang bayad. Upang makipag-usap sa isang tagasalin-wika, tumawag sa 855-710-6984.

اردوUrdu اگر آپ کو، يا کسی ايسے فرد کو جس کی آپ مدد کررہے ہيں، کوئی سوال درپيش هے تو، آپ کو اپنی زبان ميں مفتمدد اور معلومات حاصل کرنے کا حق هے۔ مترجم سے بات کرنے کے ليے، 6984-710-855 پر کال کريں۔

Tiếng Việt Vietnamese

Nếu quý vị, hoặc người mà quý vị giúp đỡ, có câu hỏi, thì quý vị có quyền được giúp đỡ và nhận thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, gọi 855-710-6984.

bcbstx.com

Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age, sexual orientation, health status or disability.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance. Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail) 300 E. Randolph St. TTY/TDD: 855-661-6965 35th Floor Fax: 855-661-6960 Chicago, Illinois 60601 Email: [email protected]

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services Phone: 800-368-1019 200 Independence Avenue SW TTY/TDD: 800-537-7697 Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

https://ocrportal.hhs.gov/


PLAN – H.S.A. BLUE CHOICE BLUE EDGE H.S.A. MMH3





Network: $5,000Individual/$10,000 Family.Out-of-Network: $10,000Individual/$20,000 Family.



Yes. In-Network Preventive Care.Are there services coveredbefore you meet yourdeductible? services without cost-sharing and before you meet your deductible. See a list of covered

preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.You don’t have to meet deductibles for specific services.No.Are there other

deductibles for specificservices?


Yes. Network: $5,000Individual/$10,000 Family.Out-of-Network: $20,000Individual/$40,000 Family.


Even though you pay these expenses, they don't count toward the out-of-pocket limit.Preauthorization penalties,premiums, balance-billed charges,


and health care this plan doesn'tcover.


Yes. See www.bcbstx.comor call1-800-810-2583 for a list ofNetwork Providers.


a provider for the difference between the provider’s charge and what your plan pays (balancebilling). Be aware your network providermight use an out-of-network provider for some services(such as lab work). Check with your provider before you get services.You can see the specialist you choose without a referral.No.Do you need a referral to

see a specialist?


Summary of Benefits and Coverage:What this Plan Covers & What You Pay For Covered Services Coverage Period: 06/01/2020-05/31/2021: BlueChoice BlueEdge HSA MMH3 Coverage for: Individual/Family Plan Type: HSA



What You Will PayServices You May NeedCommon

Medical Event Out-of-Network Provider(You will pay the most)

Network Provider (Youwill pay the least)

None30% coinsuranceNo Charge after

deductiblePrimary care visit to treat aninjury or illness


30% coinsuranceNo Charge afterdeductible

Specialist visit

There is No Charge for Out-of-Networkimmunizations from birth through the day of

30% coinsuranceNo ChargePreventive care/screening/immunization

the 6th birthday. You may have to pay forservices that aren't preventive. Ask yourprovider if the services you need arepreventive. Then check what your plan willpay for.


deductibleDiagnostic test (x-ray, bloodwork)If you have a test 30% coinsuranceNo Charge after

deductibleImaging (CT/PET scans, MRIs)

Up to a 90-day supply for generic and branddrugs. Up to a 30-day supply for Specialty

No Charge afterdeductible


Preferred generic drugsIf you need drugs totreat your illness orcondition

Drugs. Certain women's preventive serviceswill be covered with no cost to the member.



Non-preferred generic drugs

More information aboutprescription drugcoverage is available atwww.bcbstx.com/member/rx_drugs.html



Preferred brand drugs



Non-preferred brand drugs



Specialty drugs


deductibleFacility fee (e.g., ambulatorysurgery center)If you have outpatient

surgery 30% coinsuranceNo Charge afterdeductible

Physician/surgeon fees

None



Emergency room care

If you need immediatemedical attention



Emergency medicaltransportation


Urgent care

2 of 6





Preauthorization required Out-of-Network;failure to preauthorize at least two business


Facility fee (e.g., hospitalroom)

If you have a hospitalstay

days prior to admission will result in $250reduction in benefits.

None30% coinsuranceNo Charge afterdeductible

Physician/surgeon fees

Outpatient: Preauthorization required forpsychological testing, neuropsychological


Outpatient services

If you need mentalhealth, behavioralhealth, or substanceabuse services

testing, electroconvulsive therapy, repetitivetranscranial magnetic stimulation, and


Inpatient services

intensive outpatient treatment; failure topreauthorize at least two business days priorto service will result in 50% reduction inbenefits (not to exceed $500). Inpatient:Preauthorization required Out-of-Network;failure to preauthorize at least two businessdays prior to admission will result in $250reduction in benefits.

Cost sharing does not apply to certainpreventive services. Depending on the type of


Office visits

If you are pregnant services deductiblemay apply. Maternity care30% coinsuranceNo Charge afterdeductible

Childbirth/delivery professionalservices may include tests and services described

elsewhere in the SBC (i.e. ultrasound).30% coinsuranceNo Charge afterdeductible

Childbirth/delivery facilityservices

60 visit maximum per benefit period.Preauthorization required for Out-of-Network.


Home health care

If you need helprecovering or haveother special healthneeds

For Outpatient, limited to combined 35 visitsper year, including Chiropractic.


Rehabilitation services


Habilitation services

25 day maximum per benefit period.Preauthorization required for Out-of-Network.


Skilled nursing care

None30% coinsuranceNo Charge afterdeductible

Durable medical equipment

Preauthorization required for Out-of-Network.30% coinsuranceNo Charge afterdeductible

Hospice services

3 of 6





NoneNot CoveredNot CoveredChildren’s eye exam

If your child needsdental or eye care Not CoveredNot CoveredChildren’s glasses

Not CoveredNot CoveredChildren’s dental check-up


Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)Private-duty nursingCosmetic surgeryAbortion

Acupuncture Routine eye care (Adult and Child)Dental care (Adult)Long-term careBariatric surgery Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document)Routine foot care (Only covered in connectionwithdiabetes, circulatory disorders of the lowerextremities, peripheral vascular disease, peripheralneuropathy, or chronic arterial or venousinsufficiency)

Infertility treatment (Invitro and artificialinsemination are not covered unless shown inyour Plan document)

Chiropractic careHearing aids

Non-emergency care when traveling outside theU.S.




4 of 6




5 of 6


Peg is Having a baby(9 months of in-network pre-natal care and a

hospital delivery)







$5,060The total Peg would pay is









$5,060The total Joe would pay is


care)







$1,900The total Mia would pay is



PLAN – PPO BLUE CHOICE PPO 48A3





In-Network - $2,000 Individual /$6,000 FamilyOut-of-Network - $4,000 Individual/ $12,000 Family



Yes. Network office visits,prescription drugs and certain

Are there services coveredbefore you meet yourdeductible? services without cost-sharing and before you meet your deductible. See a list of covered

preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.preventive care services arecovered before you meet yourdeductible.

You must pay all of the costs for these services up to the specific deductible amount beforethis plan begins to pay for these services.

Yes. ER $500. There are no otherspecific deductibles.

Are there otherdeductibles for specificservices?


In-Network - $5,000 Individual /$14,700 FamilyOut-of-Network - UnlimitedIndividual / Unlimited Family


Even though you pay these expenses, they don't count toward the out-of-pocket limit.Premiums, balanced-billedcharges, and health care this plandoesn't cover.



Yes. Seewww.bcbstx.com/go/bcppo orcall 1-800-810-2583 for a list ofNetwork Providers.


a provider for the difference between the provider’s charge and what your plan pays (balancebilling). Be aware your network providermight use an out-of-network provider for some services(such as lab work). Check with your provider before you get services.You can see the specialist you choose without a referral.No.Do you need a referral to

see a specialist?


Summary of Benefits and Coverage:What this Plan Covers & What You Pay For Covered Services Coverage Period: 06/01/2020-05/31/2021

: MTBCP48A3 Blue Choice PPOSM 48A3 Coverage for: Individual/Family Plan Type: PPO






Virtual Visits are available. See your benefitbooklet* for details.

40% coinsurance$30/visit; deductible doesnot apply

Primary care visit to treat aninjury or illness


None40% coinsurance$60/visit; deductible doesnot apply

Specialist visit

You may have to pay for services that aren'tpreventive. Ask your provider if the services

40% coinsuranceNo Charge; deductibledoes not apply

Preventive care/screening/immunization

needed are preventive. Then check what yourplan will pay for.

Preauthorization may be required; see yourbenefit booklet* for details.

40% coinsuranceNo ChargeDiagnostic test (x-ray, bloodwork)If you have a test

40% coinsurance20% coinsuranceImaging (CT/PET scans, MRIs)






Limited to a 30-day supply at retail (or a90-day supply at a network of select retail

Retail - $10/prescription;deductible does not apply

Retail - Preferred - NoChargeNon-Preferred -$10/prescriptionMail - No Charge;deductible does not apply

Preferred generic drugs

If you need drugs totreat your illness orcondition

More information aboutprescription drugcoverage is available athttps://www.bcbstx.com/member/prescription-drug-plan-information/drug-lists

pharmacies). Up to a 90-day supply at mailorder. Specialty drugs limited to a 30-daysupply. Payment of the difference betweenthe cost of a brand name drug and a genericmay also be required if a generic drug isavailable. All Out-of-Network prescriptionsare subject to a 50% additional charge afterthe applicable copay/coinsurance. Additionalcharge will not apply to any deductible orout-of-pocket amounts.


Retail - Preferred -$10/prescriptionNon-Preferred -$20/prescriptionMail - $30/prescription;deductible does not apply

Non-preferred generic drugs

Retail: $70/prescription;deductible does not apply


Preferred brand drugs



Non-preferred brand drugs

$150/prescription;deductible does not apply


Preferred specialty drugs



Non-preferred specialty drugs

Preauthorization may be required. Abortionis not covered except in limitedcircumstances.For Outpatient Infusion Therapy, see yourbenefit booklet* for details.

40% coinsurance20% coinsuranceFacility fee (e.g., ambulatorysurgery center)If you have outpatient

surgery 40% coinsurance20% coinsurancePhysician/surgeon fees






Per occurrence deductible waived if admitted.$500/visit plus20% coinsurance

$500/visit plus20% coinsurance

Emergency room care

If you need immediatemedical attention

None

20% coinsurance20% coinsuranceEmergency medicaltransportation

40% coinsurance$75/visit; deductible doesnot apply

Urgent care

Preauthorization required. Preauthorizationpenalty: $250 Out-of-Network. See yourbenefit booklet* for details.

40% coinsurance20% coinsuranceFacility fee (e.g., hospitalroom)If you have a hospital

stay40% coinsurance20% coinsurancePhysician/surgeon fees

Outpatient: Certain services must bepreauthorized, failure to preauthorize at least

40% coinsurance$30/office visits or20%coinsurance for otheroutpatient services

Outpatient services

If you need mentalhealth, behavioralhealth, or substanceabuse services

two business days prior to service will resultin 50% reduction in benefits (not to exceed$500), refer to benefit booklet* for details.Inpatient: Preauthorization requiredOut-of-Network; failure to preauthorize at least

40% coinsurance20% coinsuranceInpatient services

two business days prior to admission willresult in $250 reduction in benefits.Copay applies to first prenatal visit (perpregnancy). Cost sharing does not apply to

40% coinsurancePrimary Care: $30Specialist: $60;deductible does not apply

Office visits

If you are pregnantcertain preventive services. Depending on thetype of services, coinsurance may apply.40% coinsurance20% coinsuranceChildbirth/delivery professional

services Maternity caremay include tests and servicesdescribed elsewhere in the SBC (i.e.ultrasound).

40% coinsurance20% coinsuranceChildbirth/delivery facilityservices






60 visits/year. Preauthorization required forOut-of-Network.

40% coinsurance20% coinsuranceHome health care

If you need helprecovering or haveother special healthneeds

Preauthorization may be required. ForOutpatient, limited to combined 35 visits peryear, including Chiropractic.

40% coinsurance20% coinsuranceRehabilitation services40% coinsurance20% coinsuranceHabilitation services

25 day maximum per calendar year.Preauthorization required for Out-of-Network.

40% coinsurance20% coinsuranceSkilled nursing care

None40% coinsurance20% coinsuranceDurable medical equipmentPreauthorization required for Out-of-Network.40% coinsuranceNo ChargeHospice services

NoneNot CoveredNot CoveredChildren’s eye exam

If your child needsdental or eye care Not CoveredNot CoveredChildren’s glasses

Not CoveredNot CoveredChildren’s dental check-up


Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)Private-duty nursingDental care (Adult)Abortion (Except for a pregnancy that, as certified

by a physician, places the woman in danger ofdeath or a serious risk of substantial impairmentof a major bodily function unless an abortion isperformed)

Routine eye care (Adult and Child)Long-term careNon-emergency care when traveling outside theU.S.

Weight loss programs

AcupunctureBariatric surgeryCosmetic surgery

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document)Routine foot care (Only covered in connectionwithdiabetes, circulatory disorders of the lowerextremities, peripheral vascular disease, peripheralneuropathy, or chronic arterial or venousinsufficiency)

Infertility treatment (Invitro and artificialinsemination are not covered unless shown inyour plan document)

Chiropractic care (Outpatient -Max. 35 visits/year)Hearing aids (Limited to two hearing aids everythree years)

5 of 7







6 of 7


Peg is Having a Baby(9 months of in-network pre-natal care and a

hospital delivery)

The plan's overall deductible $2,000Specialist copayment $60Hospital (facility) coinsurance 20%Other coinsurance 20%




$2,000Deductibles$30Copayments

$2,000CoinsuranceWhat isn't covered

$60Limits or exclusions$4,090The total Peg would pay is







$1,900Deductibles$1,000Copayments

$0CoinsuranceWhat isn't covered

$60Limits or exclusions$2,960The total Joe would pay is


care)





$1,600Deductibles$200Copayments

$0CoinsuranceWhat isn't covered

$0Limits or exclusions$1,800The total Mia would pay is


BENEFITS ADMINITRATION & INSURANCE SERVICES, LLC.

PLAN – MEC USA ONLY


1 of 5

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services YWCA Employee Benefit Plan – USA

Coverage Period: 06/01/2020 – 05/31/2021Coverage for: Individual & Family | Plan Type: EPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, 1-888-511-5247. For general definitions of

common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.baandis.com or call 1-888-511-5247 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible?

$5,000 See the Common Medical Events chart below for your costs for services this plan covers.

Are there services covered before you meet your deductible?

Yes.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventative services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

No. You don’t have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

Not Applicable The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they must meet their own out-of-pocket limits until the overall family out-of pocket limit has been met. This plan has a $5,000 annual maximum benefit for all covered services.

What is not included in the out-of-pocket limit?

Copayments for certain services, premiums, balance-billing charges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

Will you pay less if you use a network provider?

Yes. See www.firsthealthlbp.com or call 1-888-511-5247 for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist?

No. You can see the specialist you choose without a referral.

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Released on April 6, 2016

2 of 5


Common

Medical Event Services You May Need Network Provider

(You will pay the least)

Out-of-Network Provider

(You will pay the most) Limitations, Exceptions, & Other Important Information

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

$35 copay/office visit Not Covered None

Specialist visit $75 copay/office visit Not Covered None

Preventive care/screening/ immunization

No Charge Not Covered You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.

If you have a test

Diagnostic test (x-ray, blood work)

$20 copay + coins/Lab work $20 copay + coins/X-ray

Not Covered These services at hospitals are excluded.

Imaging (CT/PET scans, MRIs) Not Covered Not Covered These services are excluded.

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.magellanrx.com

Generic drugs (Tier 1)

Retail- $10 copay/ prescription; Mail order- $20 copay/ prescription

Not Covered

Covers up to a 30-day supply (retail); 31-90 day supply (mail order).

Preferred brand drugs (Tier 2)

Retail- $50 copay + 50% coins/ prescription; Mail order- $100 copay + 50% coins/ prescription

Not Covered

Non-preferred brand drugs (Tier 3)

Retail- $75 copay + 75% coins/ prescription; Mail order- $150 copay + 75% coins/ prescription

Not Covered

Specialty drugs (Tier 4) Not Covered Not Covered

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

Not Covered Not Covered These services are excluded.

Physician/surgeon fees Not Covered Not Covered These services are excluded.

If you need immediate medical attention

Emergency room care Not Covered Not Covered These services are excluded.

Emergency medical transportation

Not Covered Not Covered These services are excluded.

Urgent care $25 copay + 80% Coins Not Covered None

theresa.lopez

Rectangle

theresa.lopez

Typewritten Text

$100

3 of 5

Common

Medical Event Services You May Need Network Provider



(You will pay the most) Limitations, Exceptions, & Other Important Information

If you have a hospital stay

Facility fee (e.g., hospital room) Not Covered Not Covered These services are excluded.

Physician/surgeon fees Not Covered Not Covered These services are excluded.

If you need mental health, behavioral health, or substance abuse services

Outpatient services Not Covered Not Covered

These services are excluded. Inpatient services Not Covered Not Covered

If you are pregnant

Office visits $35 copay/visit Not Covered Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

Childbirth/delivery professional services

Not Covered Not Covered

These services are excluded. Childbirth/delivery facility services

Not Covered Not Covered

If you need help recovering or have other special health needs

Home health care Not Covered Not Covered

These services are excluded.

Rehabilitation services Not Covered Not Covered

Habilitation services Not Covered Not Covered

Skilled nursing care Not Covered Not Covered

Durable medical equipment Not Covered Not Covered

Hospice services Not Covered Not Covered

If your child needs dental or eye care

Children’s eye exam Not Covered Not covered

These services are excluded. Children’s glasses Not Covered Not covered

Children’s dental check-up Not Covered Not covered


Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Cosmetic Surgery

Dental Care

Infertility Treatment

Long Term Care

Weight Loss Program

Private Duty Nursing

Routine eye care

Routine Foot Care

See Summary Plan Description (SPD) for complete list of exclusions.

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

None.

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: California Department of Insurance at 1-800-927-4357 (HELP), the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be

4 of 5

available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596 or contact the plan at 1-888-511-5247. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: 1-888-511-5247. Does this plan provide Minimum Essential Coverage? Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? No. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (español): Para obtener asistencia en español, llame al 1-888-511-5247.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

5 of 5

The plan would be responsible for the other costs of these EXAMPLE covered services.

Peg is Having a Baby

(9 months of in-network pre-natal care and a hospital)

Mia’s Simple Fracture

(in-network emergency room visit and follow up care)

Managing Joe’s type 2 Diabetes

(a year of routine in-network care of a well-controlled condition)

The plan’s overall deductible $5000 Specialist copayment $75 Hospital (facility) coinsurance 100% Other coinsurance 50% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost $12,800

In this example, Peg would pay:

Cost Sharing

Deductibles $0

Copayments $1,481

Coinsurance $523

What isn’t covered

Limits or exclusions $9,019

The total Peg would pay is $11,023

The plan’s overall deductible $5000 Specialist copayment $75 Hospital (facility) coinsurance 100% Other coinsurance 50% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)


In this example, Joe would pay:

Cost Sharing

Deductibles $250

Copayments $1,412

Coinsurance $1,818



The total Joe would pay is $5,263

The plan’s overall deductible $5000 Specialist copayment $75 Hospital (facility) coinsurance 100% Other coinsurance 50% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)


In this example, Mia would pay:

Cost Sharing

Deductibles $0

Copayments $273

Coinsurance $123



The total Mia would pay is $1,782

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

BENEFITS ADMINITRATION &

INSURANCE SERVICES, LLC. PLAN – EPO

USA / MEXICO NETWORK


Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services YWCA Employee Benefit Plan – US/MEX

Coverage Period: 06/01/2020 – 05/31/2021 Coverage for: Individual & Family | Plan Type: EPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, 1-888-511-5247. For general definitions of

common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.baandis.com or call 1-888-511-5247 to request a copy.

Important Questions Answers Why This Matters:

$5,000 See the Common Medical Events chart below for your costs for services this plan covers.

Are there services covered before you meet your deductible?

Are there other

Yes.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventative services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

deductibles for specific services?

What is the out-of-pocket

No. You don’t have to meet deductibles for specific services.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family

limit for this plan? Not Applicable

Copayments for certain services,

members in this plan, they must meet their own out-of-pocket limits until the overall family out-of pocket limit has been met. This plan has a $5,000 annual maximum benefit for all covered services.

What is not included in the out-of-pocket limit?

Will you pay less if you use a network provider?

Do you need a referral to

premiums, balance-billing charges, and health care this plan doesn’t cover.

Yes. See www.firsthealthlbp.com or call 1-888-511-5247 for a list of network providers.

Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

see a specialist? No. You can see the specialist you choose without a referral.

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Released on April 6, 2016

1 of 5

What is the overall deductible?

http://www.baandis.com/

http://www.baandis.com/

http://www.healthcare.gov/coverage/preventive-care-benefits/



http://www.firsthealthlbp.com/

2 of 5

Common

Medical Event

Services You May Need

What You Will Pay Limitations, Exceptions, & Other

Important Information

Network Provider USA


Network Provider Mexico



(You will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

$35 copay/office visit $20 copay/office visit Not Covered None

Specialist visit $75 copay/office visit $45 copay/office visit Not Covered None

Preventive care/screening/ immunization

No Charge

No Charge

Not Covered

You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.

If you have a test

Diagnostic test (x-ray, blood work)

$20 copay + coins/Lab work $20 copay + coins/X-ray

$25 copay/Lab work $25 copay/X-ray

Not Covered These services at hospitals are excluded.

Imaging (CT/PET scans, MRIs) Not Covered $250 copay Not Covered None

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.magellanrx.com

Generic drugs (Tier 1)

Retail- $10 copay/ prescription; Mail order- $20 copay/ prescription

Not Covered

Not Covered

Covers up to a 30-day supply (retail); 31-90 day supply (mail order).

Preferred brand drugs (Tier 2)

Retail- $50 copay + 50% coins/prescription; Mail order- $100 copay + 50% coins/prescription

Retail- $25 copay/ prescription

Not Covered

Non-preferred brand drugs (Tier 3)

Retail- $75 copay + 75% coins/prescription; Mail order- $150 copay + 75% coins/prescription

Not Covered

Not Covered

Specialty drugs (Tier 4) Not Covered Not Covered Not Covered

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

Not Covered Not Covered Not Covered These services are excluded.

Physician/surgeon fees Not Covered Not Covered Not Covered These services are excluded.

If you need immediate medical attention

Emergency room care

Not Covered

Not Covered

Not Covered



http://www.magellanrx.com/

3 of 5

Common

Medical Event

Services You May Need

What You Will Pay Limitations, Exceptions, & Other

Important Information

Network Provider USA


Network Provider Mexico



(You will pay the most)

Emergency medical transportation

Not Covered Not Covered Not Covered These services are excluded.

Urgent care $100 copay + 80% Coins Not Covered Not Covered None

If you have a hospital stay

Facility fee (e.g., hospital room) Not Covered Not Covered Not Covered These services are excluded.

Physician/surgeon fees Not Covered Not Covered Not Covered These services are excluded.

If you need mental health, behavioral health, or substance abuse services

Outpatient services Not Covered Not Covered Not Covered

These services are excluded. Inpatient services Not Covered Not Covered Not Covered

If you are pregnant

Office visits

$35 copay/visit

$20 copay/visit

Not Covered

Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

Childbirth/delivery professional services

Not Covered Not Covered Not Covered

These services are excluded. Childbirth/delivery facility services

Not Covered Not Covered Not Covered

If you need help recovering or have other special health needs

Home health care Not Covered Not Covered Not Covered


Rehabilitation services Not Covered Not Covered Not Covered

Habilitation services Not Covered Not Covered Not Covered

Skilled nursing care Not Covered Not Covered Not Covered

Durable medical equipment Not Covered Not Covered Not Covered

Hospice services Not Covered Not Covered Not Covered

If your child needs dental or eye care

Children’s eye exam Not Covered Not Covered Not covered

These services are excluded. Children’s glasses Not Covered Not Covered Not covered

Children’s dental check-up Not Covered Not Covered Not covered


Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Cosmetic Surgery

Dental Care

Infertility Treatment

Long Term Care

Weight Loss Program

Private Duty Nursing

Routine eye care

Routine Foot Care

See Summary Plan Description (SPD) for complete list of exclusions.

4 of 5

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: California Department of Insurance at 1-800-927-4357 (HELP), the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444- 3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596 or contact the plan at 1-888-511-5247.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: 1-888-511-5247.

Does this plan provide Minimum Essential Coverage? Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet Minimum Value Standards? No. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services: Spanish (español): Para obtener asistencia en español, llame al 1-888-511-5247.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

None.

http://www.dol.gov/ebsa

http://www.cciio.cms.gov/

http://www.healthcare.gov/



Peg is Having a Baby (9 months of in-network pre-natal care and a

hospital)

Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well-

controlled condition)

Mia’s Simple Fracture (in-network emergency room visit and follow up

care)

The plan’s overall deductible

$5000


$5000


$5000

Specialist copayment $75 Specialist copayment $75 Specialist copayment $75 Hospital (facility) coinsurance 100% Hospital (facility) coinsurance 100% Hospital (facility) coinsurance 100% Other coinsurance 50% Other coinsurance 50% Other coinsurance 50%

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:

Cost Sharing

Deductibles $0

Copayments $273

Coinsurance $123



The total Mia would pay is $1,782

Cost Sharing

Deductibles $250

Copayments $1,412

Coinsurance $1,818



The total Joe would pay is $5,263

Cost Sharing

Deductibles $0

Copayments $1,481

Coinsurance $523



The total Peg would pay is $11,023

Total Example Cost $1,900 Total Example Cost $7,400 Total Example Cost $12,800

About these Coverage Examples:

This is not a cost estimator. Treatments shown are j

ust examples of how this plan might cover medical care. Your actual costs will be

different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of

costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

METLIFE

DENTAL

DN-GCERT-GOLD GCERT Voluntary Dental Benefit Summary

200 Park Ave., New York, NY 10166 © 2018 MetLife Services and Solutions, LLC

L1018509236[exp1019][xDC,GU,MP,NM,PR,VI]

DentalMetropolitan Life Insurance Company

Plan Design for: YWCA OF EL PASO INC

Network: PDP Plus The Preferred Dentist Program was designed to help you get the dental care you need and help lower your costs. You get benefi ts for a wide range of covered services — both in and out of the network. The goal is to deliver affordable protection for a health ier smile and a healthier you.

Coverage Type: In-Network1 % of Negotiated Fee2

Out-of-Network1 % of R&C Fee4

Type A - Preventive 100% 100% Type B - Basic Restorative 80% 80% Type C - Major Restorative 50% 50%

Deductible3 Individual $50 $50 Family $150 $150

Annual Maximum Benefit: Per Individual $1500 $1500 Dependent Age: Eligible for benefits until the day that he or she turns 26.

1. "In-Netw ork Benefits" refers to benefits provided under this plan for covered dental services that are provided by aparticipating dentist. "Out-of-Netw ork Benefits" refers to benefits provided under this plan for covered dental services thatare not provided by a participating dentist.

2. Negotiated fees refer to the fees that participating dentists have agreed to accept as payment in full for covered services,subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change.

3. Applies to Type B and C services only.4. Out-of-netw ork benefits are payable for services rendered by a dentist w ho is not a participating provider. The Reasonable

and Customary charge is based on the low est of: the dentist’s actual charge (the 'Actual Charge'), the dentist’s usual charge for the same or similar services (the 'Usual Charge') or the usual charge of most dentists in the same geographic area for the same or similar services as determined by

MetLife (the 'Customary Charge'). For your plan, the Customary Charge is based on the 90th percentile. Servicesmust be necessary in terms of generally accepted dental standards.




Understanding Your Dental Benefits Plan The Preferred Dentist Program is designed to provide the dental coverage you need w ith the features you w ant. Like the freedom to visit the dentist of your choice – in or out of the netw ork. .

If you receive in-netw ork services, you w ill be responsible for any applicable deductibles, cost sharing, negotiated charges after benefit maximums are met, and costs for non-covered services. If you receive out-of-netw ork services, you w ill be responsible for any applicable deductibles, cost sharing, charges in excess of the benefit maximum, charges in excess of the negotiated fee schedule amount or R&C Fee, and charges for non-covered services.

Plan benefits for in-netw ork covered services are based on a percentage of the Negotiated fee – the Fee that participating dentists have agreed to accept as payment in full for covered services, subject to any deductibles, copayments, cost sharing and benefit maximums. Negotiated fees are subject to change.

Plan benefits for out-of-netw ork services are based on a percentage of the Reasonable and Customary (R&C) charge. If you choose a dentist w ho does not participate in the netw ork, your out-of-pocket expenses may be greater.

Once you’re enrolled you may take advantage of online self-service capabilities w ith MyBenefits. Check the status of your claims Locate a participating dentist Access MetLife’s Oral Health Library Elect to view your Explanation of Benefits

online To register, just go to

www.metlife.com/mybenefits and follow the easy registration instructions.

IMPORTANT RATE INFORMATION

Monthly Premium Payment Employee $26.47

Employee + Spouse $52.94 Employee + Child(ren) $63.79

Employee + Family $98.86 Cancellation/Termination of Benefits: Coverage is provided under a group insurance policy (Policy form GPN99) issued by Metropolitan Life Insurance Company. Subjec t to the terms of the group policy, rates are effective for one year from your plan's effective date. Once coverage is issued, the terms of the group policy permit Metropolitan Life Insurance Company to change rates during the year in certain circumstances. Coverage terminates when your f ull-time employment ceases, when your dental contributions cease or upon termination of the group policy by the Policyholder. The group policy may also terminate if participation requirements are not met, or on the date of the employee’s death, if the Policyholder fails to per form any obligations under the policy, or at MetLife's option. The dependent's coverage terminates when a dependent ceases to be a dependent. There is a 30 -day limit for the following services that are in progress: Completion of a prosthetic device, crown or root canal therapy after individual termination of coverage.

IMPORTANT ENROLLMENT INFORMATION You may only enroll for Dental Expense Benefits within 31 days of your Personal Benefits Eligibility Date, or if you have a Q ualifying Event or during the Plan's Annual Open Enrollment Period. Qualifying Ev ent: Request to be covered, or to change your coverage, upon a Qualifying Event If there is a Qualifying Event you may request to be covered, or to change your coverage, only within 31 days of a Qualifying Event. Such a request will not be a late request. Except for marriage or the birth or adoption of a child, you must give us proof of prior dental coverage under your spouse's plan if you are requesting coverage under this Plan because of a loss of the prior dental coverage. If you make a request to be covered under this Plan or request a change(s)in coverage under this Plan within thirty-one days of a Qualifying Event, your coverage or the change(s) in coverage will become effective on the first day of the month following the date of your request, subject to the Active Work Requirement, and provided that the change in coverage is consistent with your new family status.




Selected Covered Services and Frequency Limitations*

Type A - Preventive How Many/How Often: Oral Examinations 1 in 6 months

Full Mouth X-rays 1 in 60 months Y4

Bitewing X-rays (Adult/Child) 1 in a year

Prophylaxis - Cleanings 1 in 6 months

Topical Fluoride Applications 1 in 12 months - Children to age 14

Sealants 1 in 60 months - Children to age 14

Space Maintainers 1 per l ifetime per tooth area - Children up to age 14

Type B - Basic Restorative How Many/How Often:

Amalgam and Composite Fil lings 1 in 24 months.

Periodontal Scaling & Root Planing 1 in 24 months per quadrant

Periodontal Maintenance 2 in 1 year, includes 2 cleanings

Oral Surgery (Simple Extractions)

Emergency Palliative Treatment

General Anesthesia

Type C - Major Restorative How Many/How Often: Crowns/Inlays/Onlays 1 per tooth in 10 years

Prefabricated Crowns 1 per tooth in 10 years

Repairs 1 in 24 months

Endodontics Root Canal 1 per tooth per l ifetime

Periodontal Surgery 1 in 36 months per quadrant

Oral Surgery (Surgical Extractions)

Other Oral Surgery

Bridges 1 in 10 years

Dentures 1 in 10 years

Consultations 2 in 12 months

Implant Services 1 service per tooth in 10 years - 1 repair per 10 years

*Alternate Benefits: Where two or more professionally acceptable dental treatments for a dental condition exist, reimbursement is based on the least costly treatment alternative. If you and your dentist have agreed on a treatment that is more costly than the treatment upon which the plan benefit is based, you will be responsible for any additional payment responsibility. To avoid any misunderstandings, we sugg est you discuss treatment options with your dentist before services are rendered, and obtain a pretreatment estimate of benefits prior to receiving certain high cost services such as crowns, bridges or dentures. You and your dentist will each receive an Explanation of Benefits (EOB) ou tlining the services provided, your plan’s reimbursement for those services, and your out-of-pocket expense. Actual payments may vary from the pretreatment estimate depending upon annual maximums, plan frequency limits, deductibles and other l imits applicable at time of payment. The service categories and plan limitations shown above represent an overview of your Plan of Benefits. This document presents many services within each category, but is not a complete description of the Plan. Please see your Plan description/Insurance certificate for complete details. In the event of a conflict with this summary, the terms of your insurance certificate will govern. We will not pay Dental Insurance benefits for charges incurred for: 1. Services w hich are not Dentally Necessary, those w hich do not meet generally accepted standards of care for treating the

particular dental condition, or w hich We deem experimental in nature; 2. Services for w hich You w ould not be required to pay in the absence of Dental Insurance; 3. Services or supplies received by You or Your Dependent before the Dental Insurance starts for that person; 4. Services w hich are primarily cosmetic (For residents of Texas, see notice page section in your certif icate). 5. Services w hich are neither performed nor prescribed by a Dentist except for those services of a licensed dental hygienist

w hich are supervised and billed by a Dentist and w hich are for: scaling and polishing of teeth; or f luoride treatments.

For NY Sitused Groups, this exclusion does not apply. 6. Services or appliances w hich restore or alter occlusion or vertical dimension. 7. Restoration of tooth structure damaged by attrition, abrasion or erosion. 8. Restorations or appliances used for the purpose of periodontal splinting. 9. Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco. 10. Personal supplies or devices including, but not limited to: w ater piks, toothbrushes, or dental f loss. 11. Decoration, personalization or inscription of any tooth, device, appliance, crow n or other dental w ork. 12. Missed appointments




. 13. Services

covered under any w orkers’ compensation or occupational disease law ; covered under any employer liability law ; for w hich the employer of the person receiving such services is not required to pay; or received at a facility maintained by the Employer, labor union, mutual benefit association, or V A hospital. For North Carolina and Virginia Sitused Groups , this exclusion does not apply.

14. Services paid under any w orker’s compensation, occupational disease or employer liability law as follow s: for persons w ho are covered in North Carolina for the treatment of an Occupational Injury or Sickness w hich are paid

under the North Carolina Workers’ Compensation Act only to the extent such services are the liability of the employee, employer or w orkers’ compensation insurance carrier according to a f inal adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers’ compensation Act;

or for persons w ho are not covered in North Carolina, services paid or payable under any w orkers compensation or occupational disease law . This exclusion only applies for North Carolina Sitused Groups.

15. Services: for w hich the employer of the person receiving such services is required to pay; or received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital.

This exclusion only applies for North Carolina Sitused Groups. 16. Services covered under any w orkers' compensation, occupational disease or employer liability law for w hich the employee/or

Dependent received benefits under that law . This exclusion only applies for Virginia Sitused Groups.

17. Services: for w hich the employer of the person receiving such services is not required to pay; or received at a facility maintained by the policyholder, labor union, mutual benefit association, or VA hospital. This exclusion only applies for Virginia Sitused Groups.

18. Services covered under other coverage provided by the Employer. 19. Temporary or provisional restorations. 20. Temporary or provisional appliances. 21. Prescription drugs. 22. Services for w hich the submitted documentation indicates a poor prognosis. 23. The follow ing w hen charged by the Dentist on a separate basis:

claim form completion; infection control such as gloves, masks, and sterilization of supplies; or local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide.

24. Dental services arising out of accidental injury to the teeth and supporting structures, except for injur ies to the teeth due to chew ing or biting of food. For NY Sitused Groups, this exclusion does not apply.

25. Caries susceptibility tests. 26. Initial installation of a f ixed and permanent Denture to replace one or more natural teeth w hich w ere missing before such

person w as insured for Dental Insurance, except for congenitally missing natural teeth. 27. Other f ixed Denture prosthetic services not described elsew here in this certif icate. 28. Precision attachments, except w hen the precision attachment is related to implant prosthetics. 29. Initial installation or replacement of a full or removable Denture to replace one or more natural teeth w hich w ere missing

before such person w as insured for Dental Insurance, except for congenitally missing natural teeth. 30. Addition of teeth to a partial removable Denture to replace one or more natural teeth w hich w ere missing before such person

w as insured for Dental Insurance, except for congenitally missing natural teeth. 31. Adjustment of a Denture made w ithin 6 months after installation by the same Dentist w ho installed it. 32. Implants to replace one or more natural teeth w hich w ere missing before such person w as insured for Dental Insurance,

except for congenitally missing natural teeth. 33. Implants supported prosthetics to replace one or more natural teeth w hich w ere missing before such person w as insured for

Dental Insurance, except for congenitally missing natural teeth. 34. Fixed and removable appliances for correction of harmful habits.1 35. Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards and night guards.1 36. Diagnosis and treatment of temporomandibular joint (TMJ) disorders. This exclusion does not apply to residents of Minnesota.1 37. Orthodontic services or appliances. 1 38. Repair or replacement of an orthodontic device.1 39. Duplicate prosthetic devices or appliances. 40. Replacement of a lost or stolen appliance, Cast Restoration, or Denture. 41. Intra and extraoral photographic images. 42. Services or supplies furnished as a result of a referral prohibited by Section 1 -302 of the Maryland Health Occupations Article. A prohibited

referral is one in which a Health Care Practitioner refers You to a Health Care Entity in which the Health Care Practitioner or Health Care Practitioner’s immediate family or both own a Beneficial Interest or have a Compensation Agreement. For the purposes of this exclusion, the terms “Referral”, “Health Care Practitioner” , “Health Care Entity”, “Beneficial Interest” and Compensation Agreement have the same meaning as provided in Section 1-301 of the Maryland Health Occupations Article.

This exclusion only applies for Maryland Sitused Groups 1Some of these exclusions may not apply. Please see your Certif icate of Insurance.




Common Questions … Important Answers Who is a participating dentist? A participating, or netw ork, dentist is a general dentist or specialist w ho has agreed to accept negotiated fees as payment in full for covered services provided to plan members, subject to any deductibles, copayments, cost sharing and benefit maximums. Negotiated fees typically range from 30-45% below the average fees charged in a dentist’s community for the same or substantially similar services.* In addition to the standard MetLife netw ork, your employer may provide you w ith access to a select netw ork of dental providers that may be unique to your employer’s dental program. When visiting these providers, you may receive a better benefit, have low er out-of-pocket costs and/or have access to care at facilities at your w orksite. Please sign into MyBenefits for more details. * Based on internal analysis by MetLife. Negotiated fees refer to the fees that participating dentists have agreed to accept as payment in full for covered services, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change. Savings from enrolling in a dental benefits plan will depend on v arious factors, including the cost of the plan, how of ten members visit a dentist and the cost of servic es rendered. Negotiated fees are subject to change. How do I find a participating dentist? There are thousands of general dentists and specialists to choose from nationw ide --so you are sure to f ind one that meets your needs. You can receive a list of these participating dentists online at w ww.metlife.com/dental or call 1-800-275-4638 to have a list faxed or mailed to you. What services are covered by my plan? Please see your Certif icate of Insurance for a list of covered services. May I choose a non-participating dentist? Yes. You are alw ays free to select the dentist of your choice. How ever, if you choose a non-participating (out-of-netw ork) dentist, your out-of-pocket costs may be greater than your out-of-pocket costs w hen visiting an in-netw ork dentist. Can my dentist apply for participation in the network? Yes. If your current dentist does not participate in the netw ork and you w ould like to encourage him or her to apply, ask your dentist to visit w ww.metdental.com, or call 1-866-PDP-NTWK for an application.* The w ebsite and phone number are for use by dental professionals only. * Due to contractual requirements, MetLife is prevented from soliciting certain providers. How are claims processed? Dentists may submit your claims for you w hich means you have little or no paperw ork. You can track your claims online and even receive email alerts w hen a claim has been processed. If you need a claim form, visit w ww.metlife.com/dental or request one by calling 1-800-275-4638. Can I get an estimate of what my out-of-pocket expenses will be before receiving a service? Yes. You can ask for a pretreatment estimate. Your general dentist or specialist usually sends MetLife a plan for your care and requests an estimate of benefits. The estimate helps you prepare for the cost of dental services. We recommend that you request a pre-treatment estimate for services in excess of $300. Simply have your dentist submit a request online at w ww.metdental.com or call 1-877-MET-DDS9. You and your dentist w ill receive a benefit estimate for most procedures w hile you are still in the off ice. Actual payments may vary depending upon plan maximums, deductibles, frequency limits and other conditions at time of payment. Can MetLife help me find a dentist outside of the U.S. if I am traveling? Yes. Through international dental travel assistance services* you can obtain a referral to a local dentist by calling +1-312-356-5970 (collect) w hen outside the U.S. to receive immediate care until you can see your dentist. Coverage w ill be considered under your out-of-netw ork benefits.** Please remember to hold on to all receipts to submit a dental claim. *International Dental Travel Assistance services are administered by AXA Assistance USA, Inc. (AXA Assistance). AXA Assistance provides dental referral services only. AXA Assistance is not affiliated with MetLife and any of its affiliates, and the services they provide are separate and apart from the benefits provided by MetLife. Referral services are not available in all locations. ** Refer to your Certificate of Insurance for your out-of-network dental coverage. How does MetLife coordinate benefits with other insurance plans? Coordination of benefits provisions in dental benefits plans are a set of rules that are follow ed w hen a patient is covered by more than one dental benefits plan. These rules determine the order in w hich the plans w ill pay benefits. If the MetLife dental benefit plan is primary, MetLife w ill pay the full amount of benefits that w ould normally be available under the plan. If the MetLife dental benefit plan is secondary, most coordination of benefits provisions require MetLife to determine benefits after benefits have been determined under the primary plan. The amount of benefits payable by MetLife may be reduced due to the benefits paid under the primary plan. Do I need an ID card? No, You do not need to present an ID card to confirm that you are eligible. You should notify your dentist that you are enrolled in a MetLife Dental Plan. Your dentist can easily verify information about your coverage through a toll-free automated Computer Voice Response system. Do my dependents have to visit the same dentist that I select? No. You and your dependents each have the freedom to choose any dentist.

METLIFE

VISION

https://www.bing.com/images/search?view=detailV2&ccid=hi%2bVPA8I&id=1A5971168D2DC77AE7EDD28E8510CD517C710329&thid=OIP.hi-VPA8I7EXXS5muXYYoKwHaDk&mediaurl=http://www.clipartbest.com/cliparts/dc6/ojj/dc6ojjbxi.png&exph=1230&expw=2555&q=cartoon+images+of+eyeglasses&simid=608046459355663302&selectedIndex=11

VI-STAND Vision Benefit Summary


L0618506358[exp0819][All States]

Vision Plan Summary

Metropolitan Life Insurance Company

In-network benefits There are no claims for you to f ile w hen you go to a participating vision specialist. Simply pay your copay and, if applicable, any amount over your allow ance at the time of service.

Frequency With your Vision Preferred Provider Organization Plan, you can:

Go to any licensed vision specialist and receive coverage. Just remember your benefit dollars go further w hen you stay in netw ork. Choose from a large netw ork of ophthalmologists, optometrists and opticians, from private practices to retailers like Costco® Optical and Visionw orks.

Take advantage of our service agreement w ith Walmart and Sam's Club—they check your eligibility and process claims even though they are out of netw ork. In-network value added features:

Additional lens enhancements: In addition to standard lens enhancements, enjoy an average 20-25% savings on all other lens enhancements. 1 Savings on glasses and sunglasses: Get 20% savings on additional pairs of prescription glasses and non-prescription sunglasses, including lens enhancements. At times, other promotional offers may also be available. Laser vision correction: 2 Savings averaging 15% off the regular price or 5% off a promotional offer for laser surgery including PRK, LASIK and Custom LASIK. This offer is only available at MetLife participating locations.

Eye exam

Once every 12 months Eye health exam, dilation, prescription and refraction for glasses: Covered in full after $10

copay. Retinal imaging: Up to a $39 copay on routine retinal screening w hen performed by a

private practice provider.

Frame

Once every 24 months

Allow ance: $130 after $10 eyew ear copay.

Costco: $70 allow ance after $10 eyew ear copay. You w ill receive an additional 20% savings on the amount that you pay over your allow ance. This offer is available from all participating locations except Costco.

Standard corrective lenses

Once every 12 months Single vision, lined bifocal, lined trifocal, lenticular: Covered in full after $10 eyew ear copay

Standard lens enhancements1

Once every 12 months Polycarbonate (child up to age 18) and Ultraviolet (UV) coating: Covered in full after $10

eyew ear copay.

Progressive, Polycarbonate (adult), Photochromic, Anti-reflective, Scratch-resistant coatings and Tints: Your cost w ill be limited to a copay that MetLife has negotiated for you. These copays can be view ed after enrollment at metlife.com/mybenefits .

Contact lenses instead of eye glasses

Once every 12 months

Contact f itting and evaluation: Covered in full w ith a maximum copay of $60. Elective lenses: $130 Necessary lenses: Covered in full after eyew ear copay. We’re here to help

Find a participating vision specialist:

www.metlife.com/mybenefits or call [1-855-MET-EY E1 (1-855-638-3931)] Get a claim form: www.metlife.com/mybenefits General questions: www.metlife.com/mybenefits or call [1-855-MET-EY E1 (1-855-638-3931)]

http://www.metlife.com/mybenefits




VI-STAND Vision Benefit Summary


L0618506358[exp0819][All States]

Out-of-network reimbursement You pay for services and then submit a claim for reimbursement. The same benefit frequencies for In-network benefits apply. Once you enroll, visit www.metlife.com/mybenefits for detailed out-of-netw ork benefits information. Eye exam: up to $45 Single vision lenses: up to $30 Lined trifocal lenses: up to $65

Frames: up to $70 Lined bifocal lenses: up to $50 Progressive lenses: up to $50

Contact lenses: Lenticular lenses: up to $100

- Elective up to $105 - Necessary up to $210

Exclusions and Limitations of Benefits

This plan does not cover the follow ing services, materials and treatments. Services and Eyewear Services and/or materials not specif icallyincluded in the Vision Plan Benefits Overview (Schedule of Benefits). Any portion of a charge above the Maximum Benefit Allow ance or reimbursement indicated in the Schedule of Benefits. Any eye examination or corrective eyew earrequired as a condition of employment. Services and supplies received by you or yourDependent before the Vision Insurance starts. Missed appointments.

Services or materials resulting from or in thecourse of a Covered Person’s regularoccupation for pay or profit for w hich theCovered Person is entitled to benefits underany Workers’ Compensation Law , Employer’sLiability Law or similar law . You must promptlyclaim and notify the Company of all suchbenefits.Local, state and/or federal taxes, except w hereMetLife is required by law to pay.Services or materials received as a result ofdisease, defect, or injury due to w ar or an act of w ar (declared or undeclared), taking part in ariot or insurrection, or

committing or attempting to commit a felony. Services and materials obtained w hile outsidethe United States, except for emergency vision care. Services, procedures, or materials for w hich acharge w ould not have been made in the absence of insurance. Services: (a) for w hich the employer of theperson receiving such services is not required to pay; or (b) received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital. Services, to the extent such services, orbenefits for such services, are available under a Government Plan. This exclusion w ill apply w hether or not the person receiving the services is enrolled for the Government Plan. We w ill not exclude payment of benefits for such services if the Government Plan requires that Vision Insurance under the Group Policy be paid f irst. Government Plan means any plan, program, or coverage w hich is established under the law s or regulations of any government. The term does not include any plan, program, or coverage provided by a government as an employer or Medicare. Plano lenses (lenses w ith refractive correctionof less than ± .50 diopter). Tw o pairs of glasses instead of bifocals.Replacement of lenses, frames and/or contactlenses furnished under this Plan w hich are lost,stolen, or damaged (w ithin the 12 monthbenefit period from date of purchase.)

Contact lens insurance policies andservice agreements.

Refitting of contact lenses after theinitial (90-day) f itting period.

Contact lens modif ication, polishing,and cleaning.

TreatmentsOrthoptics or vision training and anyassociated supplemental testing.

Medical and surgical treatment ofthe eye(s).

MedicationsPrescription and non-prescriptionmedication

1All lens enhancements are available at participating private practices. Maximum copays and pricing are subject to change without notice. Please check with your provider for details and copays applicable to your lens choice. Please contact your local Costco to confirm the availability of lens enhancements and pricing prior to receiving services. Additional discounts may not be available in certain states.

2 Custom LASIK coverage only available using wavefront technology with the microkeratome surgical device. Other LASIK procedures may be performed at an additional cost to the member. Additional savings on laser vision care is only available at participating locations.

Important: If you or your family members are covered by more than one health care plan, y ou may not be able to collect benefits from both plans. Each planmay require you to follow its rules or use specific doctors and hospitals, and itmay be impossible to comply with both plans at the same time. Before you enrollin this plan, read all of the rules very carefully and compare them with the rules of any other plan that covers you or your family.

M130D-10/10Benef its are underwritten by Metropolitan Life Insurance Company, New York, NY.Certain claims and network administration services are provided through Vision Serv ice Plan. Like most group benefit programs, benefit programs offered byMetLif e and its affiliates contain certain exclusions, exceptions, reductions, limitations, waiting periods and terms for keeping them in force. Please contact MetLif e or y our plan administrator for costs and complete details.


METLIFE

BASIC TERM LIFE

AND AD & D

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LI-GCERT-BASIC GCERT Life Benefit Summary

200 Park Ave., New York, NY 10166 © 2018 MetLife Services and Solutions, LLC L1018509510[exp1219][xDC,GU,MP,PR,V I]

Basic Term Life / AD&DMetropolitan Life Insurance Company

Plan Design for: YWCA OF EL PASO INCOriginal Plan Effective Date: February 1, 2019For All Active Full Time Employees working at least 30 hours per week

Basic Life $5,000

Accidental Death & Dismemberment An amount equal to Your Basic Life Insurance.

Plan Maximum $5,000

Non-Medical Maximum $5,000

Age Reduction Formula (reduces by) 35% at Age 70, 60% at Age 75, 75% at Age 80, 85% at Age 85

Employee Contribution Basic Life AD&D

0% 0%

Term Life Features (1): Continuation of Life insurance w hile totally disabled as defined by the Group Policy (2) Life Settlement Account (3) Portability (4) Grief Counseling (5) Funeral Discounts and Planning Services (6) WillsCenter.com (7)

AD&D Features (1): Seat Belt Benefit (8) Air Bag Benefit Child Care Benefit Common Carrier Benefit Life Settlement Account (3)

LI-GCERT-BASIC GCERT Life Benefit Summary


What Is Not Covered? Like most insurance plans, this plan has exclusions. In addition, a reduction schedule may apply. Please see your benefits administrator or certificate for specific details. Accidental Death & Dismemberment insurance does not include payment for any loss which is caused by or contributed to by: physical or mental illness, diagnosis of or treatment of the illness; an infection, unless caused by an external wound accidentally sustained; suicide or attempted suicide; injuring oneself on purpose; the voluntary intake or use by any means of any drug, medication or sedative, unless taken as prescribed by a doctor or an over-the-counter drug taken as directed; voluntary intake of alcohol in combination with any drug, medication or sedative; war, whether declared or undeclared, or act of war, insurrection, rebellion or riot; committing or trying to commit a felony; any poison, fumes or gas , voluntarily taken, administered or absorbed; service in the armed forces of any country or international authority, except the United States National Guard; operating, learning to operate, or serving as a member of a crew of an aircraft; while in any aircraft for the purpose of descent from such aircraft while in flight (except for self preservation); or operating a vehicle or device while intoxicated as defined by the laws of the jurisdiction in which the accident occurs. Life and AD&D coverages are provided under a group insurance policy (Policy Form GPNP99 or G2130-S) issued to your employer by MetLife. Life and AD&D coverages under your employer’s plan terminates when your employment ceases when your Life and AD&D contributions cease, or upon termination of the group insurance policy. Should your life insurance coverage terminate for reasons other than non-payment of premium, you may convert it to a MetLife individual permanent policy without providing medical evidence of insurability. This summary provides an overview of your plan’s benefits. These benefits are subject to the terms and conditions of the contract between MetLife and your employer. Specific details regarding these provisions can be found in the certificate. If you have additional questions regarding the Life Insurance program underwritten by MetLife, please contact your benefits administrator or MetLife. Like most group life insurance policies, MetLife group policies contain exclusions, limitations, terms and conditions for keeping them in force. Please see your certificate for complete details.

(1) Features may vary depending on jurisdiction. (2) Total disability or totally disabled means your inability to do your job and any other job for w hich you may be f it by education,

training or experience, due to injury or sickness. Please note that this benefit is only available after you have participated in the Basic/Supplemental Term Life Plan for 1 year and it is only available to the employee.

(3) Subject to state law , and/or group policyholder direction, the Total Control Account is provided for all Life and AD&D benefits of $5,000 or more. The TCA is not insured by the Federal Deposit Insurance Corporation or any government agency. The assets backing TCA are maintained in MetLife’s general account and are subject to MetLife’s creditors. MetLife bears the investment risk of the assets backing the TCA, and expects to earn income suff icient to pay interest to TCA Accountholders and to provide a profit on the operation of the TCAs. Guarantees are subject to the f inancial strength and claims paying ability of MetLife.

(4) Subject to state availability. To take advantage of this benefit, coverage of at least $20,000 must be elected. (5) Grief Counseling services are provided through an agreement w ith LifeWorks US Inc. LifeWorks is not an aff iliate of MetLife, and

the services LifeWorks provides are separate and apart from the insurance provided by MetLife. LifeWorks has a nationw ide netw ork of over 30,000 counselors. Counselors have masters or doctoral degrees and are licensed professionals. The Grief Counseling program does not provide support for issues such as: domestic issues, parenting issues, or marital/relationship issues (other than a f inalized divorce). For such issues, members should inquire w ith their human resources department about available company resources. This program is available to insureds, their dependents and beneficiaries w ho have received a serious medical diagnosis or suffered a loss. Events that may result in a loss are not covered under this program unless and until such loss has occurred. Services are not available in all jurisdictions and are subject to regulatory approval. Not available on all policy forms.

(6) Services and discounts are provided through a member of the Dignity Memorial® Netw ork, a brand name used to identify a netw ork of licensed funeral, cremation and cemetery providers that are aff iliates of Service Corporation International (together w ith its aff iliates, “SCI”), 1929 Allen Parkw ay, Houston, Texas. The online planning site is provided by SCI Shared Resources, LLC. SCI is not aff iliated w ith MetLife, and the services provided by Dignity Memorial members are separate and apart from the insurance provided by MetLife. Not available in some states. Planning services, expert assistance, and bereavement travel services are available to anyone regardless of aff iliation w ith MetLife. Discounts through Dignity Memorial’s netw ork of funeral provider s are pre-negotiated. Not available w here prohibited by law . If the group policy is issued in an approved state, the discount is available for services held in any state except KY and NY, or w here there is no Dignity Memorial presence (AK, MT, ND, SD, and WY). For MI and TN, the discount is available for “At Need” services only. Not approved in AK, FL, KY, MT, ND, NY and WA.

(7) WillsCenter.com is a document service provided by SmartLegalForms, Inc., an aff iliate of Epoq Group, Ltd. SmartLegalForms, Inc. is not aff iliated w ith MetLife and the WillsCenter.com service is separate and apart from any insurance or service provided by MetLife. The WillsCenter.com service does not provide access to an attorney, does not provide legal advice, and may not be suitable for your specif ic needs. Please consult w ith your f inancial, legal, and tax advisors for advice w ith respect to such matters.

(8) The Seat Belt Benefit is payable if an insured person dies as a result of injuries sustained in an accident w hile driving or riding in a private passenger car and w earing a properly fastened seat belt _or a child restraint if the insured is a child_. In such case, his or her benefit can be increased by 10 percent of the Full Amount — but not less than $1,000 or more than $25,000.

METLIFE

SUPPLEMENTAL TERM LIFE

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LI-GCERT-SUPP-OV ER EOL Benefit Summary


Supplemental Term LifeMetropolitan Life Insurance Company

Plan Design for: YWCA OF EL PASO INC

For All Active Full Time Employees working at least 30 hours per weekBuild Your Benefit With MetLife's Supplemental Term Life insurance, your employer gives you the opportunity to buy valuable life insurance coverage for yourself, your spouse and your dependent children -- all at affordable group rates.

Employee Spouse & Child

Spouse1 Child Life Coverage: provides a benefit in the event of death Schedules:

Increments of $10,000 Increments of $5,000 Flat Amount: $1,000, $2,000, $4,000, $5,000, or $10,000

Non Medical Maximum $100,000 $25,000 $10,000

Overall Benefit Maximum

The lesser of 5 times Your Basic Annual Earnings, or

$500,000 $100,000 $10,000

AD&D Coverage: provides a benefit in the event of death or dismemberment resulting from a covered accident Schedules:

Yes (benefit amount is same as Supplemental Term Life

coverage)


coverage)


coverage)

AD&D Maximum Maximum amount is same as Supplemental Term Life

coverage Maximum amount is same as

Supplemental Term Life coverage Maximum amount is same as

Supplemental Term Life coverage

Employee Contribution 100% 100% 100% Any purchase or increase in benefits, which does not take place within 31 days of employee’s or dependent's eligibility effec tive date is subject to evidence of insurability. Coverage is subject to the approval of MetLife.

To request coverage: 1. Choose the amount of employee coverage that you want to buy.2. Look up the premium costs for your age group for the coverage amount you are selecting on the chart

below.3. Choose the amount of coverage you want to buy for your spouse. Again, find the premium costs on the chart

below. Note: Premiums are based on your age, not your spouse’s.4. Choose the amount of coverage you want to buy for your dependent children. The premium costs for each

coverage option are shown below.5. Fill in the enrollment form with the amounts of coverage you are selecting. (To request coverage over the

non-medical maximum, please see your Human Resources representative for a medical questionnaire thatyou will need to complete.) Remember, you must purchase coverage for yourself in order to purchasecoverage for your spouse or children.



Employee Age Employee & Spouse Coverage -- Monthly Premium For:

Dependent Child Coverage2 Monthly

Premium For: $1,000 $10,000 $20,000 $40,000 $50,000 $100,000 $1,000 $0.29 Under 30 $0.07 $0.67 $1.34 $2.68 $3.35 $6.70

30-34 $0.09 $0.87 $1.74 $3.48 $4.35 $8.70 $2,000 $0.58 35-39 $0.12 $1.17 $2.34 $4.68 $5.85 $11.70 40-44 $0.18 $1.77 $3.54 $7.08 $8.85 $17.70 $4,000 $1.16 45-49 $0.29 $2.87 $5.74 $11.48 $14.35 $28.70 50-54 $0.47 $4.67 $9.34 $18.68 $23.35 $46.70 $5,000 $1.46 55-59 $0.81 $8.07 $16.14 $32.28 $40.35 $80.70 60-64 $0.89 $8.87 $17.74 $35.48 $44.35 $88.70 $10,000 $2.91 65-69 $1.40 $13.97 $27.94 $55.88 $69.85 $139.70 70+ $2.50 $24.97 $49.94 $99.88 $124.85 $249.70

Due to rounding, your actual payroll deduction amount may vary slightly.

Features available with Supplemental Life

Grief Counseling3: You, your dependents, and your beneficiaries access to grief counseling sessions and funeral related concierge services to help cope with a loss – at no extra cost. Grief counseling services provide confidential and professional support during a difficult time to help address personal and funeral planning needs. At your time of need, you and your dependents have 24/7 access to a work/life counselor. You simply call a dedicated 24/7 toll-free number to speak with a licensed professional experienced in helping individuals who have suffered a loss. Sessions can either take place in-person or by phone. You can have up to five face-to-face grief counseling sessions per event to discuss any situation you perceive as a major loss, including but not limited to death, bankruptcy, divorce, terminal illness, or losing a pet.3 In addition, you have access to funeral assistance for locating funeral homes and cemetery options, obtaining funeral cost estimates and comparisons, and more. You can access these services by calling 1-1-888-319-7819 or log on to www.metlifegc.lifeworks.com (Username: metlifeassist; Password: support).

Funeral Discounts and Planning Services4: As a MetLife group life policyholder, you and your family may have access to funeral discounts, planning and support to help honor a loved one’s life - at no additional cost to you. Dignity Memorial provides you and your loved ones access to discounts of up to 10% off of funeral, cremation and cemetery services through the largest network of funeral homes and cemeteries in the United States.

When using a Dignity Memorial Network you have access to convenient planning services - either online at www.finalwishesplanning.com, by phone (1-866-853-0954), or by paper - to help make final wishes easier to manage. You also have access to assistance from compassionate funeral planning experts to help guide you and your family in making confident decisions when planning ahead as well as bereavement travel services - available 24 hours, 7 days a week, 365 days a year - to assist with time-sensitive travel arrangements to be with loved ones.

Will Preparation5:Like life insurance, a carefully prepared Will is important. With a Will, you can define your most important decisions such as who will care for your children or inherit your property. By enrolling for Supplemental Term Life coverage, you will have in person access to Hyatt Legal Plans' network of 14,000+ participating attorneys for preparing or updating a will, living will and power of attorney. When you enroll in this plan, you may take advantage of this benefit at no additional cost to you if you use a participating plan attorney. To obtain the legal plan's toll-free number and your company's group access number, contact your employer or your plan administrator for this information.

MetLife Estate Resolution Services (ERS)5 :is a valuable service offered under the group policy. A Hyatt Legal Plan attorney will consult with your beneficiaries by telephone or in person regarding the probate process for your estate. The attorney will a lso handle the probate of your estate for your executor or administrator.. This can help alleviate the financial and administrative burden upon your loved ones in their time of need.

Portability6: If your present employment ends, you can choose to continue your current life benefits.



What Is Not Covered? Like most insurance plans, this plan has exclusions. Supplemental and Dependent Life Insurance do not provide payment of benefits for death caused by suicide within the first two years (one year in North Dakota) of the effective date of the certi ficate, or payment of increased benefits for death caused by suicide within two years (one year in North Dakota or Colorado) of an increase in coverage. In addition, a reduction schedule may apply. Please see your benefits administrator or certificate for specific details. Accidental Death & Dismemberment insurance does not include payment for any loss which is caused by or contributed to by: physical or mental illness, diagnosis of or treatment of the illness; an infection, unless caused by an external wound accidentally sustained; suicide or attempted suicide; injuring oneself on purpose; the voluntary intake or use by any means of any drug, medication or sedative, unless taken as prescribed by a doctor or an over-the-counter drug taken as directed; voluntary intake of alcohol in combination with any drug, medication or sedative; war, whether declared or undeclared, or act of war, insurrection, rebellion or riot; committing or trying to commit a felony; any poison, fumes or gas, voluntarily taken, administered or absorbed; service in the armed forces of any country or international authority, except the United States National Guard; operating, learning to operate, or serving as a member of a crew of an aircraft; while in any aircraft for the purpose of descent from such aircraft while in flight (except for self preservation); or operating a vehicle or device while intoxicated as defined by the laws of the jurisdiction in which the accident occurs. Life and AD&D coverages are provided under a group insurance policy (Policy Form GPNP99 or G2130-S) issued to your employer by MetLife. Life and AD&D coverages under your employer’s plan terminates when your employment ceases, when your Life and AD&D contributions cease, or upon termination of the group insurance policy. Dependent Life coverage will terminate when a dependent no longer qualifies as a dependent. Should your life insurance coverage terminate for reasons other than non-payment of premium, you may convert it to a MetLife individual permanent policy without providing medical evidence of insurability. This summary provides an overview of your plan’s benefits. These benefits are subject to the terms and conditions of the contract between MetLife and your employer and are subject to each state’s laws and availability. Specific details regarding these provisions can be found in the certificate. If you have additional questions regarding the Life Insurance program underwritten by MetLife, please contact your benefits administrator or MetLife. Like most group life insurance policies, MetLife group policies contain exclusions, limitations, terms and conditions for keeping them in force. Please see your certificate for complete details. 1. Spouse amount cannot exceed 50% of the employee’s Supplemental Life benefit. 2. Child benefits for children under 6 months old are limited. 3. Grief Counseling services are provided through an agreement w ith LifeWorks US Inc. LifeWorks is not an aff iliate of MetLife, and the services

LifeWorks provides are separate and apart from the insurance provided by MetLife. LifeWorks has a nationw ide network of over 30,000 counselors. Counselors have master’s or doctoral degrees and are licensed professionals. The Grief Counseling program does not provide support for issues such as: domestic issues, parenting issues, or marital/relationship issues (other than a f inalized divorce). For such issues, members should inquire w ith their human resources department about available company resources. This program is available to insureds, their dependents and beneficiaries who have received a serious medical diagnosis or suffered a loss. Events that may result in a loss are not covered under this program unless and until such loss has occurred. Services are not available in all jurisdictions and are subject to regulatory approval. Not available on all policy forms.

4. Services and discounts are provided through a member of the Dignity Memorial® Netw ork, a brand name used to identif y a netw ork of licensed funeral, cremation and cemetery providers that are aff iliates of Service Corporation International (together w ith its aff iliates, “SCI”), 1929 Allen Parkw ay, Houston, Texas. The online planning site is provided by SCI Shared Resources, LLC. SCI is not aff iliated w ith MetLife, and the services provided by Dignity Memorial members are separate and apart from the insurance provided by MetLife. Not available in some states. Planning services, expert assistance, and bereavement travel services are available to anyone regardless of affiliation w ith MetLife. Discounts through Dignity Memorial’s netw ork of funeral providers are pre-negotiated. Not available w here prohibited by law. If the group policy is issued in an approved state, the discount is available for services held in any state except KY and NY, or w here there is no Dignity Memorial presence (AK, MT, ND, SD, and WY). For MI and TN, the discount is available for “At Need” services only. Not approved in AK, FL, KY, MT, ND, NY and WA.

5. Will Preparation and MetLife Estate Resolution Services are offered by Hyatt Legal Plans, Inc., Cleveland, Ohio. In certain states, legal services benefits are provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and Aff iliates, Warwick, Rhode Island. Will Preparation and Estate Resolution Services are subject to regulatory approval and currently available in all states. For New York sitused cases, the Will Preparation service is an expanded offering that includes office consultations and telephone advice for certain other legal matters beyond Will Preparation. Please note that certain services are not covered by Estate Resolution Services, including matters in w hich there is a conflict of interest between the executor and any beneficiary or heir and the estate; any disputes w ith the group policyholder, MetLife and/or any of its aff iliates; any disputes involving statutory benefits; will contests or litigation outside probate court; appeals; court costs, f iling fees, recording fees, transcripts, witness fees, expenses to a third party, judgments or f ines; and frivolous or unethical matters.

6. Subject to state availability. To take advantage of this benefit, coverage of at least $10,000 must be elected.

PRESENTATION FOR

SW-101 69859

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Colonial Life and Accident Employee Benefits

Free $10,000 AD&D And Wellness Cards This offer is free to anyone who sits down with a benefits counselor. The Wellness Card helps with lowering costs at the pharmacy.

Group Accident Insurance Starting at $7.09 a paycheck for Employee Only. $7.95Employee/Spouse, $9.01 Employee/Dependents, $12.13 Two-Parent Family. Pays you directly when seeking medical treatment as the result of an accident!

Group Term Iife Insurance Starting at $.37 cents a paycheck for $15,000 for Employee Only.

Example rates: 24 yr old non-smoker $100,000 life and another $100,000 AD&D for $3.92 a check,39 yr old non-smoker $25,000 life and another $25,000 AD&D for $1.58 a check,

54 yr old non-smoker $100,000 life and another $100,000 AD&D for $17.77 a check,44 yr old smoker $100,000 life and another $100,000 AD&D for $13.20 a check!

Group Short Term Disability Income $700 a month for a 3 Months Benefit, Starts paying 14 Days after On/Off Job Accident and 14 days after On/Off Job Sickness.

Starting at $5.49 a paycheck for Employee Only. Premiums will vary based on age and replaces up to 60% of income!

Group Critical Illness with $50 Wellness/Health Screening Starting at $4.38 a paycheck for $5,000 in coverage for Employee Only. $9.96 Employee/Spouse, $6.15 Employee/Dependents, $10.23 Two-Parent Family. Pays a lump sum of $5,000 to $75,000 when you are diagnosed with heart attack, stroke, Major Organ failure, End stage renal failure, Permanent Paralysis, coma, blindness, occupational infections HIV or Hepatitis B, C, or D. Guaranteed Issue base is $20,000

Premiums will vary based on age and benefit amount

These coverages may not be available in all states; product benefits vary by state. Policies have exclusions and limitations that may affect benefits payable. For cost and complete details, please see your Colonial Life benefits counselor.

© 2011 Colonial Life & Accident Insurance CompanyColonial Life products are underwritten by Colonial Life & AccidentInsurance Company, for which Colonial Life is the marketing brand.

NS-11831-1

YWCA of El Paso

Colonial Life Employee Benefits

Enrollment Options:

2) Phone enrollment /Co-Browsing: If you prefer to speakwith one of our Benefits Counselors, you can make anappointment through our online scheduler by clicking inthe link -

https://coloniallife.rivs.com/22-04-59/ or

call 915-472-9785

1) Self-Enroll – if you feel tech savvy and comfortabledoing your open enrollment online, please click on the link-

https://harmonyenroll.coloniallife.com/

Your login ID is: YWCA2020 + Employee IDPassword: YWCA2020

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You can’t predict when or where an accident will strike. But you can make sure you have a safety net of financial protection to help if an accidental injury occurs.Accidents can happen anytime, anywhere—at home or at work, on the playground or on the road. Some of the most common injuries include:

l Broken bonesl Burnsl Concussionsl Lacerations

Colonial Life’s Group Accident Insurance helps you fill some of the gaps caused by increasing deductibles, co-payments and out-of-pocket costs related to an accidental injury. With this coverage you may not need to use your savings or secure a loan to help pay those unexpected out-of-pocket expenses associated with a covered accident.

Here’s how it works...

l Back or knee injuries

l Accidental injuries that send you to the Emergency Room, Urgent Care or a doctor’s office.

Group Accident Insurance

Imagine while cleaning the gutters, you fall from the ladder and break your leg.

These are out-of-pocket expenses you may encounter:

$100 Emergency room copay

$250 Deductible (copays do not count toward deductible) $35 Specialist visit copay – orthopedic physician $350 Specialist visit copay – occupational/physical therapy for 10 days

$735 Out-of-pocket expenses

And here is a sample of benefits you may be eligible for with Colonial Life’s Group Accident Insurance:

$125 Accident Emergency Treatment $150 Accident Follow-up Doctor Visit ($50 per visit, up to 3 per accident) $100 Appliance (crutches) $1,125 Fracture (broken leg) $250 Occupational/Physical Therapy ($25/day for 10 days) $30 X-Ray (for diagnosis of broken leg)

$1,780 of benefits paid to you in addition to other coverage you may have with other insurance companies.

The claims example above is based on a covered person aged 41 who receives a complete fracture of the leg and requires non-surgical repair. The policy has exclusions and limitations. Costs of treatment and benefit amounts may vary.

Your Colonial Life certificate also provides benefits for the following injuries received as a result of a covered accident. l Burn (based on size and degree) ..................................................................................... $1,000 to $12,000 l Burn - Skin Graft for 2nd or 3rd degree burns ........................................................50% of Burn benefit l Coma ..............................................................................................................................................................$10,000 l Concussion ........................................................................................................................................................$150 l Emergency Dental Work ......................................$100 Extraction, $300 Crown, Implant, or Denture l Lacerations (based on size) ............................................................................................................$25 to $600

Requires Surgery l Eye Injury ............................................................................................................................................................$300 l Ruptured Disc ...................................................................................................................................................$500 l Tendon/Ligament/Rotator Cuff ............................................................. $500 - one, $750 - two or more l Torn Knee Cartilage ........................................................................................................................................$500

Surgical Care l Blood/Plasma/Platelets .................................................................................................................................$300 l Surgery (arthroscopic or exploratory) .....................................................................................................$150 l Surgery (cranial, open abdominal or thoracic) ................................................................................. $1,500

l Surgery (hernia) ...............................................................................................................................................$200

Benefits listed are for each covered person per covered accident unless otherwise specified.

Initial Carel Accident Emergency Treatment ..............$125

lAir Ambulance ............................................ $1,500

Common Accidental Injuries

Dislocation (Separated Joint) Non-Surgical Surgical

Hip $3,000 $6,000Knee $1,500 $3,000Ankle – Bone or Bones of the Foot $1,200 $2,400Collarbone (sternoclavicular) $750 $1,500Lower Jaw, Shoulder, Elbow, Wrist $450 $900Bone or Bones of the Hand $450 $900Collarbone (acromioclavicular and separation) $150 $300One Toe or Finger $150 $300

Fracture (Broken Bone) Non-Surgical Surgical

Depressed Skull $3,750 $7,500 Non-Depressed Skull $1,500 $3,000 Hip, Thigh $2,250 $4,500 Body of Vertebrae, Pelvis, Leg $1,125 $2,250 Bones of Face or Nose $525 $1,050 Upper Jaw, Maxilla $525 $1,050 Upper Arm between Elbow and Shoulder $525 $1,050 Lower Jaw, Mandible; Kneecap, Ankle, Foot $450 $900 Shoulder Blade, Collarbone, Vertebral Process $450 $900 Forearm, Wrist, Hand $450 $900 Rib $375 $750 Coccyx $300 $600 Finger, Toe $150 $300

l Ambulance .......................................................$200

l X-Ray Benefit .....................................................$30

Transportation/Lodging AssistanceIf injured, the covered person must travel more than 50 miles from residence to receive special treatment and confinement in a hospital.

l Lodging (family member or companion) .................................................$150 per night up to 30 days for ............................................................................................ a hotel/motel lodging costs

l Transportation ...............................................................................$500 per round trip up to 3 round trips

Accident Hospital Care l Hospital Admission1 ............................................................................................................$1,000 per accident

l Hospital ICU Admission1 ....................................................................................................$1,500 per accident 1 We will not pay the hospital admission benefit and the hospital intensive care unit (ICU) admission benefit for the same covered accident simultaneously.

l Hospital Confinement2 ...........................................................$200 per day up to 365 days per accident

l Hospital ICU Confinement2 ..................................................... $400 per day up to 15 days per accident 2 We will not pay the hospital confinement benefit and the hospital ICU confinement benefit simultaneously.

Accident Follow-Up Care l Accident Follow-Up Doctor Visit .............................................................$50 (up to 3 visits per accident)

l Appliances ..............................................................................................$100 (such as wheelchair, crutches)

l Medical Imaging Study ......................................................................................................... $150 per accident (limit 1 per covered accident and 1 per calendar year)

l Occupational or Physical Therapy ......................................................................$25 per day up to 10 days

l Pain Management (Epidural Anesthesia) ......................................$100 (limit 1 per covered accident)

l Prosthetic Devices/Artificial Limb ....................................................... $500 - one, $1,000 - two or more

l Rehabilitation Unit Confinement 3 ..................... $100 per day up to 15 days per covered accident, ................................................................................................................................and 30 days per calendar year 3 We will not pay the hospital confinement benefit and the rehabilitation unit confinement benefit simultaneously.

Accidental Dismemberment l Loss of Finger/Toe .................................................................................... $750 – one, $1,500 – two or more l Loss or Loss of Use of Hand/Foot/Sight of Eye ........................ $7,500 – one, $15,000 – two or more

Catastrophic AccidentFor severe injuries that result in the total and irrecoverable:

l Loss of one hand and one foot l Loss of the sight of both eyes

l Loss of both hands or both feet l Loss of the hearing of both ears

l Loss or loss of use of one arm and one leg l Loss of the ability to speak

l Loss or loss of use of both arms or both legs

Named Insured ................ $50,000 Spouse ..............$50,000 Child(ren) .........$25,000

365-day elimination period. Payable once per lifetime for each covered person.

Accidental Death

Accidental Death Common Carrierl Named Insured $25,000 $100,000

l Spouse $25,000 $100,000

l Child(ren) $5,000 $20,000

Benefits listed are for each covered person per covered accident unless otherwise specified.

EXCLUSIONS AND LIMITATIONS

We will not pay any benefits for losses that are caused by, contributed to by or occur as a result of: felonies or illegal occupations; hazardous avocations; racing; semi-professional or professional sports; sickness; suicide or injuries which any covered person intentionally does to himself; war or armed conflict; in addition to the exclusions listed above, we also will not pay the Catastrophic Accident benefit for injuries that are caused by or are the result of: birth or intoxicants and narcotics. The covered person must incur a charge and the certificate must be in force for benefits to be payable.

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number GACC1.0-P and certificate number GACC1.0-C (including state abbreviations where used, for example: GACC1.0-C-TX). This is not an insurance contract and only the actual policy provisions will control.

100813

My Coverage Worksheet (For use with your Colonial Life benefits counselor)

Who will be covered? (check one)

Employee Only Employee & Spouse

One-Parent Family Two-Parent Family

When are covered accident benefits available? (check one)

On and Off-Job Benefits Off-Job Only Benefits

Colonial Life 1200 Colonial Life BoulevardColumbia, South Carolina 29210coloniallife.com

© 2012 Colonial Life & Accident Insurance Company Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

10/12

Group A

ccident Plan 2

Will I have to answer health questions to receive coverage?Coverage is Guaranteed Issue. No health questions will be asked.

What additional features are included?

l Worldwide coverage

l Portable

l Compliant with Health Savings Account (HSA) guidelines

How do I know how much a benefit pays?Benefit amounts are preset and not based on the medical expenses you are charged. You get a lump sum payment that is specific to the injury or treatment required.

Will my accident claim payment be reduced if I have other insurance?You’re paid regardless of any other insurance you may have with other insurance companies, and the benefits are paid directly to you (unless you specify otherwise).

How do I file a claim?Visit coloniallife.com or call our Customer Service Department at 1.800.325.4368 for additional information.

For more information, talk with your

benefits counselor.

Group Critical Illness InsurancePlan 1 Full

ColonialLife.com

If you’re diagnosed with a covered critical illness or cancer, group critical illness insurance* from Colonial Life can help with your expenses, so you can concentrate on what’s most important – your treatment, care and recovery.

*The policy name is Critical Illness and Cancer Group Specified Disease Insurance.

Face amount: $_______________

For the diagnosis of this covered critical illness condition:1 This percentage of the face amount is payable:

Heart attack (myocardial infarction) 100%

Stroke 100%

End-stage renal (kidney) failure 100%

Major organ failure 100%

Coma 100%

Permanent paralysis due to a covered accident 100%

Blindness 100%

Occupational infectious HIV or occupational infectious hepatitis B, C or D 100%

Coronary artery bypass graft surgery/disease2 25%

Critical illness benefit

GROUP CRITICAL CARE PLAN 1 FULL

Subsequent diagnosis of a different critical illness3

If you receive a benefit for a critical illness, and later you are diagnosed with a different critical illness, the original percentage of the face amount is payable for that particular critical illness.

Subsequent diagnosis of the same critical illness3

If you receive a benefit for a critical illness, and later you are diagnosed with the same critical illness, 25% of the original face amount is payable. Critical illness conditions that do not qualify are: coronary artery bypass graft surgery/coronary artery disease2 and occupational infectious HIV or occupational infectious hepatitis B, C or D.

ColonialLife.com

Covered cancer benefits

For this condition:1 The amount payable is:

Diagnosis of cancer (internal or invasive) 100% of the face amount

Diagnosis of carcinoma in situ 25% of the face amount

Skin cancer $500

Diagnosis of cancer benefit

Cancer treatment and care benefit: $___________ per calendar month for ____ monthsThis benefit is payable if you incur charges for one or more of the following for your treatment or care of cancer (internal or invasive) or carcinoma in situ:

Cancer vaccine benefit: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50

This benefit is payable if you or your covered family members incur a charge for any FDA-approved cancer vaccine while your certificate is inforce.

1 Please refer to the certificate for complete definitions of covered conditions.

2 Benefit for coronary artery disease applicable in lieu of benefit for coronary artery bypass graft surgery when health savings account (HSA) compliant plan is selected.

3 Dates of diagnoses of a covered critical illness must be separated by at least 180 days.

THIS POLICY PROVIDES LIMITED BENEFITS.

Insureds in MA must be covered by comprehensive health insurance before applying for this coverage.

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESSWe will not pay the Critical Illness Benefit or Benefit Payable Upon Subsequent Diagnosis of a Critical Illness that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; psychiatric or psychological conditions; suicide or injuries which any covered person intentionally does to himself; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.

EXCLUSIONS AND LIMITATIONS FOR CANCER We will not pay the Diagnosis of Cancer Benefit, Diagnosis of Carcinoma in Situ Benefit, the Cancer Treatment and Care Benefit or the Skin Cancer Benefit for a covered person’s cancer (internal or invasive), carcinoma in situ or skin cancer that: is diagnosed or treated outside the territorial limits of the United States, its possessions, or the countries of Canada and Mexico; is a pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is initially diagnosed as having cancer (internal or invasive), carcinoma in situ or skin cancer. No pre-existing condition limitation will be applied for dependent children who are born or adopted while you are covered under the policy, and who are continuously covered from the date of birth or adoption.

This is not an insurance contract and only the actual certificate provisions will control. Applicable to certificate form GCC1.0-C (including state abbreviations where used, for example: GCC1.0-C-TX). The certificate or its provisions may vary or be unavailable in some states. Please see your Colonial Life benefits counselor for details.

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� Hospice care

� Confinement

� Chemotherapy

� Radiation

� Surgery

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

Group Disability Insurance

GROUP DISABILITY BASE

You never know when a disability could impact your way of life. Fortunately, there’s a way to help protect your income. If a covered accident or sickness prevents you from earning a paycheck, disability insurance can provide a monthly benefit to help you cover your ongoing expenses.

Can you afford to not protect your income? You don’t have the same lifestyle expenses as the next person. That’s why you need disability coverage that can be customized to fit your specific needs.

After calculating your monthly expenses, your benefits counselor can help you complete the benefits worksheet.

ColonialLife.com

MONTHLY EXPENSESRound to the nearest hundred.

1 Rent or mortgage $

2 Transportation $

3 Utilities (phone, internet, electricity/gas, water, etc.) $

4 Food and necessities $

5 Other expenses $

Total monthly expenses (add lines 1-5 together) $

Benefits worksheetHow much coverage do I need?

Monthly benefit amount for off-job accident and off-job sickness: ______________Choose a monthly benefit amount between $400 and $7,500.*

If your plan includes on-job accident/sickness benefits, the benefit is 50% of the off-job amount.

What is the benefit period?

Benefit period: _______ monthsThe partial disability benefit period is three months.

When may my total disability benefits start?

After an accident: _______ days After a sickness: _______ days

*Subject to income requirements

EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of: alcoholism or drug addiction, felonies or illegal occupations, flying, hazardous avocations, intoxicants and narcotics, psychiatric or psychological conditions, racing, semi-professional or professional sports, suicide or injuries which you intentionally do to yourself, war or armed conflict. We will not pay for losses due to you giving birth within the first nine months after the coverage effective date of the certificate. We will not pay for loss when the disability is a pre-existing condition as described in the certificate.Pre-Existing Condition means a sickness or physical condition, whether diagnosed or not, for which you were treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date.We will not pay for loss when the disability is a pre-existing condition as defined in this certificate, unless you have satisfied the pre-existing condition limitation period (typically 12 months) shown on the Certificate Schedule on the date you suffer a loss due to a covered accident or covered sickness.For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form GDIS-P-EE-TX and certificate form GDIS-C-EE-TX. This is not an insurance contract and only the actual policy and certificate provisions will control.

Product information and features

Total disabilityTotally disabled or total disability means you are: unable to perform the material and substantial duties of your regular occupation, not working at any occupation, and under the regular and appropriate care of a doctor.

Partial disabilityIf you are able to return to work part time after at least 14 days of being paid for a total disability, you may be able to still receive 50% of your total disability benefit.

Waiver of premiumWe will waive your premium payments after 90 consecutive days of a covered disability.

Geographical limitationsIf you are disabled while outside of the United States, Mexico or Canada, you may receive benefits for up to 60 days before you have to return to the U.S.

Issue ageCoverage is available from ages 17 to 74.

PortabilityYou may be able to keep your coverage even if you change jobs.

For more information, talk with your benefits counselor.

10-19 | 101296-3

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

You

$____________________

n Available in $1,000 incrementsn Minimum of $10,000 to a maximum of five times your salary to $500,000

Your spouse

$____________________

n Available in $1,000 incrementsn Minimum of $5,000 to a maximum of $500,000n Spouse coverage cannot exceed your coverage amount2

Your dependent children(up to age 26)

$____________________

n Available in $1,000 incrementsn Minimum of $1,000 to a maximum of $10,000 per dependent childn Each dependent child is covered for the same amount, except children

from live birth to six months for whom the death benefit is $1,000

How secure is your family’s financial future?If something happened to you, would your family be able to maintain their way of life? Funeral expenses and medical bills could be just the beginning. How would they cover ongoing living expenses, such as a mortgage, utilities and health care?

Colonial Life & Accident Insurance Company’s group term life insurance can help provide financial security for your family. You can also apply for coverage for your spouse and eligible dependent children with no health questions.1

VOLUNTARY GROUP TERM LIFE

Group Term Life InsuranceVoluntary Coverage

How much group term life coverage do I need?

1 Spouse and dependent coverage will not be effective if they are currently totally disabled. Being totally disabled means the inability to perform two or more activities of daily living, being confined to a hospital or similar institution, or being unable to attend school outside the home (for a dependent child age 5 up to age 26). In CT, ID, NH and TX, the definition of total disability does not include Activities of Daily Living (ADL) requirements. The ability to work does not determine disability. You can pay premiums on insurance for your dependents with no health questions asked. Coverage isn’t effective until the earlier of the date they are no longer totally disabled or two years after the date that coverage would have otherwise become effective for the spouse or dependent child. This provision does not apply to newborn children born while dependent insurance is in effect.

2 The maximum benefit is 50% of your benefit in NE.

3 Terminal illness means an injury or sickness that results in the covered person having a life expectancy of 12 months or less and from which there is no reasonable prospect of recovery. A life expectancy of 24 months or less in IL, KS, MA, TX and WA.

4 The Employee Assistance Program and Life Planning Services, provided by Health Advocate, are available with Colonial Life & Accident Insurance Company’s Group Term Life offering. Terms and availability of service are subject to change. The service provider does not provide legal advice; please consult your attorney for guidance. Services are not valid after coverage terminates. Please contact the company for full details.

BENEFIT AGE REDUCTION SCHEDULE

When a covered person reaches age 70, but not 75, the amount of insurance will be: • 65% of the amount of insurance prior to age 70; or • 65% of the amount of insurance applied for on or after age 70 but before age 75.

When a covered person reaches age 75 or more, the amount of insurance will be: • 50% of the amount of insurance prior to the first reduction; or • 50% of the amount of insurance the employee applied for on or after age 75.

Once the benefit reduction schedule begins, there will be no further increases in insurance for a covered person. If the proposed insured is age 70, but not age 75 at the time of enrollment, the amount of insurance applied for will be reduced by 65%. If the proposed insured is age 75 or older at the time of enrollment, the amount applied for will be reduced by 50%.

This policy has exclusions and limitations. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number GTL1.0-P and certificate number GTL1.0-C (including state abbreviations where used, for example: GTL1.0-P-TX and GTL1.0-C-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control.

Get the most out of your coverage n Portability: If you retire or change jobs, you may still be able to take your coverage with you at an affordable rate. Eligibility may be based on your health.

n Conversion: You may be eligible to convert your coverage to a whole life policy without proof of good health when coverage ends under the group certificate.

n Waiver of Premium: If included in your plan, premium payments are waived if you become disabled.

Why is group term life insurance a good option?

n Death benefit protection

n Lower cost option

n Coverage for specified periods of time, which can be during high-need years

n Benefit is typically paid tax-free to your beneficiaries

9-19 | 100272-5

Additional benefits and services n Built-in Accelerated Death Benefit provides an advance of up to 75% of the death benefit, to a maximum of $150,000, if the covered person is diagnosed with a terminal illness.3

n Health Advocate Employee Assistance Program provides 24-hour confidential personal support and referral service, including a medical bill saver service.Face-to-face sessions and video counseling with mental health professionals are available.4

n Life Planning Services offer financial and legal counseling services, as well as grief support and referral for up to 12 months after a claim.4

TELEPHONE1-888-645-1772

ONLINEColonialLife.com/EAP

To learn more, talk with your Colonial Life

benefits counselor.

ColonialLife.com


Your cost will vary based on the level of coverage you select.

Whole Life Insurance

You can’t predict your family’s future, but you can be prepared for it.You like to think that you’ll be there for your family in the years to come. But if something happened to you, would your family have the income they need?

It’s not easy to think about such serious circumstances, but it’s important to make sure your family is financially protected. You can gain peace of mind with whole life insurance from Colonial Life.

Advantages of whole life insurance � Permanent coverage that stays the same throughout the life of the policy

� Guaranteed level premiums that do not increase because of changes in health or age

� Access to the policy’s cash value through a policy loan for emergencies1 � Benefit for the beneficiary that is typically tax-free

Benefits and features � Two plan options to choose what age your premium payments will end – Paid-Up at Age 70 or Paid-Up at Age 100

� Stand-alone spouse policy available whether or not you buy a policy for yourself

� Flexibility to keep the policy if you change jobs or retire � Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness2

� Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses

� Pays cash surrender value at age 100 (when the policy endows)

WHOLE LIFE (IWL5000)

HealthAffairs.org, End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported, July 2017.

Talk with your benefits counselor for information about what level of coverage would work best for you.

In the U.S., medical spending in the last 12 months of life is

nearly $80,000 per person.

$

£ YOU $ ___________________ Select the option:£ Paid-Up at Age 70£ Paid-Up at Age 100

£ SPOUSE $ _______________ Select the option:£ Paid-Up at Age 70£ Paid-Up at Age 100

EXCLUSIONS AND LIMITATIONSIf the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. Product may vary by state. For costs and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.

This brochure is applicable to policy forms ICC19-IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/R-IWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-R-IWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000-GPO/R-IWL5000-GPO and applicable state variations.

Additional coverage optionsSpouse term life riderCover your spouse up to a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available.

Juvenile whole life policyYou can purchase a policy while children are young and premiums are low – whether or not you buy a policy on yourself. You may also increase the coverage when the child is 18, 21 and 24 without providing proof of good health. The plan is paid-up at age 70.

Children’s term life riderYou may purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both.

Accidental death benefit riderThe beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.

Chronic care accelerated death benefit riderIf a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments.2 A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living (bathing, continence, dressing, eating, toileting and transferring). Premiums are waived during the benefit period.

Critical illness accelerated death benefit riderIf you suffer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable.2 A subsequent diagnosis benefit is included.

Guaranteed purchase option riderIf you are age 50 or younger when you purchase the policy, you can add the rider, which allows you to purchase additional whole life coverage – without having to answer health questions – at three different points in the future. You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options.

Waiver of premium benefit riderPremiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. Once you are no longer disabled, premium payments will resume.

Benefits worksheetFor use with your

benefits counselor

Select any optional riders:£ Spouse term life rider

$ _____________ face amount for ________-year term period

£ Children’s term life rider $ _____________ face amount

£ Accidental death benefit rider

£ Chronic care accelerated death benefit rider

£ Critical illness accelerated death benefit rider

£ Guaranteed purchase option rider

£ Waiver of premium benefit rider

HOW MUCH COVERAGE DO YOU NEED?

To learn more, talk with your benefits counselor.

ColonialLife.com

6-19 | 101935

£ DEPENDENT STUDENT $____________£ Paid-Up at Age 70 £ Paid-Up at Age 100

1 Loan should be repaid to protect the policy’s value. 2 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

Juvenile Whole Life Insurance

JUVENILE WHOLE LIFE (IWL5000)

A lower rate for lifeBy purchasing juvenile whole life insurance for a child or grandchild, you can begin a lifetime of protection at affordable rates. The younger the child is when you purchase coverage, the lower the rate will be for the life of the policy.

Also, if an unexpected accident or illness makes life insurance more expensive – or even unavailable – for them later on, they’ll have this whole life coverage to help protect their loved ones.

Coverage features � Available for your children or grandchildren through age 17 (dependent students ages 18-26 may be eligible for an adult plan)

� Accumulates cash value at a guaranteed rate over the life of the coverage

� Stays in force as long as you continue making payments

� Option to add accidental death benefit rider at any time

� Ability to pass ownership or enhance coverage with optional riders after your child or grandchild’s 18th birthday

Talk with your benefits counselor for information about how much

coverage would work best for you.

Your cost will vary based on the amount of coverage you select.

HOW MUCH COVERAGE DO YOU NEED?

FACE AMOUNT $ ___________________

EXCLUSIONS AND LIMITATIONSIf the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. Product may vary by state. For costs and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.This product is underwritten by Colonial Life & Accident Insurance Company.This brochure is applicable to policy forms ICC19-IWL5000J/IWL5000J, rider forms ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/R-IWL5000-CTR, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-R-IWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC and applicable state variations.

Additional features$3,000 immediate claim paymentThis payment can help meet immediate needs, such as funeral costs, by providing an initial death benefit payment of $3,000 to the designated beneficiary.

Terminal illness accelerated death benefitIf the insured child is diagnosed with a terminal illness, you can request up to 75% of the policy’s death benefit, up to $150,000.

Guaranteed purchase optionAdditional whole life coverage may be purchased on the child – without health questions – at ages 18, 21 and 24. Coverage up to the initial face amount may be purchased, not to exceed a total combined maximum of $100,000 for all options.

Optional riderAccidental death benefit riderWhen you purchase this rider, it pays an additional benefit if the insured child or grandchild dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% of the accidental death benefit will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seat belt.

Additional options available at age 18(and after policy ownership has been passed to child)Chronic care accelerated death benefit riderIf a licensed health care practitioner certifies the insured has a chronic illness, the policy owner may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments.1 A chronic illness means substantial supervision is required due to a severe cognitive impairment or the inability to perform at least two of the six Activities of Daily Living (bathing, continence, dressing, eating, toileting and transferring). Premiums are waived during the benefit period.

Critical illness accelerated death benefit riderIf the insured suffers a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable.1 A subsequent diagnosis benefit is included.

Spouse term life riderThe policy owner can purchase term life coverage for a spouse, with a maximum death benefit of up to $50,000. 10-year and 20-year coverage periods are available. Coverage may be converted to a cash value policy within certain time periods later on – without having to answer health questions.

Children’s term life riderThe policy owner may purchase up to $20,000 in term life coverage for all eligible dependent children and pay one premium. Each eligible child can later convert this coverage to a cash value life insurance policy – without having to answer health questions – upon the parent’s or grandparent’s 70th birthday or the child’s 25th birthday, whichever comes first.

1 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.

To learn more, talk with your

benefits counselor.

ColonialLife.com

6-19 | 101936

RETIREMENTAs years go by, know they’re protected by the coverage you purchased.

CHILDRENThey can extend coverage as their family grows.

WEDDINGThey can purchase coverage on a new spouse.

FIRST JOBProvide a base to build on as they establish themselves.

18TH BIRTHDAYGive them ownership of their policy as they take more control of their future.

CHILDHOODThey grow up so fast. Get them off to a great start.

GIVE A GIFT THAT LASTS A LIFETIME


IMPORTANT NOTICES

03224.121250840.0716

Get the Most from Your Health Plan

Welcome to Blue Cross and Blue Shield of Texas (BCBSTX), a leader in health care benefits. We have been helping people like you get the most from their health care plans for many years.

Read this guide to learn about benefits your employer is offering. Think about how you and your family will use these benefits. Learn more about products, services and how to be a smart health care user at bcbstx.com.

Your ID CardAfter you enroll, you will get a member ID card in the mail. Show this ID card when you see a doctor, visit the hospital or go to any other place for care. The back of the card has phone numbers you might need.

Blue Access for MembersSM

Go to bcbstx.com/member and sign up for the secure member website, Blue Access for Members. Find the ”Log In” tab and click “Register Now.” Use the information on your ID card to complete the process. On this site, you can check your claims, order more ID cards, get health information and much more.

Save Money – Stay In-NetworkUsing independently contracted network providers can help you save. Look at your ID card to find your network. Then go to bcbstx.com to look for doctors, hospitals and other places for care.

Call Customer Service for HelpOur team knows your health plan and can help you get the most from your benefits. Just call the toll-free number on the back of your ID card.

Get information about your health benefits, anytime, anywhere. Use your computer, phone or tablet to access the Blue Cross and Blue Shield of Texas (BCBSTX) secure member website, Blue Access for Members (BAMSM).

With BAM, you can:

• Check the status or history of a claim

• View or print Explanation of Benefits statements

• Locate a doctor or hospital in your plan’s network

• Find Spanish-speaking providers

• Request a new ID c ard – or print a temporary one

03224.121255525.0917

It’s easy to get started1. Go to bcbstx.com/member

2. Click Register Now

3. Use the information on your BCBSTX ID card to complete the registration process.

Text* BCBSTXAPP to 33633 to get the BCBSTX App that lets you use BAM while you’re on the go.

*Message and data rates may apply

Get all the advantages your health plan offers

Blue Access for MembersSM

Blue365 is just one more advantage you have by being a Blue Cross and Blue Shield of Texas (BCBSTX) member. With this program, you may save money on health and wellness products and services from top retailers that are not covered by insurance. There are no claims to file and no referrals or pre-authorizations.

Once you sign up for Blue365 at blue365deals.com/bcbstx, weekly “Featured Deals” will be emailed to you. These deals offer special savings for a short period of time.

Below are some of the ongoing deals offered through Blue365.

EyeMed | Davis VisionYou may save on eye exams, eyeglasses, contact lenses and accessories. You have access to national and regional retail stores and local eye doctors. You may also get possible savings on laser vision correction.

TruHearing® | Beltone™

You may get possible savings on hearing tests, evaluations and hearing aids. Discounts may also be available for your immediate family members.

Dental SolutionsSM

You may get dental savings with Dental Solutions. You may receive a dental discount card that provides access to discounts of up to 50 percent at more than 61,000 dentists and more than 185,000 locations*.

Jenny Craig® | Seattle Sutton’s® | Nutrisystem®

Help reach your weight loss goals with savings from leading programs. You may save on healthy meals, membership fees (where applicable), nutritional products and services.

RetrofitSM

Receive 15 percent off Retrofit’s online, private weight loss coaching sessions. Retrofit includes the use of a wireless Fitbit® device and smart-scale, one-on-one videoconferencing with a personal team of experts and unlimited online support. You will enjoy flexibility in scheduling and the ability to meet with coaches anywhere there is an Internet connection.

50530.1217 POD

See all the Blue365 deals and learn more at blue365deals.com/bcbstx.

A Discount Program for You

Blue365®

• Find an in-network doctor, hospital or urgent care facility

• Access your claims, coverage and deductible information

• View and email your member ID card

• Log in securely with your fingerprint

• Access Health Care Accounts and Health Savings Accounts

• Download and share your Explanation of Benefits*

• Get Push Notifications and access to Message Center*

Available in Spanish

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 727545.1117

Stay connected with Blue Cross and Blue Shield of Texas (BCBSTX) and access important health benefit information wherever you are.

bcbstx.com/mobile

Text** BCBSTXAPP to 33633 to get the app. * Currently only available on iPhone®. iPhone is a registered trademark of Apple Inc.

** Message and data rates may apply. Terms and conditions and privacy policy at bcbstx.com/mobile/text-messaging.

The BCBSTX App!

24/7 Nurseline1

The 24/7 Nurseline can help you identify some options when you or a family member have a health problem or concern. Nurses are available at 800-581-0393, 24 hours a day, seven days a week, to answer your health questions. 24/7 Nurseline is available to you at no additional cost as part of your BCBSTX health plan.

Doctor’s Office

• Office hours vary

• Generally the best place to go for non-emergency care

• Doctor-to-patient relationship established and therefore able to treat, based on knowledge of medical history

• Average wait time is 24 minutes2

Retail Health Clinic

• Based upon retail store hours

• Usually lower out-of-pocket cost to you than urgent care

• Often located in stores and pharmacies to provide convenient, low-cost treatment for minor medical problems

Urgent Care Provider

• Generally includes evenings, weekends and holidays

• Often used when your doctor’s office is closed, and there is no true emergency

• Average wait time is 11-20 minutes3

• Many have online and/or telephone check-in

Hospital ER

• Open 24 hours, seven days a week

• Average wait time is 4 hours, 7 minutes4

• Multiple bills for services such as doctor and facility

$ $ $ $ $ $

FreestandingER

• Open 24 hours, seven days a week

• Could be transferred to a hospital ER based on medical situation

• Services do not include trauma care

• Many freestanding ERs are out-of-network. If you receive care from an out-of-network provider, you may have to pay more. Providers outside the network may “balance bill” you, which means they may charge you more than your health plan’s fee schedule.

• All freestanding ERs charge a facility fee that urgent care centers do not. You may receive other bills for laboratory fees and each doctor you see.5

$ $ $ $ $ $ $

Confused About Where to Go for Care? Smart health care choices may save you money.Sometimes it’s easy to know when you should go to an emergency room (ER). At other times, it’s less clear. Where do you go when you have an ear infection, or you are generally not feeling well? The emergency room can be an expensive option. The chart below can help you figure out when to use each type of care.

When you use Blue Cross and Blue Shield of Texas (BCBSTX) in-network providers for your family’s health care, you usually pay less for care. Search for in-network providers in your area at bcbstx.com or by calling the Customer Service number on the back of your member ID card.

1 24/7 Nurseline is not a substitute for a doctor’s care. Talk to your doctor about any health questions or concerns.2 Medical Practice Pulse Report 2009, Press Ganey Associates.3 Urgent Care Benchmarking Study Results. Journal of Urgent Care Medicine, January 2012.4 Emergency Department Pulse Report 2010 Patient Perspectives on American Health Care. Press Ganey Associates.5 The Texas Association of Health Plans.

Note: The relative costs described here are for independently contracted network providers. Your costs for out-of-network providers may be significantly higher. Wait times described are just estimates.

The information provided in this guide is not intended as medical advice, nor meant to be a substitute for the individual medical judgment of a doctor or other health care professional. Please check with your doctor for individualized advice on the information provided. Coverage may vary depending on your specific benefit plan and use of network providers. For questions, please call the number on the back of your member ID card.

$ $ $ $ $ $$

If you need emergency care, call 911 or seek help from any doctor or hospital immediately.

Doctor’s Office Retail Health Clinic

Urgent Care Center

Hospital ER Freestanding ER

Who usually provides care

Primary Care Doctor

Physician Assistant or Nurse Practitioner

Internal Medicine, Family Practice, Pediatric and ER Doctors

ER Doctors, Internal Medicine, Specialists

ER Doctors, Internal Medicine, Specialists

Sprains, strains ■ ■ ■ • Any life-threatening or disabling conditions

• Sudden or unexplained loss of consciousness

• Major injuries

• Chest pain; numbness in the face, arm or leg; difficulty speaking

• Severe shortness of breath

• High fever with stiff neck, mental confusion or difficulty breathing

• Coughing up or vomiting blood

• Cut or wound that won’t stop bleeding

• Possible broken bones

• Most major injuries except for trauma1

• May also provide imaging and lab services but do not offer trauma or cardiac services requiring catheterization1

• Do not always accept ambulances

Animal bites ■ ■ ■

X-rays ■

Stitches ■

Mild asthma ■ ■ ■

Minor headaches ■ ■ ■

Back pain ■ ■ ■

Nausea, vomiting, diarrhea ■ ■ ■

Minor allergic reactions ■ ■ ■

Coughs, sore throat ■ ■ ■

Bumps, cuts, scrapes ■ ■ ■

Rashes, minor burns ■ ■ ■

Minor fevers, colds ■ ■ ■

Ear or sinus pain ■ ■ ■

Burning with urination ■ ■ ■

Eye swelling, irritation, redness or pain

■ ■ ■

Vaccinations ■ ■ ■

1 “Freestanding ED 101: What you need to know” July 2016, The Advisory Board Company.

2 The Texas Association of Health Plans.

3 The closest urgent care center may not be in your network. Be sure to check Provider Finder® to make sure the center you go to is in-network.

4 Message and data rates may apply. Read terms, conditions and privacy policy at bcbstx.com/mobile/text-messaging.

This information is intended solely as a general guide to what services may be available. The actual availability of services may vary greatly from location to location. The information is not intended to be medical advice. If you have questions about any health concern, you should discuss them with your health care provider.

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Deciding Where to Go? Doctor, Retail Clinic, Urgent Care or ER.

732078.0617

Urgent Care Center or Freestanding ER Knowing the Difference Can Save You MoneyUrgent care centers and freestanding ERs can be hard to tell apart. Freestanding ERs often look a lot like urgent care centers, but costs are higher. A visit to a freestanding ER often results in surprise medical bills that can be 10 times the rate charged by urgent care centers for the same services.2 Here are some ways to know if you are at a freestanding ER.

Freestanding ERs:

• Look like urgent care centers, but include EMERGENCY in facility names.

• Are open 24 hours a day, seven days a week.

• Are physically separate from a hospital.• Are subject to the same copay as hospital ER

and are staffed by ER physicians

Find urgent care centers3 near you by texting4 URGENTTX to 33633.

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BENEFITS ADMINISTRATION & INSURANCE SERVICES

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Hospital México Americano Nuevo Laredo, Tamaulipas

Mexican Network of Medical & Dental Providers

Medical

Medical & DentalPrivada Esteban Baca Calderón 4400 Col. La Concordia Nuevo Laredo, Tamaulipas 88298 MX: +52 867 454-1000 USA: (855) 500-9181 http://nvl.hma.com.mx/

Jose Centelles Suarez, DDS Dental

201 Avénida dé las Américas,

Paseo de la Victoria 4370-629Ciudad Juarez, Chihuahua, 32618 MX: +52 656 648-3413

Cuidad Juarez, Chihuahua Centro Medico de Especialidades

32300 Cd Juárez, Chih., Mexico MX: +52 656-686-0400centromedicojrz.com

Nogales, Sonora Hospital del Socorro de Nogales

Dental Laser NogalesDental

MedicalHermosillo 425 Granja, Nogales, Sonora 84065 MX: +52 631 314-6061

Pesqueira 26, Fundo LegalNogales, Sonora 84030US: USA: (520) 223-4349nogalesdentallaser.com

USA: (760) 512-0366 www.promed.mx/

Hospital Santa Margarita San Luis R.C., Sonora

Tijuana, Baja Calif.

MX: +52 686 554 1400

Calle B 210 Medical & Dental

Zona Centro 21100 Mexicali, B.C.

Mexicali, Baja Calif. PRO-MED

Dental

Nuevo Algodones Los Algodones, B.C.Phone(US): 1(928)377-4565 www.lovaldentalclinic.com/

Phone(US): 1(928)377-4565 www.lovaldentalclinic.com/

Loval Dental San Luis RC

Mexican Network of Medical & Dental Providers

Medical

Dental

Ave. Robles Y Calle Encinos

MX: +52 653 534 0020 83449 San Luis R.C, Son., Av. 16 De Septiembre Y Calle 7

USA: 01152 (653) 534-3065 www.hsm.com.mx/

Callejon Juarez y 7San Luis Rio Colorado, Son.,

Los Algodones, Baja Calif. Loval Dental Los Algodones

Medical & DentalPaseo de Los Héroes 2507 Zona Rio 22320 Tijuana, B.C. MX: +52 800 211 0690 USA: (619) 308-7093 www.hospitalexcel.com/

Hospital Excel

Hospital México

Avenida de la Amistad 9077 Colonia Federal 22010 Tijuana, B.C. MX: +52 664 683 6363 USA: (619) 482-8608 www.hospitalmexico.org/

Medical & Dental

ADF# MULTI1321.16

metlife.com

Like most insurance policies and benefit programs, insurance policies and benefit programs offered by Metropolitan Life Insurance Company and its affiliates contain certain exclusions, exceptions, waiting periods, reductions of benefits, limitations and terms for keeping them in force. Please contact MetLife for complete details.

1. To use the MetLife mobile app, employees can choose to register at metlife.com/mybenefits from a computeror directly through the app.

2. Certain features of MetLife US Mobile App are not available for some MetLife Dental Plans.

Mobile App

Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166 L0119511820[exp0220][All States] © 2019 MetLife Services and Solutions, LLC

Benefits at your employees’ fingertipsWe care about the success of your benefits program. And your employees’ convenience is one of our top priorities. With MetLife’s mobile app, employees who prefer a digital service experience can securely and easily view and manage their benefits information on their mobile device.

Count on us for an exceptional service experience. Contact your MetLife representative today.

The MetLife mobile experience1

Accident & Health • View policy details

Auto and Home • View policy details• View ID Card• File a claim and upload accident details• Pay auto insurance bills

Dental2 • Find a provider• Add/change dentist (DHMO only)• View ID Card (PPO only)• Get estimates for most dental procedures (PPO only)• View plan summary (PPO only)• View claims (PPO only)• Track brushing and flossing activity

Disability • View and update claim information• Set up Direct Deposit

Legal Services • Find an attorney• View coverage details• Get a case number

Life • View policy details

Vision • Find a provider

Experience the MetLife difference

Extensive provider network

The MetLife dental network includes over 146,000 providers, so finding the right dentist is easy.

Flexibility to see any dentist

Our plans give you the flexibility to visit providers in or out of network. Most cleanings and exams are covered 100%.

Dental InsurancePreventive oral care not only provides benefits for your overall health, it also helps avoid unexpected expenses like oral surgery. Our large network and flexible coverage options help keep your out-of-pocket costs down.

Dental Insurance Products

Page 1 of 12Dental Insurance | MetLife

6/19/2019https://www.metlife.com/insurance/dental-insurance/

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Have a dentist in your pocket.

The MetLife App is always on hand to help. You can manage your policy, file claims, and find a dentist. Use Bright Smile to help you keep track of your good brushing habits and set a reminder to maintain good oral hygeine.

GET THE APP

Manage your account

Log in to your MetLife account, access claim forms, or access information if you are a dental provider.

Register Or Log In Download A Claim Form

For Dental Care Providers

MetLife Dental Insurance FAQ's:

What is the MetLife Preferred Dentist Program?

What is a participating dentist?

Page 8 of 12Dental Insurance | MetLife

6/19/2019https://www.metlife.com/insurance/dental-insurance/

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Dental

The recent COVID-19 pandemic is changing how patients receive certain types of dental care. As part of MetLife’s teledentistry benefit, you can still talk with a dentist and get necessary treatment, such as emergency care, when you need it.

What is teledentistry? Similar to telemedicine, teledentistry uses digital technologies – like a smartphone, tablet, or computer – that enables the dentist to perform problem-focused exams and reevaluations while you remain at home.

You can also provide photos, videos, and health history that the dentist can use to help diagnose your issue. MetLife aims to provide coverage for emergency dental care whether it is delivered in a dental office or by teledentistry.

How you’ll get treatment It’s up to the dentist on how treatment will be delivered. Some conditions, like a gum infection, can be diagnosed via a teledentistry problem-focused exam and treated with a prescription that the dentist can call in to your local pharmacy for you.

For some other dental emergencies, the dentist can decide whether you’ll get treated at their office or another location.

What is a dental emergency?The American Dental Association recommends that you get care immediately for the following conditions:

• Bleeding that doesn’t stop• Painful swelling in or around your mouth• Pain in a tooth, teeth, or jawbone• Gum infection with pain or swelling• After-surgery treatment (dressing change, stitch removal)• Broken or knocked-out tooth• Denture adjustment for people receiving radiation or other treatment for cancer• Snipping or adjusting wire of braces that hurt cheeks or gums• Biopsy of abnormal tissue

MetLife Teledentistry BenefitProtecting your smile during COVID-19

Like most group benefit programs, benefit programs offered by Metropolitan Life Insurance Company (MetLife) and its affiliates contain certain exclusions, exceptions, waiting periods, reductions, limitations and terms for keeping them in force. Please contact MetLife or your plan administrator for complete details.

To learn more about keeping your teeth healthy during the COVID-19 pandemic, visit our online Oral Health Library.

Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166 L0420003209[exp0421][All States] © 2020 MetLife Services and Solutions, LLC

Submitting a teledentistry claim

The dentist can submit the claim for the dental services delivered via teledentistry for you to MetLife, which will process it the same way as a regular office visit for a problem-focused exam or an evaluation claim. Benefit coverage for services delivered by teledentistry is based on your specific dental plan and is subject to the terms and conditions of that plan.

MetLife dental plans provide coverage for dental services delivered through teledentistry. The coverage is handled the same as if the patient was receiving the dental services in a dental office. Dental services that can be delivered through teledentistry typically include problem-focused exams and reevaluations. The coverage is subject to the plan terms and conditions. Dentists can verify benefit coverage using MetLife’s web portal, www.MetDental.com as well as MetLife’s interactive voice response [IVR] capabilities. To the extent a state has enacted mandates regarding teledentistry due to the COVID-19 pandemic, MetLife will fully comply.

https://oralfitnesslibrary.com/Home/Covid

Vision Insurance

Learn more about your MetLife benefits

The MetLife Mobile App is available on the iTunes App Store and Google Play.1 Download the app and use it to find a participating provider.

MetLife benefits information right from your laptopThe MyBenefits website is a quick and easy way for you to get the information you need about your MetLife benefits — all in one place. Log in to metlife.com/mybenefits to see how we’ve taken personalization and integration to a new level.

Personalized homepage to all your MetLife benefitsGet more information on your MetLife benefits, where you can link to detailed coverage information and can perform tasks, such as:

Vision Plans — Easily find a vision provider or view your benefits and claims online. Plus, you will have access to our extensive Vision Health Library to research important vision topics.

Vision ID cards are available online for you to download and print at your convenience. Cards contain your name, MetLife’s claims submission address, website and customer service telephone number.

Additional MyBenefits features include:• Planning tools that you can use to help you make informed decisions regarding your

retirement and benefits coverage as well as other useful information for a variety ofeveryday topics.

• Forms and documents that you may need are located in the “Tools & Resources” area atthe bottom of the MyBenefits home page for you to download.

• In the “News & Updates” section you’ll find information from MetLife and your employersuch as enrollment dates and new product offerings.

• Online claims tracking and email notifications called eAlerts, which will provideinformation regarding status changes to your claims for certain benefits.

metlife.com/mybenefits

Protect your family’s financial future with our will preparation services

MetLife AdvantagesSM Life Insurance

Experts at hand Having a will prevents unnecessary stress and ensures your final wishes are clear. We offer valuable legal resources through Hyatt Legal Plans to assist you with creating or updating a binding will at no additional cost with your [Supplemental Life, Group Variable Universal Life, Group Universal Life] coverage. Get expert guidance and unlimited consultations with a plan attorney so you can feel confident you’re making the right decisions – and stop difficult decisions from ending up in your family’s hands.

Tailored guidance when it matters most Choose to meet any of our more than 14,000 participating plan attorneys in-person or by phone for a one-to-one consultation in a private and supportive environment. There are no claim forms to file for covered services – fees are taken care of through your plan. To help you find the right fit for you, you can use an out-of-network attorney, the fees for these services are based on a set fee schedule.1

You’ve got it covered Take advantage of covered services including: • Unlimited access: Talk to an attorney as many times as needed to prepare, update or revise a will. • Protection for the unexpected: Prepare living wills and powers of attorney to help ease the stress if

individuals become unable to make decisions for themselves.

These services [are][will] automatically [be] available to you [as][when] your life insurance coverage starts.

[Expert guidance is just a conversation away] [Simply contact a Client Services Representative to get started. We’ll give you a case number and help you find a participating plan attorney. • Call Hyatt Legal Plans’ toll-free number 1-800-821-6400 • Give the company name, customer number [customer number] [(if available) and the last

4 digits of the policy holder’s Social Security number.] • And find the best participating plan attorney for you]

[Other services that may also be included with your life coverage] • [Estate Resolution Services2: Settle an estate with ease.] • [Grief Counseling Services3: Access professional support in a time of need.] • [Funeral Discount & Planning Services4:] Pre-plan to help lighten the burden of making funeral

arrangements from loved ones. • [Digital Legacy5: Create and share a digital legacy.]

Included with Supplemental Life Insurance. Will Preparation is offered by Hyatt Legal Plans, Inc., a MetLife company, Cleveland, Ohio. In certain states, legal services benefits are provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and Affiliates, Warwick, Rhode Island. For New York sitused cases, the Will Preparation service is an expanded offering that includes office consultations and telephone advice for certain other legal matters beyond Will Preparation. Tax Planning and preparation of Living Trusts are not covered by the Will Preparation Service

1. Individuals have the option to use the out-of-network reimbursement feature to retain an attorney who does not participate in Hyatt Legal Plans’ network of plan attorneys. If a non-network attorney is chosen, the individual will be responsible for any attorneys’ fees that exceed the reimbursed amount.

2. [Included with Supplemental Life Insurance. MetLife Estate Resolution Services are offered by Hyatt Legal Plans, Inc., a MetLife company, Cleveland, Ohio. In certain states, legal services benefits are provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and Affiliates, Warwick, Rhode Island. Certain services are not covered by Estate Resolution Services, including matters in which there is a conflict of interest between the executor and any beneficiary or heir and the estate; any disputes with the group policyholder, MetLife and/or any of its affiliates; any disputes involving statutory benefits; will contests or litigation outside probate court; appeals; court costs, filing fees, recording fees, transcripts, witness fees, expenses to a third party, judgments or fines; and frivolous or unethical matters.]

3. Grief Counseling and Funeral Assistance services are provided through an agreement with LifeWorks. US Inc. LifeWorks is not an affiliate of MetLife, and the services LifeWorks provides are separate and apart from the insurance provided by MetLife. LifeWorks has a nationwide network of over 30,000 counselors. Counselors have master’s or doctoral degrees and are licensed professionals. The Grief Counseling program does not provide support for issues such as: domestic issues, parenting issues, or marital/relationship issues (other than a finalized divorce). For such issues, members should inquire with their human resources department about available company resources. This program is available to insureds, their dependents and beneficiaries who have received a serious medical diagnosis or suffered a loss. Events that may result in a loss are not covered under this program unless and until such loss has occurred. [Services are not available in all jurisdictions and are subject to regulatory approval. Not available on all policy forms.]

4. [Services and discounts are provided through a member of the Dignity Memorial® Network, a brand name used to identify a network of licensed funeral, cremation and cemetery providers that are affiliates of Service Corporation International (together with its affiliates, “SCI”), 1929 Allen Parkway, Houston, Texas. The online planning site is provided by SCI Shared Resources, LLC. SCI is not affiliated with MetLife, and the services provided by Dignity Memorial members are separate and apart from the insurance provided by MetLife. Not available in some states. Planning services, expert assistance, and bereavement travel services are available to anyone regardless of affiliation with MetLife. Discounts through Dignity Memorial’s network of funeral providers are pre-negotiated. Not available where prohibited by law. If the group policy is issued in an approved state, the discount is available for services held in any state except KY and NY, or where there is no Dignity Memorial presence (AK, MT, ND, SD, and WY). For MI and TN, the discount is available for “At Need” services only. Not approved in AK, FL, KY, MT, ND, NY and WA.]

5. [MetLife Infinity is offered by MetLife Consumer Services, Inc., an affiliate of Metropolitan Life Insurance Company. MetLife Infinity is available to anyone regardless of affiliation with MetLife.]

Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166 L0118501813[exp0319][All States][DC,GU,MP,PR,VI] © 2017 METLIFE, INC.

YWCA El Paso Del Norte Region Employee Benefits Notices and Forms

Annual, New Hire, and Other Notices and Forms

Please note: While HUB is providing these notices as a courtesy to its clients, HUB does not provide legal or tax advice. HUB makes no representation or warranty as to the accuracy or completeness of these documents and is not obligated to update them. Consult your attorney and/or professional advisor as to your organization’s specific circumstances and legal, tax or other requirements.

JIMENA CENTELLES, LHICHUB INTERNATIONAL INSURANCE SERVICES 201 E MAIN, SUITE 800 EL PASO, TX 79901 (915) 206-6038

Section I: Annual Notices and Forms for All Plans

Medicare Part D Creditable Coverage Notice Important Notice from YWCA El Paso Del Norte Region About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with YWCA El Paso Del Norte Region (the “Plan Sponsor") and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

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

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

(2) The Plan Sponsor has determined that the prescription drug coverage offered by the Blue Cross Blue Shield plans is, on average for all

plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

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 Plan Sponsor coverage may be affected. Moreover, if you do decide to join a Medicare drug plan and drop your current Plan Sponsor coverage, be aware that you and your dependents may not be able to get this coverage back.

Please contact the person listed at the end of this notice for more information about what happens to your coverage if you enroll in a Medicare Part D prescription Drug 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 Plan Sponsor and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information about This Notice or Your Current Prescription Drug Coverage… Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the Plan Sponsor changes. You also may request a copy of this notice at any time.

For More Information about Your Options under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage: o Visit www.medicare.gov.

http://www.medicare.gov./

o Call your State Health Insurance Assistance Program (see theinside back cover of your copy of the “Medicare & You”handbook for their telephone number) for personalized helpCall 1-800-MEDICARE (1-800-633-4227). TTY users shouldcall 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

Date: Name of Entity/Sender: Contact-Position/Office: Address:

Phone Number:

June 01, 2020 YWCA El Paso Del Norte Region Human Resource Department 201 E. Main , Suite 400 El Paso, TX 79901(915) 519-0000

http://www.socialsecurity.gov/

Medicare Part D Non-Creditable Coverage Notice

Important Notice From YWCA El Paso Del Norte Region About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with YWCA El Paso Del Norte Region (the “Plan Sponsor”) and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. Information about where you can get help to make decisions about your prescription 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 a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

(2) The Plan Sponsor has determined that the prescription drug coverage offered by the Benefits Administrators & Insurance Services (the “Plan”) is, on average for all plan participants, NOT expected to pay out as much as standard Medicare prescription drug coverage pays. Therefore, your coverage is considered Non- Creditable Coverage. This is important

because, most likely, you will get more help with your drug costs if you join a Medicare drug plan, than if you only have prescription drug coverage from the Plan. This also is important because it may 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 from the Plan. However, because your coverage is non-creditable, you have decisions to make about Medicare prescription drug coverage that may affect how much you pay for that coverage, depending on if and when you join a drug plan. When you make your decision, you should compare your current coverage, including what drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. Read this notice carefully - it explains your options.

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 decide to drop your current coverage with the Plan Sponsor, since it is employer/union sponsored group coverage, you will be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan; however you also may pay a higher premium (a penalty) because you did not have creditable coverage under the Plan.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?

Since the coverage under the Plan, is not creditable, depending on how long you go without creditable prescription drug coverage you may pay a penalty to join a Medicare drug plan. Starting with the end of the last month that you were first eligible to join a Medicare drug plan but didn’t join, if you go 63 continuous days or longer without prescription drug coverage that’s creditable, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

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 Plan Sponsor coverage may be affected. Moreover, if you do decide to join a Medicare drug plan and drop your current Plan Sponsor coverage, be aware that you and your dependents may not be able to get this coverage back.

Please contact the person listed at the end of this notice for more information about what happens to your coverage if you enroll in a Medicare Part D prescription Drug Plan.

For More Information about This Notice or Your Current Prescription Drug Coverage… Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan and if this coverage through the Plan Sponsor changes. You also may request a copy of this notice at any time.

For More Information about Your Options under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:

o Visit www.medicare.govo Call your State Health Insurance Assistance Program (see the

inside back cover of your copy of the “Medicare & You”handbook for their telephone number) for personalized help

o Call 1-800-MEDICARE (1-800-633-4227). TTY users shouldcall 1-877-486-2048.

http://www.medicare.gov/

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Date: June 1, 2020 Name of Entity/Sender: YWCA El Paso Del Norte Region Contact-Position/Office: Human Resource Department Address: 201 E. Main , Suite 400

Phone Number: El Paso, TX 79901(915) 519-0000

http://www.socialsecurity.gov/

CHIPRA/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 January 31, 2020 Contact your State for more information on eligibility –

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

Website: http://myalhipp.com/ Phone: 1-855-692-5447

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711

ALASKA – Medicaid FLORIDA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

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

ARKANSAS – Medicaid GEORGIA – Medicaid

Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

Website: https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp Phone: 678-564-1162 ext 2131

CALIFORNIA – Medicaid INDIANA – Medicaid

Website: https://www.dhcs.ca.gov/services/Pages/TPLRD_CA U_cont.aspx Phone: 1-800-541-5555

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


http://www.insurekidsnow.gov/

http://www.askebsa.dol.gov/

http://myalhipp.com/

https://www.healthfirstcolorado.com/

https://www.colorado.gov/pacific/hcpf/child-health-plan-plus

https://www.colorado.gov/pacific/hcpf/child-health-plan-plus

http://myakhipp.com/

mailto:[email protected]

http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

http://flmedicaidtplrecovery.com/hipp/

http://myarhipp.com/

https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp

https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp

https://www.dhcs.ca.gov/services/Pages/TPLRD_CA%20U_cont.aspx

https://www.dhcs.ca.gov/services/Pages/TPLRD_CA%20U_cont.aspx

http://www.in.gov/fssa/hip/

http://www.indianamedicaid.com/

IOWA – Medicaid and CHIP (Hawki) MONTANA – Medicaid Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563

Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPPPhone: 1-800-694-3084

KANSAS – Medicaid NEBRASKA – Medicaid

Website: http://www.kdheks.gov/hcf/default.htm Phone: 1-800-792-4884

Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178

KENTUCKY – Medicaid NEVADA – Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: [email protected]

KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718

Kentucky Medicaid Website: https://chfs.ky.gov

Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900

LOUISIANA – Medicaid NEW HAMPSHIRE – Medicaid

Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)

Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext 5218

MAINE – Medicaid NEW JERSEY – Medicaid and CHIP

Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840

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

MINNESOTA – Medicaid NORTH CAROLINA – Medicaid Website: https://mn.gov/dhs/people-we-serve/children-and-families/health-care/health-care-programs/programs-and-services/medical-assistance.jsp [Under ELIGIBILITY tab, see “what if I have other health insurance?”] Phone: 1-800-657-3739

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

MISSOURI – Medicaid NORTH DAKOTA – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

https://dhs.iowa.gov/ime/members

http://dhs.iowa.gov/Hawki

http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP

http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP

http://www.kdheks.gov/hcf/default.htm

http://www.accessnebraska.ne.gov/

https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx

https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx


https://kidshealth.ky.gov/Pages/index.aspx

https://chfs.ky.gov/

http://dhcfp.nv.gov/

http://www.medicaid.la.gov/

http://www.ldh.la.gov/lahipp

https://www.dhhs.nh.gov/oii/hipp.htm

http://www.maine.gov/dhhs/ofi/public-assistance/index.html

http://www.maine.gov/dhhs/ofi/public-assistance/index.html

http://www.state.nj.us/humanservices/dmahs/clients/medicaid/

http://www.state.nj.us/humanservices/dmahs/clients/medicaid/

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

http://www.mass.gov/eohhs/gov/departments/masshealth/

http://www.mass.gov/eohhs/gov/departments/masshealth/

https://www.health.ny.gov/health_care/medicaid/

https://mn.gov/dhs/people-we-serve/children-and-families/health-care/health-care-programs/programs-and-services/medical-assistance.jsp



https://medicaid.ncdhhs.gov/

http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

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

To see if any other states have added a premium assistance program since January 31, 2020, or for more information on special enrollment rights, contact either:

Employee Benefits Security Administration Centers for Medicare & Medicaid Services

U.S. Department of Labor U.S. Department of Health and Human Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

OKLAHOMA – Medicaid and CHIP UTAH – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

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

OREGON – Medicaid VERMONT– Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

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

PENNSYLVANIA – Medicaid VIRGINIA – Medicaid and CHIP Website: https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HIPP-Program.aspx Phone: 1-800-692-7462

Website: https://www.coverva.org/hipp/ Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282

RHODE ISLAND – Medicaid and CHIP WASHINGTON – Medicaid Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)

Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022

SOUTH CAROLINA – Medicaid WEST VIRGINIA – Medicaid

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

Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

SOUTH DAKOTA - Medicaid WISCONSIN – Medicaid and CHIP

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

Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002

TEXAS – Medicaid WYOMING – Medicaid

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

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

https://www.dol.gov/agencies/ebsa

http://www.cms.hhs.gov/

http://www.insureoklahoma.org/

https://medicaid.utah.gov/

http://health.utah.gov/chip

http://healthcare.oregon.gov/Pages/index.aspx

http://www.oregonhealthcare.gov/index-es.html

http://www.greenmountaincare.org/

https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HIPP-Program.aspx

https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HIPP-Program.aspx

https://www.coverva.org/hipp/

http://www.eohhs.ri.gov/

https://www.hca.wa.gov/

https://www.scdhhs.gov/

http://mywvhipp.com/

http://dss.sd.gov/

https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf

https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf

http://gethipptexas.com/

Annual Notice of Women’s Health and Cancer Rights Act

Do you know that your plan, as required by the Women’s Health and Cancer Right Act of 1998, provides benefits for mastectomy-related services, including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses and treatment for complications resulting from a mastectomy, including lymphedema? Call your plan administrator with YWCA El Paso Del Norte Region at (915) 519-0000 for more information.

Section II: Notices and Forms that Apply Before, On, or Shortly After Initial Enrollment

19

Notice of Availability of HIPAA Notice of Privacy Practices

YWCA El Paso del Norte RegionNotice of Privacy Practices

June 1, 2020

To: Participants in the medical plans offered by Blue Cross Blue Shield, Benefits Administration and Insurance Services plus the dental, vision and life offered by MetLife.

From: YWCA El Paso del Norte Region

Re: Availability of Notice of Privacy Practices

The medical plans offered by Blue Cross Blue Shield, Benefits Administration and Insurance Services plus the dental, vision and life offered by MetLife (each a “Plan”) maintains a Notice of Privacy Practices that provides information to individuals whose protected health information (PHI) will be used or maintained by the Plan. If you would like a copy of the Plan's Notice of Privacy Practices, please contact the YWCA El Paso del Norte Region, Human Resource Department at (915) 519-0000.

20

Patient Protection Disclosures

Blue Cross Blue Shield generally requires the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. Until you make this designation, Blue Cross Blue Shield designates one for you. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the YWCA of El Paso, Human Resource Department , at (915) 519-0000, 201 E Main, Suite 400, El Paso, TX 79901.

For plans that require or allow for the designation of a primary care provider for a child: For children, you may designate a pediatrician as the primary care provider.

Notice of Marketplace Coverage Options

PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment based health coverage offered by your employer.

What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins November 1, 2019 for coverage starting January 1, 2020.

Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit.1

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis.

How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact: YWCA El Paso Del Norte Region, Human Resource Department at (915) 519-000, 201 E. Main Suite 400, El Paso, TX 79901.

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.

1 An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs

covered by the plan is no less than 60 percent of such costs.

New Health Insurance Marketplace Coverage Options and Your Health Coverage


Notice of Availability of HIPAA Notice of Privacy Practices

YWCA El Paso Del Norte Region Notice of Privacy Practices

June 01, 2020

To: Participants in BlueCross BlueShield and Benefits Administration & Insurance Services Inc. Medical Plan

From: YWCA El Paso Del Norte Region

Re: Availability of Notice of Privacy Practices

The BlueCross BlueShield and Benefits Administration & Insurance Services LLC. (each a “Plan”) maintains a Notice of Privacy Practices that provides information to individuals whose protected health information (PHI) will be used or maintained by the Plan. If you would like a copy of the Plan's Notice of Privacy Practices, please contact the Human Resource Department at YWCA El Paso Del Norte Region 201 E. Main , Suite 400, El Paso, TX 79901.

Part B: Information About Health Coverage Offered by Your Employer

This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.

Here is some basic informtion about health coverage offered by this employer: o As your employer, we offer a health plan to:

☒ All employees. Eligible employees are:

☐ Some employees. Eligible employees are:

o With respect to dependents:☒ We do offer coverage. Eligible dependents are:

☐ We do not offer coverage.

☒ If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages.

Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.

3. Employer name

YWCA El Paso Del Norte Region

4. Employer Identification Number (EIN)

5. Employer address, 7. City, 8. State, 9. Zip Code 6. Employer phone number

10. Who can we contact about employee health coverage at this job?

11. Phone number (if different from above) 12. Email address

201 E. Main Suite 400 El Paso, TX 79901

74-1109650

(915) 519-0000

Human Resource Department

(915) 519-0000 [email protected]


Notice of Special Enrollment Rights

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment no later than 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment no later than 30 days after the marriage, birth, adoption, or placement for adoption.

Effective April 1, 2009, if either of the following two events occur, you will have 60 days after the date of the event to request enrollment in your employer’s plan:

o Your dependents lose Medicaid or CHIP coverage because they are no longer eligible.o Your dependents become eligible for a state’s premium assistance program.

To take advantage of special enrollment rights, you must experience a qualifying event and provide the employer plan with timely notice of the event and your enrollment request.

To request special enrollment or obtain more information, contact YWCA El Paso Del Norte Region, Human Resource Dept. at (915) 519-0000.

General COBRA Notice

General Notice of COBRA Continuation Coverage Rights

Continuation Coverage Rights Under COBRA

Introduction

You’re getting this notice because you recently gained coverage under a group health plan (the Plan). 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:

o Your hours of employment are reduced, oro 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:

o Your spouse dies;o Your spouse’s hours of employment are reduced;o Your spouse’s employment ends for any reason other than his or her gross misconduct;o Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); oro 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:

o The parent-employee dies;o The parent-employee’s hours of employment are reduced;o The parent-employee’s employment ends for any reason other than his or her gross misconduct;o The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);o The parents become divorced or legally separated; oro The child stops being eligible for coverage under the Plan as a “dependent child.”

Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to YWCA El Paso Del Norte Region, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.

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:

o The end of employment or reduction of hours of employment;o Death of the employee;o Commencement of a proceeding in bankruptcy with respect to the employer; oro 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. You must provide this notice to: YWCA El Paso Del Norte Region, Attention Human Resource Department at (915) 519-0000, 201 E. Main Suite 400 , El Paso, TX 79901.

How is COBRA continuation coverage provided?

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

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

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

Disability extension of 18-month period of COBRA continuation coverage

If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. YWCA El Paso Del Norte Region, may request an Attending Physician’s statement to support the disability determination.

Second qualifying event extension of 18-month period of continuation coverage

If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

Are there other coverage options besides COBRA Continuation Coverage?

Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.

If you have questions

Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.

Keep your Plan informed of address changes

To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.

Plan contact information

YWCA El Paso Del Norte Region Human Resource Department 201 E. Main Suite 400El Paso, TX 79901(915) 519-0000

https://www.dol.gov/ebsa/www.healthcare.gov


APPLICATIONS

https://www.bing.com/images/search?q=application+clip+art+free&id=5C84112637125409E355047CD3295D4F80FF422C&FORM=IQFRBA

Dear Employee: This is to confirm that YWCA El Paso Del Norte Region offers full-time employees (who average 30 or more hours per week) the opportunity to enroll in health insurance coverage that offers Minimum Value and/or Minimum Essential Coverage, required under the Patient Protection and Affordable Care Act. For you to become enrolled or make any changes to your current coverage for 2020 – 2021, you have to enroll and make changes via employee navigator at https://harmonyenroll.coloniallife.com/SelfEnrollLogin.Web/Login.aspx by May 15, 2020. Please contact the Human Resource Department at (915) 519-0000 within receipt of this notice. If YWCA El Paso Del Norte Region does not receive either an enrollment form or waiver confirmation and you are currently enrolled on the medical plan, your medical coverage will be defaulted into the new HMO H.S.A. option (Base). Other coverages will rollover based on the current selections you have on file. If you have any questions please call. Sincerely, YWCA El Paso Del Norte Region Human Resource Department (915) 519-0000 ________________________________ Employee Name (Print) ________________________________ Employee Signature _________________ Date

https://harmonyenroll.coloniallife.com/SelfEnrollLogin.Web/Login.aspx

https://www.ywcaelpaso.org/

Health I n s urance Waiver Form

I, ·' was offered the opportunity to enroll in an employerprovided group health insurance program that was affordable (according to one of the 3 IRS provided safe harbors) offered minimum value and/or minimum essential coverage. I have elected to waive the opportunity to enroll at open enrollment knowing that the next opportunity to enroll will not be until 12 months from now, unless I experience a qualifying event.

Instead, I have health insurance coverage through:

A spouse's employer plan

A parent's employer plan

Medicare

Medicaid

Individual/Group Plan

Champus/Tri Care

VA

The State Exchange

Affordable Care Act

Uninsured

I certify this information to be true and accurate. False statements on this form may subject me to disciplinary action, up to and including discharge.

Employee Name (Print)

Employee Signature Date

Witness Date

http://www.hubinternational.com/

ENROLLMENT APPLICATION/CHANGE FORM

1

SECTION 1 — ENROLLMENT EVENTS

SECTION 2 — PLEASE TELL US ABOUT YOURSELF

SECTION 3 — SELECT YOUR COVERAGE PLEASE CHECK ALL THAT APPLY

Who is covered for dental? (select one) Employee OnlyEmployee/SpouseEmployee/Child(ren)FamilyI am not applying for Dental coverage

COMPLETE EVEN IF DECLINING COVERAGE

Who is covered for health? (select one) Employee OnlyEmployee/Spouse***Employee/Child(ren)FamilyI am not applying for Health coverage

Primary Language: n Check here to request a Spanish HMO Member Handbook Do you have a disability affecting your ability to communicate or read? n Yes n No If “Yes,” describe special communication materials needed:

Small Group Plans (2-50 Employees)

Large Group Plans (more than 50 Employees)Who is covered for dental? (select one)

Employee OnlyEmployee/SpouseEmployee/Child(ren)FamilyI am not applying for Dental coverage

Dental CoverageYesNo

Plan # (required)

Who is covered for health? (select one) Employee OnlyEmployee/SpouseEmployee/Child(ren)FamilyI am not applying for Health coverage

Please Note: If your group offers a Consumer Choice health plan you have the option to choose a Consumer Choice of Benefits Health Insurance Plan or Consumer Choice of Benefits Health Maintenance Organization health care plan that, either in whole or in part, does not provide state-mandated health benefits normally required in accident and sickness insurance policies or evidences of coverage in Texas. This standard health benefit plan may provide a more affordable health insurance policy or health plan for you, although, at the same time, it may provide you with fewer health benefits than those normally included as state-mandated health benefits in policies or evidences of coverage in Texas. If you choose this standard health benefit plan, please consult with your insurance agent to discover which state-mandated health benefits are excluded in this policy or evidence of coverage.

PLEASE CHECK ALL THAT APPLY – IF YOU ARE DECLINING COVERAGE, COMPLETE SECTIONS 2, 8 AND 9 ONLY

Do you usually work at least 30 hours a week for this employer? n Yes No

Cancel Enrollee Cancel Dependent

Cancel Coverage: Health Dental Term Life Dependent Life Short-Term Disability Long-Term Disability

List names of those canceling in Section 4 belowEvent: Divorce** Death

Terminated Employment Other

Indicate Event Date: ____ / ____ / ____

Last Name First Name MI (opt) Suffix Birth Date (MM/DD/YYYY) Social Security # – –

Mailing Address - Street - Apt # City State ZIP code

Email Address Male Home/Cell Phone #Female

Name of Employer Job Title Business Phone # Employment Date (MM/DD/YYYY)

Eligibility Status: n Active Employee n Retired Employee - Date of Retirement: n COBRA Continuationn State Continuation of Group Coverage (insured plans only) n Dependent State Continuation of Group Coverage (insured plans only)

Health Coverage (select one)Blue Choice PPOSM Blue EssentialsSM

Blue PremierSM Blue Essentials Access SM

Blue Premier AccessSM Other

Plan #

New Enrollee Add Dependent Open Enrollment Other Changes Are you applying as a result of a Special Enrollment Event?

No Yes, Event Date: ____ / ____ / ____ Event: New Hire Marriage* Birth

Adoption or Suit for Adoption (provide legal documents)Court Order (provide court order or decree)Loss of Other CoverageOther (explain): _______________________________________________________________

Effective Date of Benefits: ____ / ____ / ____ Completion of Other Eligibility Requirements

BlueCare DentalSM Coverage

YesNo

Health Coverage (select one)Blue Premier AccessSM Blue Choice PPOSM

Blue EssentialsSM Blue Advantage HMOSM

Blue Essentials AccessSM

Other Plan # (required)

I am not applying for Group Term Life, AD&D or Disability Insurance coverage Employee Occupation/Job Title: ___________________________ Wage Rate $__________________ per hour week month year Group Basic Term Life and AD&D I do not apply I do apply Amount $___________________________ Group Dependents’ Life I do not apply I do apply Group Supplemental Life I do not apply I do apply Employee Election: $__________________ Spouse Election: $__________________ Child Election: $__________________ Short-Term Disability I do not apply I do apply Long-Term Disability I do not apply I do apply Primary First Name Initial Last Name Relationship Birth Date (MM/DD/YYYY) Social Security #Beneficiary – –

Contingent First Name Initial Last Name Relationship Birth Date (MM/DD/YYYY) Social Security #Beneficiary – –

* The term “marriage” includes legal marriage and the establishment of a domestic partnership (coverage subject to your employer’s plan). ** The term “divorce” includes legal divorce and the comparable termination of a domestic partnership (coverage subject to your employer’s plan). *** The use of the term “spouse” includes a legal spouse. It also includes a party to a domestic partnership (coverage subject to your employer’s plan). ̂ Life and Disability insurance is underwritten by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Dearborn Life Insurance Company is an independent Blue Cross and Blue Shield licensee. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

Group Term Life, Accidental Death and Dismemberment (AD&D) and Disability Insurance^

Group # Section # Social Security #

Account # Category

730197.0120

ACCEPT______CHANGE____ CANCEL____ DECLINE_____

0 1 9 4 1 3

0 1 9 4 1 3

HMO-HSA-A1AH PPO-HSA-MMH3 PPO-MTBCP48A3

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Name of person covered: Medicare A (Hospital) Effective Date: ________________ End Date: ________________ Medicare HIC #Medicare B (Medical) Effective Date: _________________ End Date: ________________ (From Medicare Card)Medicare D (Drug) Effective Date: ___________________ End Date: ________________Medicare D (Drug) Carrier: ______________________________________

Name of person covered: Medicare A (Hospital) Effective Date: ________________ End Date: ________________ Medicare HIC #Medicare B (Medical) Effective Date: _________________ End Date: ________________ (From Medicare Card)Medicare D (Drug) Effective Date: ___________________ End Date: ________________Medicare D (Drug) Carrier: ______________________________________

Complete this section only if you or any of your dependents have other health and/or dental coverage that will not be canceled when the coverage under this application becomes effective. List names of each individual covered:Group Coverage Individual Coverage Name and Address of Other Insurance Carrier Effective Date (MM/DD/YYYY)

Name of Policyholder Birth Date (MM/DD/YYYY) Male Relationship to Applicant Female Self Spouse Dependent

Employer’s Name Employment Date (MM/DD/YYYY) Health Group # Health ID # Dental Group # Dental ID #

SECTION 6 — OTHER COVERAGE INFORMATION

SECTION 7 — MEDICARE COVERAGE INFORMATION

Last Name: Social Security #: Group #— —

Name Employee Reason for declining Health: Other Group Health Coverage – Carrier: __________________________________ Medicare Medicaid Other Individual Health Coverage – Carrier: ________________________________ Other (explain) _______________________________ I am not enrolled in any health insurance plan, but do not want this coverage

Name Employee Reason for declining Dental: Other Group Dental Coverage Medicaid Individual Dental Coverage Other (explain)_______________________________________ I am not enrolled in any dental insurance plan, but do not want this coverage

Name Spouse Reason for declining: Other Group Health Coverage Medicare Medicaid Other Individual Health Coverage Other (explain)_____________________________________ I am not enrolled in any health insurance plan, but do not want this coverage

Name Dependent Reason for declining: Other Group Health Coverage Medicare Medicaid Other Individual Health Coverage Other (explain)_____________________________________ I am not enrolled in any health insurance plan, but do not want this coverage

Name Dependent Reason for declining: Other Group Health Coverage Medicare Medicaid Other Individual Health Coverage Other (explain)_____________________________________ I am not enrolled in any health insurance plan, but do not want this coverage

SECTION 8 — DECLINATION OF COVERAGE

SECTION 9 — COVERAGE CONDITIONS

Please indicate reason for Medicare Eligibility: Entitled Age Entitled Disability End-Stage Renal Disease Disability and Current Renal Disease

This is to certify the available coverage has been explained to me. I have been given the opportunity to apply for the coverage offered to me and my eligible dependents and have voluntarily elected to decline the coverage as indicated below. If I desire to apply for coverage at a later date, I understand there may be a delay in the effective date of the coverage.

• I am an employee of the employer named in this enrollment application. I am eligible to participate in the coverage(s) afforded by my employer’s plan, which is either underwritten or administered by Blue Cross and Blue Shieldof Texas (BCBSTX) or Dearborn Life Insurance Company. On behalf of myself and any dependents listed on this enrollment application, I apply for those coverage(s) for which I am eligible. I state that the information given on this enrollment application is true and correct. I understand and agree that any intentional misrepresentation of a material fact made by me will invalidate my coverage(s).

• Only those coverage(s) and amounts for which I am eligible will be available to me. I understand that if this enrollment application is accepted, the coverage(s) will become effective in accordance with the provisions of theContract(s)/Plan(s).

• I agree that my employer acts as my agent. I authorize necessary payroll deduction by my employer, if any, to cover the cost of my coverage(s). As applies to HMO coverage, I will accept an electronic copy of my coverage documents (whether certificate of coverage or benefit booklet) if my employer requests that BCBSTX deliver the information electronically. I understand that a hard copy is available to me upon request.

• I understand that my participation in the coverage(s) is subject to any future amendment. I also understand that all notices given to my employer are applicable to me.• I understand that written communications that are required by law may be delivered to me electronically, with my consent. I understand that if I consent to receive my documents electronically, that I have a right to obtain a

paper copy and to withdraw my consent.

WARNING: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON.

Applicant’s Signature Date

2

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield AssociationLife and Disability insurance is underwritten by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Dearborn Life Insurance Company is an independent Blue Cross and Blue Shield licensee. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

If disabled child is over the dependent age limit of your employer’s plan, please attach a completed Disabled Dependent Authorization and Disabled Dependent Physician Certification.

SECTION 5 — DISABLED DEPENDENTName of Disabled Dependent Nature of Disability

Name of Disabled Dependent Nature of Disability

Please indicate reason for Medicare Eligibility: Entitled Age Entitled Disability End-Stage Renal Disease Disability and Current Renal Disease

Type of Policy Employee Only Employee/SpouseEmployee/Child(ren) Family

SECTION 4 — COVERAGE OPTIONS

Is this dependent a natural child, stepchild, foster child, adopted child, or a child in suit for adoption?

Y N

If not your eligible natural child, stepchild, foster child, adopted child or child in suit for adoption, are you (or your spouse) responsible for this dependent? Y N


Y N


Employee/Enrollee’s Name PCP Name PCP # New Patient? HMO OB/GYN Name (optional) HMO OB/GYN # Y N

Dependent’s PCP Name PCP # New Patient? HMO OB/GYN Name (optional) HMO OB/GYN # Y N

Dependent’s Social Security # Birth Date (MM/DD/YYYY) Address (if different) - # and Street Address City State ZIP code– –

Dependent’s Name Dependent’s Social Security # Dependent’s PCP Name PCP # New Patient? HMO OB/GYN Name (optional) HMO OB/GYN #

Son Daughter Other Eligible Dependent – – Y N

Birth Date (MM/DD/YYYY) Home Address (If different) Street/City/State/ZIP code







PLEASE COMPLETE ALL AREAS THAT APPLY. PCP SELECTION IS REQUIRED FOR BLUE ADVANTAGE, BLUE PREMIER AND BLUE ESSENTIALS PLANS. PCP SELECTION IS NOT REQUIRED FOR BLUE PREMIER ACCESS AND BLUE ESSENTIALS ACCESS PLANS.



Y N

Yes No Yes No

PLEASE COMPLETE IF APPLICABLE

PLEASE COMPLETE ALL AREAS THAT APPLY

PLEASE COMPLETE IF APPLICABLE

PLEASE COMPLETE IF YOU ARE DECLINING COVERAGE

Dependent’s Name Husband Wife Domestic Partner

730197.0120

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Tel: (949) 206-0272 / Fax: (949) 206-0274

ACCEPT_________ CHANGE________ DECLINE________ CANCEL__________

FOR BA&IS USE ONLY Effective

Date: _____________

PLAN SPONSOR INFORMATION

SECTION 1. EMPLOYEE INFORMATION Name (Last, First, M.I) Social Security Number Date of Birth: Hire Date:

- - / / / /Home Address (Number, Street Apt #) : City, State, Zip Code:

Gender: Marital Status: Home Phone Number: ☐ Male ☐ Female ☐ Single ☐ Separated ☐ Divorced ☐ Married ☐ Domestic Partner ( ) -

SECTION 2. QUALIFYING EVENT – This Election is For: ☐ New Enrollment ☐ Adding Dependent(s) ☐ Qualifying Event Type - Event Date: _________________

☐ Open Enrollment ☐ Deleting Dependent(s) ☐ Birth, Adoption, Etc. ☐ Marriage ☐ Divorce ☐ Loss Coverage

☐ Change in Enrollment ☐ COBRA Continuation ☐ Gained Coverage ☐ Other: ____________________________________

SECTION 3. COVERAGE ELECTION: Medical - Contribution Rates Per Pay Period

Employee Only Employee & Spouse Employee & Child(ren) Family

US ONLY NETWORK ☐ ☐ ☐ ☐

(A)dd (C)hange (D)elete

Relationship Name (Last, First, MI) Social Security Number Date of Birth Gender

Self - - / / Spouse - - / / Child 1 - - / / Child 2 - - / / Child 3 - - / /

SECTION 4. DECLINATION OF COVERAGE (Complete this section ONLY if declining coverage for yourself OR eligible dependents) DECLINE (Check all that apply and give reason) REASON ☐ Self ☐ Have Other Group Coverage

☐ Spouse/Child(ren) ☐ Have Other Individual Coverage ☐ Other: ______________________________________________________

I understand that if I refuse coverage now or if I later wish to enroll myself or my dependents, I will only be able to add coverage if I enroll coverage within 30 days of a Qualifying Event (see summary of plan for details). Applicant Signature: ____________________________________________________________ Date: ________________________

SECTION 5. EMPLOYEE SIGNATURE PLEASE READ PRIOR TO SIGNING – I accept the insurance provided by the Plan Sponsor and authorize the deductions in my earnings of the contribution required, if any, toward the cost of the premiums. I understand that if the prior information is not complete or is incorrect, this coverage may be terminated retroactively. I elect to participate in the section 125 Premium Only Plan established, maintained and administered by my employer. I authorize each salary payroll to be reduced on a pre-tax basis in accordance with the indicated elected benefits.

Applicant Signature: ____________________________________________________________ Date: ________________________

Plan Sponsor Group Number YWCA El Paso Del Norte Region

US/MEXICO NETWORK ☐ ☐ ☐ ☐

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GEF02-1 ADM

SUBMISSION INSTRUCTIONS After completion, make a copy for your records and return the original to

MetLife Administration, P.O. Box 14593, Lexington, KY 40512-4593 Fax MetLife at 1-888-505-7446

Page 1 of 3 EF-XDP-V008S-NW (04/14)

Metropolitan Life Insurance Company, New York, NY

ENROLLMENT • CHANGE FORM

GROUP CUSTOMER INFORMATION (To be Completed by the Recordkeeper) Name of Group Customer/Employer Group Customer # Division Class Dept Code

Date of Hire (MM/DD/YYYY) Coverage Effective Date (MM/DD/YYYY)

Original COBRA Effective Date if applicable (MM/DD/YYYY) COBRA Termination Date if applicable (MM/DD/YYYY)

YOUR ENROLLMENT INFORMATION (To be Completed by the Employee in blue or black ink)

Name (First, Middle, Last) Social Security # – –

Male Female

Single Married

Address (Street, City, State, Zip Code) Date of Birth (MM/DD/YYYY)

Employee Retiree

Job Title: Hours Worked Per Week:

New Enrollment Change in Enrollment COBRA Continuation If due to a Qualifying Event, enter date (MM/DD/YYYY)

I have read my enrollment materials and I request coverage for the benefits for which I am or may become eligible. I understand the amounts of insurance I request must comply with and are limited by the plan design described in my enrollment materials.

Dental Insurance

Select your level of coverage Employee Only Employee + Spouse 1 Employee + Child(ren) Employee + Spouse 1 + Child(ren)

Vision Insurance

Select your level of coverage Employee Only Employee + Spouse 1 Employee + Child(ren) Employee + Spouse 1 + Child(ren)

Dependent Information

If you are applying for coverage for your Spouse and/or Child(ren), please provide the information requested below: Name of your Spouse (First, Middle, Last) Date of Birth (MM/DD/YYYY)

Male Female Name(s) of your Child(ren) (First, Middle, Last) Date of Birth (MM/DD/YYYY)

Male Female Male Female Male Female Male Female

Check here if you need more lines. Provide the additional information on a separate piece of paper and return it with your enrollment form. 1 For California, Vermont and Washington State residents, Spouse includes your registered Domestic Partner if you and your Domestic Partner are

registered as domestic partners, civil union partners or reciprocal beneficiaries with a government agency or office where such registration is available.

YWCA El Paso Del Norte Region

ACCEPT_________ CHANGE________ DECLINE________ CANCEL__________

5957800

Metropolitan Life Insurance Company, New York, NY 10166

GEF09-1DEC(The form number above applies to residents of all states except as follows: Form number GEF09-1 applies to residents of Montana; GEF09-1DEC applies to residents of Connecticut, North Dakota and Utah)

TX (05/20)

Beneficiary Designation for Employee Insurance I designate the following person(s) as primary beneficiary(ies) for any amount payable upon my death for the MetLife insurance coverage applied for in this enrollment form. With such designation any previous designation of a beneficiary for such coverage is hereby revoked. I understand I have the right to change this designation at any time. I also understand that unless otherwise specified in the group insurance certificate, insurance due upon the death of a Dependent is payable to the Employee.

Check if you need more space for additional beneficiaries and attach a separate page. Include all beneficiary information, and sign/date the page.

Full Name (first, middle, last) SSN Date of birth (mm/dd/yyyy) Relationship

Address City State ZIP Phone number

Share %



Share %



Share %

Payment will be made in equal shares or all to the survivor unless otherwise indicated. Total: 100%If all the primary beneficiary(ies) die before me, I designate as contingent beneficiary(ies):Full Name (first, middle, last) Date of birth (mm/dd/yyyy)SSN Relationship

Address City ZIP Phone numberState

Share %

RelationshipFull Name (first, middle, last) Date of birth (mm/dd/yyyy)SSN

Address City ZIP Phone numberState

Share %

Payment will be made in equal shares or all to the survivor unless otherwise indicated. Total: 100%

SECTION 6: Declarations and SignatureBy signing below, I acknowledge:1. I have read this enrollment form and declare that all information I have given is true and complete to the

best of my knowledge and belief.2. I declare that I am actively at work on the date I am enrolling and, if I am enrolling for any contributory life

insurance, that I was actively at work for at least 20 hours during the 7 calendar days preceding my date of enrollment. I understand that if I am not actively at work on the scheduled effective date of insurance, such insurance will not take effect until I return to active work.

GEF09-1 FW


FRAUD WARNINGS Before signing this enrollment form, please read the warning for the state where you reside and for the state where the contract under which you are applying for coverage was issued. Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, New Mexico, Ohio, Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Maine, Tennessee, Virginia and Washington: I t is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. New Jersey: Any person who files an application containing any false or misleading information is subject to criminal and civil penalties. New York (only applies to Accident and Health Benefits): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Oregon and Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. Puerto Rico: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or files, assists or abets in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years. Pennsylvania and all other states: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

GEF09-1 DEC


DECLARATIONS AND SIGNATURE By signing below, I acknowledge: 1. I have read this enrollment form and declare that all information I have given is true and complete to the best of my knowledge and belief.2. I declare that I am actively at work on the date I am enrolling.3. I understand that if I do not enroll for dental coverage during the initial enrollment period, a waiting period may be required before I can enroll for such

coverage after the initial enrollment period has expired. I also understand that if I do not enroll for vision coverage during the initial enrollment period, Icannot enroll for such coverage until the next annual enrollment period.

4. I authorize my employer to deduct the required contributions from my earnings for my coverage. This authorization applies to such coverage until I rescind it in writing.

5. I affirmatively decline coverage for any benefits for which I am eligible which I do not request on this enrollment form. 6. I have read the applicable Fraud Warning(s) provided in this enrollment form.

Signature of Employee Print Name Date Signed (MM/DD/YYYY)

Sign Here

EMPLOYEE BENEFIT ENROLLMENT SELECTION FORM...EMPLOYEE BENEFIT ENROLLMENT SELECTION FORM NAME (Please...

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