THE HARTFORD – LEGAL NOTICES

Contents ABOUT YOUR PRIVACY ......................................................................................................................................3

SUMMARY OF BENEFITS AND COVERAGE .........................................................................................................4

HEALTH INSURANCE MARKETPLACE NOTICE ....................................................................................................5

IMPORTANT INFORMATION: WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998 ....................................7

SPECIAL NOTICE OF ENROLLMENT RIGHTS UNDER THE HEALTH INSURANCE PORTABILITY AND

ACCOUNTABILITY ACT (HIPAA) ..........................................................................................................................8

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) PRIVACY NOTICE ..............................9

PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) .. 16

NOTICE TO EMPLOYEES ON COBRA, LEAVE OR SEVERANCE .......................................................................... 21

IMPORTANT NOTICE FROM THE HARTFORD ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND MEDICARE

(NOTICE OF CREDIBLE COVERAGE) ................................................................................................................. 22

FIDELITY HSA .................................................................................................................................................. 25

ABOUT YOUR PRIVACY

Your personal information will remain secure and confidential, in accordance with The Hartford’s Notice of Privacy Practices. “Protected health information” under the Health Insurance Portability and Accountability Act (HIPAA) may only be used or disclosed without your authorization for purposes of treatment, payment or health care operations. For example, a use or disclosure for purposes of health care operations would include sharing the information with vendor partners that provide services on behalf of The Hartford’s medical plans. Neither the medical plan nor any of its vendors will disclose any of your individually identifiable health information to The Hartford. However, The Hartford may receive from its vendors aggregated de-identified data in the form of reports that help The Hartford better understand the health status of its medical plan participants. For example, these reports may tell us how many participants are smokers or have diabetes. With this information, The Hartford can develop health and wellness initiatives that are most helpful to its employees and retirees. The Plan’s Notice of Privacy Practices is available in the Reference Library on Fidelity’s NetBenefits or by making a written request to: HIPAA Privacy Officer, HR Compliance, One Hartford Plaza, Hartford, CT 06155 or via e-mail: compliance.hr@thehartford.com.

SUMMARY OF BENEFITS AND COVERAGE

As required under health care reform legislation, Summaries of Benefits and Coverage (SBC) and a Uniform Glossary of Health Coverage and Medical Terms are available to assist you in understanding your health plan coverage or plans that you may be eligible for. SBCs and a link to the Uniform Glossary can be found under Plan Details on NetBenefits at www.netbenefits.com/thehartford or at http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf. To request a printed copy of SBC(s) or the Uniform Glossary, contact The Hartford HR Service Center at 1-877-HR-AT-WORK.

HEALTH INSURANCE MARKETPLACE NOTICE

The Affordable Care Act (the “Act”) requires The Hartford to send you this notice to provide basic information about the Health Insurance Marketplace coverage options and the employment-based health coverage offered by The Hartford.

What is the Health Insurance Marketplace? The Marketplace is designed to help all U.S. citizens find health insurance that meets their needs and fits their budget. It offers "one-stop shopping" to find and compare individual private health insurance options. Based on their household income, some people may also be eligible for a new kind of tax credit that lowers their monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in November for coverage starting as early as January 1.

Who is eligible for Health Insurance offered by The Hartford? The Hartford offers health coverage to all employees on its payroll who work at least 20 hours a week (unless the employee’s position is specifically excluded from coverage), and to spouses, domestic partners and eligible children.*

Does employer health coverage affect eligibility for premium savings through the Marketplace? Yes. Because The Hartford offers its employees health coverage that meets the law’s standards, if you are eligible for coverage from The Hartford, you may not be eligible for a tax credit through the Marketplace, and you may wish, instead, to enroll in one of The Hartford’s health plan options.

The coverage offered by the company to its employees meets the law’s requirements for: “Minimum value” since the plan covers at least 60% - on average across the plan - of an employee’s health care costs in a given year; and “Affordability,” meaning an employee’s share of the premium is not more than 9.5% of his or her annual household income.

Please consider the following: If you enroll in the health coverage offered by The Hartford to its employees, the company contributes over 70% of your premium amount, depending on the option you select. You will lose this company contribution if you purchase coverage through the Marketplace. If you enroll in the health coverage offered by The Hartford, you can pay for that coverage on a pre-tax basis, lowering your taxable income. The portion the company pays is also not taxable to you. If you purchase coverage through the Marketplace, your payment for coverage is made on an after-tax basis.

Additional Information Health Insurance Marketplace: Visit https://www.healthcare.gov/ for information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area. Your Marketplace resource can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost.

The Hartford Health Care Plan: The Summary Plan Descriptions in the Reference Library on NetBenefits (www.netbenefits.com/thehartford.com) contain detailed information about The Hartford’s health plan options. You may also contact The Hartford HR Service Center at 1.877.HR.AT.WORK (1-877-472-8967) to speak with a Customer Service Associate. If you do decide to apply for coverage in the Marketplace, the following information will be useful in completing the Employer Information section:

Employer Name: The Hartford Financial Services Group Employer Identification Number (EIN): 06-0383750 Employer Address: One Hartford Plaza, T-1-173

Hartford, CT 06155 Employer Phone Number: (860) 547-5000 Who the Marketplace may contact: The Hartford HR Compliance Department Contact Phone Number: (860) 547-9087 Contact Email Address: compliance.hr@thehartford.com The Hartford offers a health plan to all employees on its payroll who work more than 20 hours a week, unless the employee’s position is specifically excluded from coverage, and to all spouses, domestic partners and eligible children.∗ The Hartford’s coverage meets the minimum value standard and the cost of coverage is intended to be affordable based upon employee wages. Complete information regarding eligibility for The Hartford’s health coverage can be found in the Summary Plan Descriptions in the Reference Library on NetBenefits (www.netbenefits.com/thehartford) or by calling The Hartford HR Service Center at 1.877.HR.AT.WORK (1-877-472-8967)

http://www.netbenefits.com/thehartford.com)mailto:compliance.hr@thehartford.comhttp://www.netbenefits.com/thehartford)http://1.877.hr.at/

IMPORTANT INFORMATION: WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998

(Federal law requires that this information be provided annually.)

The “Women’s Health and Cancer Rights Act of 1998” requires that all group health plans that

provide medical and surgical benefits with respect to a mastectomy must provide coverage for:

reconstruction of the breast on which the mastectomy has been performed

surgery and reconstruction of the other breast to produce a symmetrical appearance

prostheses and treatment of physical complications of all stages of mastectomy,

including lymphedema

These services must be provided in a manner determined in consultation with the attending

physician and the patient. This coverage may be subject to annual deductibles and coinsurance

provisions applicable to other such medical and surgical benefits provided under the plan. Please

refer to your Summary Plan Description for deductibles and coinsurance information app licable

to the plan option in which you choose to enroll.

SPECIAL NOTICE OF ENROLLMENT RIGHTS UNDER THE HEALTH INSURANCE

PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

Current Employees If you are a current employee of The Hartford and decline enrollment in The Hartford’s medical, dental and/or vision plans 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 The Hartford’s plans if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

If you are a current employee of The Hartford and 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 within 31 days after the marriage, birth, adoption, or placement for adoption.

In addition, you may be able to enroll yourself and your dependents in The Hartford’s medical, dental and/or vision plans if your or your dependents’ coverage under a Medicaid plan or a State Children’s Health Insurance Program (CHIP) plan terminates due to loss of eligibility for such coverage or if you or your dependent(s) become eligible for premium assistance under a Medicaid plan or a CHIP plan. However, you must request enrollment within 60 days of losing coverage under a Medicaid or CHIP plan or being determined to be eligible for premium assistance.

For plan provisions applicable to disabled dependents, refer to your Summary Plan Descriptions available on NetBenefits®.

Enrollment Information To request special enrollment or obtain more information, log on to NetBenefits for The Hartford HR Service Center at www.netbenefits.com/thehartford. If you do not have Internet access, call The Hartford HR Service Center at 1.877.HR.AT.WORK (1-877-472-8967), Monday through Friday (excluding New York Stock Exchange holidays) between 8:30 A.M. and midnight, Eastern time to speak with a Customer Service Associate.

http://www.netbenefits.com/thehartford

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) PRIVACY

NOTICE

NOTICE OF PRIVACY PRACTICES Effective September 1, 2019

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) imposes numerous requirements on employer health plans and their vendor partners concerning the use and disclosure of individual health information. This information, known as protected health information (“PHI”), includes virtually all individually identifiable health information held by a health plan — whether received in writing, in an electronic medium, or as an oral communication. This notice describes the legal duties related to your PHI, and the general privacy practices of the following self-funded health plans:

The Hartford Fire Insurance Company Employee Medical and Dental Expense Benefits Plan, of which The Hartford’s Health & Well-Being Centers are a part

The Hartford Health Reimbursement Account

The Hartford Fire Insurance Company Health Care Reimbursement Plan

The Hartford Fire Insurance Company Limited Purpose Flexible Spending Account Plan

Employee Assistance Program

These plans are collectively referred to as the “Health Plans” in this notice, unless specified otherwise. Because The Hartford is the common Plan Sponsor of all the Health Plans listed above, the Health Plans constitute an “organized health care arrangement” (“OHCA”) under federal law. As an OHCA, the Health Plans are permitted to use one common Notice of Privacy Practices distributed to all participants in the Health Plans. The Health Plans covered by this notice may share health information with each other to carry out certain purposes defined by the Standards for Privacy of Individually Identifiable Health Information issued pursuant to HIPAA (the “Privacy Rules”). If you participate in an insured health plan option, which is a health plan where the financial risk is borne by the insurer rather than the employer, your notice is provided directly to you by the insurer.

A. The Health Plans’ duties with respect to your PHI The Health Plans are required by law to maintain the privacy of your PHI, to notify you following a breach of unsecured PHI, and to provide you with this notice of the Health Plan’s legal duties and privacy practices with respect to your PHI. The Health Plans must abide by the terms of this notice as currently in effect. It is important to note that these rules apply to the Health Plans, not The Hartford as an employer. The Hartford has different policies that apply to data unrelated to the Health Plans.

B. How the Health Plans may use or disclose your PHI The Health Plans are required to disclose your PHI to you, when you exercise your right of access or to an accounting (see Section E below), and to the Secretary of the U.S. Department of Health and Human Services, when requested for the purposes of an investigation or a determination of the Health Plans’ compliance with federal privacy law. In addition, the Privacy Rules generally allow the use and disclosure of your PHI without your written permission (or “authorization”) for purposes of treatment, payment, and health care operations activities. Here are some examples of those activities: Treatment includes providing, coordinating, or managing health care by one or more health care providers or doctors. For example, the Health Plans may share your PHI with physicians who are treating you. Payment includes activities by the Health Plans to obtain premiums, make coverage determinations, and provide reimbursement for health care. This can include eligibility determinations, reviewing services for medical necessity or appropriateness, utilization management activities, claims management, and billing. For example, the Health Plans may share information about your coverage or the expenses you have incurred with another health plan in order to coordinate payment of benefits. Health Care Operations include activities by the Health Plans such as wellness and risk assessment programs, quality assessment and improvement activities, customer service, and internal grievance resolution. For example, the Health Plans may use information about your claims to review the effectiveness of wellness programs. The amount of PHI used or disclosed will be limited to the “Minimum Necessary” for these purposes, as defined under the Privacy Rules. If the Health Plans use or disclose PHI for underwriting purposes, they are prohibited from using or disclosing your genetic information for such purposes.

C. How the Health Plans may share your PHI with The Hartford The Health Plans, or their third party administrators (such as UnitedHealthcare, Delta Dental and OptumRx), may disclose your PHI without your written authorization to a limited number of staff at The Hartford for plan administration purposes. The Hartford agrees not to use or disclose your PHI other than as permitted or required by the Health Plans’ documents and by law. Only designated employees in The Hartford’s Total Rewards Department, their legal advisors, and the HIPAA Privacy Officer will have access to your PHI. The Hartford cannot and will not use PHI obtained from the Health Plans for any employment-related actions. Here is how additional information may be shared between the Health Plans and The Hartford, as permitted by the Privacy Rules: The Health Plans, or their third party administrators, may disclose “summary health information” to The Hartford, if requested, for purposes of obtaining premium bids to provide coverage under the Health Plans; for modifying, amending, or terminating the Health Plans; for reviewing trends in health care claims to direct health management activities; or to evaluate health management program effectiveness. Summary health information is information that summarizes participants’ claims information, but from which names and other identifying information have been removed. The Health Plans, or their third party

administrators, may disclose to The Hartford information on whether an individual is participating in the Health Plans, or has enrolled or disenrolled in a coverage option offered by the Health Plans.

D. Other allowable uses or disclosures of your PHI In certain cases, your PHI can be disclosed, without your written authorization, to a family member, close friend, or other person you identify, who is involved in your care or payment for your care. Information describing your location, general condition, or death may be provided to a similar person or to a public or private entity authorized to assist in disaster relief efforts. You will generally be given the chance to agree to or object to these disclosures, although exceptions may be made, for example, if you are not present or if you are incapacitated. In addition, your PHI may be disclosed, without your written authorization, to your legal representative. The Health Plans are also allowed to use and/or disclose your PHI, without your written authorization, for the following activities:

As required by law The Health Plans will share information about you if state or federal laws require it

Address workers’ compensation, law enforcement, and other government requests

The Health Plans can use or share information about you:

For workers’ compensation claims For law enforcement purposes or with a law enforcement

official With health oversight agencies for activities authorized by

law For special government functions such as military,

national security, and presidential protective services

Help with public health and safety issues

The Health Plans can share information about you to prevent or lessen a serious or imminent threat to public or personal health or safety, including in the following situations:

Preventing disease Helping with product recalls Reporting adverse reactions to medications Reporting suspected abuse, neglect, or domestic violence Preventing or reducing a serious threat to anyone’s health or

safety

Respond to lawsuits and legal actions

The Health Plans can share information about you in response to a court or administrative order, or in response to a subpoena

Respond to organ and tissue donation requests and work with a medical examiner or funeral director Research purposes

The Health Plans can share information about you with organ procurement organizations or other entities to facilitate organ, eye, or tissue donation and transplantation after death. The Health Plans can also share information with a coroner, medical examiner, or funeral director when an individual dies. The Health Plans can use or share your information for health research

Except as described in this notice, other uses and disclosures will be made only with your written authorization. For example, most uses and disclosures of psychotherapy notes, most uses and disclosures of PHI for marketing purposes, and those disclosures that constitute a sale of PHI, require your written authorization. You may revoke your authorization as allowed under the Privacy Rules. However, you cannot revoke your authorization if the Health Plans have taken action relying on it. In other words, you cannot revoke your authorization with respect to disclosures that have already been made. You will be notified of any unauthorized access, use, or disclosure of your unsecured health information as required by law.

E. Your individual rights

You have the following rights with respect to your PHI that the Health Plans maintain. These rights are subject to certain limitations, as described below. In order to exercise any of these rights, you must notify the Privacy Officer in writing (see Section H of this notice for contact information).

1. Right to request restrictions on certain uses and disclosures of your PHI and the Health Plans’ right to refuse

You have the right to ask the Health Plans not to use or disclose your PHI for treatment, payment or health care operations, except for those uses or disclosures that are required by law. The Health Plans are not required to agree to a requested restriction, except that if you are competent you may restrict disclosures to family members and friends. And, if the Health Plans do agree, a restriction may later be terminated by your written request, by agreement between you and the Health Plans, or unilaterally by the Health Plans for PHI created or received after you have been notified that the restriction has been removed. The Health Plans may also disclose your PHI if you need emergency treatment, even if the Health Plans have agreed to a restriction. If you pay out-of-pocket in full for a health care item or service, and you do not want us to disclose PHI about that item or service to the Health Plans for purposes of payment or health care operations, we must comply with your request.

2. Right to receive confidential communications of your PHI

You have the right to ask the Health Plans to contact you in a specific way or to send mail to a different address. The Health Plans will consider all reasonable requests, and must agree if you tell us that disclosure of your PHI by the usual means could endanger you in some way.

3. Right to inspect and copy your PHI

With certain exceptions, you have the right to inspect or obtain a copy of your PHI in a “Designated Record Set.” A Designated Record Set may include medical and billing records maintained by a health care provider; enrollment, payment, claims adjudication, and case or medical management record systems maintained by a plan; or a group of records each plan uses to make decisions about individuals. However, you do not have a right to inspect or obtain copies of psychotherapy notes or information compiled for civil, criminal, or administrative proceedings. In addition, the Health Plans may deny your right to access, although in certain circumstances you may request a review of the denial.

Within thirty (30) days of receipt of a request to inspect or copy PHI, the Health Plans will provide you with:

The access or copies you requested;

A written denial that explains why your request was denied and any rights you may have to have the denial reviewed or to file a complaint; or

A written statement that the time period for reviewing your request will be extended for no more than thirty (30) days, along with the reasons for the delay and the date by which the Health Plans expect to address your request.

If the Health Plans do not maintain the PHI but know where it is maintained, you will be informed of where to direct your request.

1. Right to amend your PHI that is inaccurate or incomplete

With certain exceptions, you have a right to request that the Health Plans amend your PHI in a Designated Record Set. The Health Plans may deny your request for a number of reasons. For example, your request may be denied if the PHI is accurate and complete, was not created by the Health Plans, is not part of the Designated Record Set, or is not available for inspection (e.g., psychotherapy notes or information compiled for civil, criminal, or administrative proceedings).

Within sixty (60) days of receipt of a request to amend PHI, the Health Plans will: Make the amendment as requested;

Provide a written denial that explains why your request was denied and any rights you may have to disagree or file a complaint; or

Provide a written statement that the time period for reviewing your request will be extended for no more than thirty (30) days, along with the reasons for the delay and the date by which the Health Plans expect to address your request.

2. Right to receive an accounting of disclosures of your PHI

You have the right to a list of certain disclosures the Health Plans have made of your PHI. This is often referred to as an “accounting of disclosures.” Unless otherwise indicated below, you generally may receive an accounting of disclosures if the disclosure is required by law, if the disclosure is made in connection with public health activities, or in similar situations listed in the above table of allowable uses and disclosures.

You may receive information on disclosures of your PHI going back for six (6) years from the date of your request. You do not have a right to receive an accounting of certain disclosures, including (but not limited to) those made: for treatment, payment, or health care operations; to you about your own PHI; where a written authorization was provided; to family members or friends involved in your care; for national security or intelligence purposes; or as part of a limited data set.

Within sixty (60) days of receipt of a request for an accounting of disclosures, the Health Plan will:

Provide you with the list of disclosures, or provide a written statement that the time period for providing this list will be extended for no more than thirty (30) days, along with the reasons for the delay and the date by which the Health Plans expect to address your request.

You may make one request in any 12-month period at no cost to you, but the Health Plans may charge a fee for subsequent requests. You will be notified of the fee in advance and have the opportunity to change or revoke your request.

6. Right to obtain a paper copy of this notice from the Health Plans upon request

You have the right to obtain a paper copy of this notice upon request. Even individuals who agreed to receive this notice electronically may request a paper copy at any time.

F. Changes to the information in this notice

The Health Plans must abide by the privacy notice currently in effect. The Health Plans reserve the right to change their privacy practices and to change the terms of this notice to reflect those changed practices. The Health Plans reserve the right to make the new notice provisions effective for all PHI that the Health Plans maintain. This includes health information that was previously created or received, not just health information created or received after the policy is changed. If the Health Plans make a material change to the permitted or required uses and/or disclosures of your PHI, or your rights as explained in this notice, the Health Plans will distribute a revised notice within sixty (60) days of the change.

G. Complaints

If you believe your privacy rights have been violated by the Health Plans, you may file a complaint by contacting the Privacy Officer (refer to Section H of this notice for contact information). You may also write to the Secretary of Health and Human Services. The Health Plans will not retaliate against you for filing a complaint.

H. Contact

If you have questions about this notice, wish to exercise any of your rights under Section E, or would like more information about the Health Plans’ privacy practices, please contact:

Mailing address: HIPAA Privacy Officer c/o HR Compliance One Hartford Plaza Hartford, CT 06155 E-mail: compliance.hr@thehartford.com Telephone: (860) 547-9087

mailto:compliance.hr@thehartford.com

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 1877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

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

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

ALABAMA – Medicaid FLORIDA – Medicaid

Website: http://myalhipp.com/

Phone: 1-855-692-5447

Website: http://flmedicaidtplrecovery.com/hipp/

Phone: 1-877-357-3268

ALASKA – Medicaid GEORGIA – Medicaid

The AK Health Insurance Premium Payment Program

Website: http://myakhipp.com/

Phone: 1-866-251-4861

Email: CustomerService@MyAKHIPP.com

Medicaid Eligibility:

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

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

Phone:

ARKANSAS – Medicaid INDIANA – Medicaid

http://www.healthcare.gov/http://www.insurekidsnow.gov/http://www.askebsa.dol.gov/http://myalhipp.com/http://flmedicaidtplrecovery.com/hipp/http://myakhipp.com/mailto:CustomerService@MyAKHIPP.comhttp://dhss.alaska.gov/dpa/Pages/medicaid/default.aspxhttps://medicaid.georgia.gov/health-insurance-premium-payment-program-hipphttps://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp

Website: http://myarhipp.com/

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

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

COLORADO – Health First Colorado (Colorado’s Medicaid

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

Health First Colorado Website:

https://www.healthfirstcolorado.com/

Health First Colorado Member Contact Center:

1-800-221-3943/ State Relay 711

CHP+: www.Colorado.gov/HCPF/Child-Health-Plan-Plus

CHP+ Customer Service: 1-800-359-1991/

State Relay 711

Website:

http://dhs.iowa.gov/hawk-i

Phone: 1-800-257-8563

KANSAS – Medicaid NEW HAMPSHIRE – Medicaid

Website: http://www.kdheks.gov/hcf/

Phone: 1-785-296-3512

Website: https://www.dhhs.nh.gov/ombp/nhhpp/

Phone: 603-271-5218

Toll free number for the HIPP program: 1-800-8523345,

ext 5218

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP

Website: https://chfs.ky.gov

Phone: 1-800-635-2570

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

LOUISIANA – Medicaid NEW YORK – Medicaid

Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331

Phone: 1-888-695-2447

Website:

https://www.health.ny.gov/health_care/medicaid/

Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – Medicaid

http://myarhipp.com/http://www.in.gov/fssa/hip/http://www.indianamedicaid.com/https://www.healthfirstcolorado.com/http://www.colorado.gov/HCPF/Child-Health-Plan-Plushttp://dhs.iowa.gov/hawk-ihttp://dhs.iowa.gov/hawk-ihttp://www.kdheks.gov/hcf/https://www.dhhs.nh.gov/ombp/nhhpp/https://chfs.ky.gov/http://www.state.nj.us/humanservices/dmahs/clients/medicaid/http://www.state.nj.us/humanservices/dmahs/clients/medicaid/http://www.njfamilycare.org/index.htmlhttp://dhh.louisiana.gov/index.cfm/subhome/1/n/331https://www.health.ny.gov/health_care/medicaid/

Website: http://www.maine.gov/dhhs/ofi/public-

assistance/index.html

Phone: 1-800-442-6003

TTY: Maine relay 711

Website: https://dma.ncdhhs.gov/

Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid

Website:

http://www.mass.gov/eohhs/gov/departments/masshealth/

Phone: 1-800-862-4840

Website:

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

/

Phone: 1-844-854-4825

MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP

Website:

https://mn.gov/dhs/people-we-serve/seniors/health-

care/health-care-programs/programs-and-services/other-

insurance.jsp

Phone: 1-800-657-3739

Website: http://www.insureoklahoma.org

Phone: 1-888-365-3742

MISSOURI – Medicaid OREGON – Medicaid

Website:

http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

Phone: 573-751-2005

Website:

http://healthcare.oregon.gov/Pages/index.aspx

http://www.oregonhealthcare.gov/index-es.html

Phone: 1-800-699-9075

MONTANA – Medicaid PENNSYLVANIA – Medicaid

Website:

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

Phone: 1-800-694-3084

Website:

http://www.dhs.pa.gov/provider/medicalassistance/he

althinsurancepremiumpaymenthippprogram/index.ht

m

Phone: 1-800-692-7462

NEBRASKA – Medicaid RHODE ISLAND – Medicaid

Website: http://www.ACCESSNebraska.ne.gov

Phone: (855) 632-7633

Lincoln: (402) 473-7000

Omaha: (402) 595-1178

Website: http://www.eohhs.ri.gov/

Phone: 855-697-4347

NEVADA – Medicaid SOUTH CAROLINA – Medicaid

Medicaid Website: http://dhcfp.nv.gov

Medicaid Phone: 1-800-992-0900

Website: https://www.scdhhs.gov

Phone: 1-888-549-0820

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid

http://www.maine.gov/dhhs/ofi/public-assistance/index.htmlhttp://www.maine.gov/dhhs/ofi/public-assistance/index.htmlhttps://dma.ncdhhs.gov/http://www.mass.gov/eohhs/gov/departments/masshealth/http://www.nd.gov/dhs/services/medicalserv/medicaid/http://www.nd.gov/dhs/services/medicalserv/medicaid/https://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/other-insurance.jsphttps://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/other-insurance.jsphttps://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/other-insurance.jsphttp://www.insureoklahoma.org/http://www.dss.mo.gov/mhd/participants/pages/hipp.htmhttp://healthcare.oregon.gov/Pages/index.aspxhttp://www.oregonhealthcare.gov/index-es.htmlhttp://dphhs.mt.gov/MontanaHealthcarePrograms/HIPPhttp://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htmhttp://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htmhttp://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htmhttp://www.accessnebraska.ne.gov/http://www.eohhs.ri.gov/http://dhcfp.nv.gov/https://www.scdhhs.gov/

To see if any other states have added a premium assistance program since July 31, 2019, or for more

information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services

Employee Benefits Security Administration Centers for Medicare & Medicaid Services

www.dol.gov/agencies/ebsa www.cms.hhs.gov

1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Website: http://dss.sd.gov

Phone: 1-888-828-0059

Website: http://www.hca.wa.gov/free-or-low-cost-

health-care/program-administration/premium-

payment-program

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

TEXAS – Medicaid WEST VIRGINIA – Medicaid

Website: http://gethipptexas.com/

Phone: 1-800-440-0493

Website: http://mywvhipp.com/

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

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP

Medicaid Website: https://medicaid.utah.gov/

CHIP Website: http://health.utah.gov/chip

Phone: 1-877-543-7669

Website:

https://www.dhs.wisconsin.gov/publications/p1/p1009

5.pdf

Phone: 1-800-362-3002

VERMONT– Medicaid WYOMING – Medicaid

Website: http://www.greenmountaincare.org/

Phone: 1-800-250-8427

Website: https://wyequalitycare.acs-inc.com/

Phone: 307-777-7531

VIRGINIA – Medicaid and CHIP

Medicaid Website:

http://www.coverva.org/programs_premium_assistance.cfm

Medicaid Phone: 1-800-432-5924

CHIP Website:

http://www.coverva.org/programs_premium_assistance.cfm

CHIP Phone: 1-855-242-8282

http://www.dol.gov/agencies/ebsahttp://www.cms.hhs.gov/http://dss.sd.gov/http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-programhttp://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-programhttp://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-programhttp://gethipptexas.com/http://mywvhipp.com/https://medicaid.utah.gov/http://health.utah.gov/chiphttps://www.dhs.wisconsin.gov/publications/p1/p10095.pdfhttps://www.dhs.wisconsin.gov/publications/p1/p10095.pdfhttp://www.greenmountaincare.org/https://wyequalitycare.acs-inc.com/http://www.coverva.org/programs_premium_assistance.cfmhttp://www.coverva.org/programs_premium_assistance.cfm

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to

respond to a collection of information unless such collection displays a valid Office of Management and

Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a

collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB

control number, and the public is not required to respond to a collection of information unless it displays a

currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of

law, no person shall be subject to penalty for failing to comply with a collection of information if the

collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately seven

minutes per respondent. Interested parties are encouraged to send comments regarding the burden

estimate or any other aspect of this collection of information, including suggestions for reducing this

burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and

Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington,

DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

NOTICE TO EMPLOYEES ON COBRA, LEAVE OR SEVERANCE

In general, the benefits described in this guide apply to active employees. If you are on COBRA, Leave or

Severance, please refer to your Personal Fact Sheet to review the benefits for which you are eligible.

IMPORTANT NOTICE FROM THE HARTFORD ABOUT YOUR PRESCRIPTION DRUG

COVERAGE AND MEDICARE (NOTICE OF CREDIBLE COVERAGE)

Please read this notice carefully and keep it where you can find it. This Notice has information about your

current prescription drug coverage with The Hartford and prescription drug coverage available for

individuals with Medicare. It also tells you where to find more information to help you make decisions

about your prescription drug coverage.

Starting January 1, 2006, Medicare prescription drug coverage became available to everyone with

Medicare through Medicare prescription drug plans. This Medicare coverage is separate from The

Hartford’s medical plans.

The Hartford has determined that the prescription drug coverage offered under the following Hartford

health plan options is, on average for all plan participants, expected to pay out as much as the standard

Medicare prescription drug coverage will pay: the Consumer-Directed Health Plan– Value (CDHP-Value),

Consumer-Directed Health Plan–Standard (CDHP-Standard), Consumer Directed Health Plan – Basic (CDHP-

Basic), the Exclusive Provider Organization option (EPO) and the Traditional Plan options.

Because coverage offered by The Hartford under these options is, on average, at least as good as standard

Medicare prescription drug coverage, it is considered “creditable coverage” by Medicare. Therefore, you

can keep the coverage offered under any of these options and not pay a late enrollment penalty if you

later decide to enroll in Medicare prescription drug coverage.

You should also know that if you (or your dependent eligible for Medicare coverage) drop or lose coverage

with The Hartford and do not enroll in Medicare prescription drug coverage after your coverage under one

of The Hartford’s health plan options ends, you (or your dependent eligible for Medicare coverage) may

pay more (a penalty) to enroll in Medicare prescription drug coverage later. If you or your eligible

dependent go 63 days or longer without prescription drug coverage that is at least as good as Medicare’s

prescription drug coverage, the monthly Medicare prescription drug premium will go up at least 1% per

month for every month that you or your eligible dependent did not have that coverage. For example, if you

go 19 months without coverage, your premium will always be at least 19% higher than what many other

people pay. You’ll have to pay this higher premium as long as you have Medicare coverage. In addition,

you may have to wait until the next election period to enroll.

Read This Notice Carefully

Read this Notice carefully—it explains the options you have under Medicare prescription drug coverage,

and can help you decide whether or not you want to enroll in a new Medicare prescription drug plan.

Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare

and each year thereafter from October 15th through December 7th. All Medicare prescription drug plans

provide at least a standard level of coverage set by Medicare. Some plans might also offer more coverage

for a higher monthly premium. You should compare your current coverage under The Hartford’s health

plan option, including which drugs are covered, with the coverage and cost of the plans offering Medicare

prescription drug coverage in your area.

Remember, The Hartford’s health plan options pay for other health expenses, in addition to prescription

drugs.

For More Information about This Notice or Your Current Prescription Drug Coverage For questions about

this Notice, call The Hartford HR Service Center at

1.877.HR.AT.WORK (1-877-472-8967). For questions about prescription drug coverage under any of The

Hartford’s health plan options, contact OptumRx Customer Service at 1¬844-368-8712.

NOTE: You may receive this Notice annually at other times in the future, such as before the next period in

which you can enroll in Medicare prescription drug coverage, and if coverage through The Hartford

changes. You also may request a copy.

More detailed information about Medicare plans that offer prescription drug coverage is available 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 prescription drug plans. For more information about Medicare

prescription drug plans:

Visit www.medicare.gov

Call your State Health Insurance Assistance Program (see your copy of the Medicare & You

handbook for the telephone number) for personalized help

Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

For some people with income and resources below certain levels, extra help paying for a Medicare

prescription drug plan is available. Information about this extra help is available from the Social Security

Administration (SSA) online at www.socialsecurity.gov, or you may call them at 1-800¬772-1213 (TTY 1-

800-325-0778).

http://www.medicare.gov/

Important Note: If you received this notice electronically, it is your responsibility to provide a copy of this

notice to your Medicare-eligible dependents who are covered by The Hartford’s medical plans.

Remember: Keep this Notice.

If you enroll in one of the plans approved by Medicare which offer prescription drug coverage, you may be

required to provide a copy of this Notice when you join to show that you are not required to pay a late

enrollment penalty (i.e. a higher premium amount).

Date: September 1, 2019

Name of Entity/Sender: The Hartford

Contact--Position/Office: Karen Howard, Plan Administrator

Address: One Hartford Plaza

Hartford, CT 06155

This information has been provided by The Hartford and is the sole responsibility of The Hartford.

FIDELITY HSA

Your Fidelity HSA is a brokerage account. Under federal law, an application must be completed for each

brokerage account opened. Your completed application must be submitted and approved before your

Fidelity HSA can be opened. You will receive a New Account Profile from Fidelity Personal Investments

confirming your HSA application has been approved. At that time, you will be able to view your account on

NetBenefits.com and Fidelity.com.