Benefits Open Enrollment Larimer County 2017 Plan Year

It’s That Time Again!! DURING OPEN ENROLLMENT, YOU CAN:

Open

Enrollment Dates: NOVEMBER 2 - 18, 2016

• Add, drop, or change coverage for any Larimer County benefit for yourself or your family. • Enroll in a Flexible Spending Account (FSA) • Supplemental Life and Voluntary Accidental Death & Dismemberment can be enrolled in, or changed, at any time.

Your health.Your money. Your choice.

Table of Contents

Open Enrollment Instructions........................................................................................................................................................................................3 Open Enrollment Meeting Schedule..........................................................................................................................................................................4 What's Changing for 2017...............................................................................................................................................................................................4 Where can I find more benefits information?....................................................................................................................................................... 5

Benefits Cost Summary Full-Time Employees......................................................................................................................................................................................................6 Part-Time Employees..................................................................................................................................................................................................... 7 Wellness Rate Criteria.........................................................................................................................................................................................................8 Physician's Statement................................................................................................................................................................................................ 10 Medical Benefit Overview................................................................................................................................................................................................ 11 Dental Benefit Overview.................................................................................................................................................................................................. 14 Vision Benefit Overview...................................................................................................................................................................................................15 Short & Long Term Disability...................................................................................................................................................................................... 16 Basic Life/Accidental Death & Dismemberment..........................................................................................................................................17 VOLUNTARY BENEFITS Voluntary Supplemental Term Insurance....................................................................................................................................................... 18 Voluntary Accidental Death & Dismemberment...................................................................................................................................... 18 Flexible Spending Accounts................................................................................................................................................................................... 19 AFLAC.................................................................................................................................................................................................................................... 21 ANNUAL NOTICES............................................................................................................................................................................................................. 22 Medicare Part D Notice.................................................................................................................................................................................................. 23 HIPAA Comprehensive Notice of Privacy Policy & Procedures.........................................................................................................25 Special Enrollment Notice........................................................................................................................................................................... 28 Women's Health and Cancer Rights of 1998................................................................................................................................ 28 Notice of No Obligation for Pre-Authorization for OB/Gyn Care..................................................................................... 29 Premium Assistance under Medicaid and the Children's Health Ins. Program..............................................................................................................30 Benefit Vendor Contact Information.......................................................................................................................................................................................................................................32

IMPORTANT:

If you neglect to complete open enrollment, the benefits you are enrolled in on December 31, 2016 will continue for 2017. Remember, after the open enrollment deadline, you cannot make any changes to your benefits until a future Open Enrollment, unless you have a qualified status change.

Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

Page 2 of 32

Open Enrollment Instructions

1. Do I have to complete open enrollment this year?

No. If you are not changing your benefits, you do not need to do anything. Your current benefits will carry over to the new plan year. However, it is strongly recommended that you review and confirm your benefits annually, especially if you have had changes in your family status within the last year.

2. Where can I find the online enrollment website? The Quick Link to the online enrollment can be found on the Bulletin Board homepage. Click on the Benefits tab, then Health & Welfare. You can also complete your on-line Open Enrollment by logging into the ADP portal from any internet connection: https://portal.adp.com . The on-line enrollment process will allow you to continue to make changes to your enrollment selections, even after you’ve confirmed elections, until the deadline date. Be sure to “Confirm Elections”. If you do not, your new elections will not be saved. At completion, be sure to print or save your confirmation.

3. Who is eligible for coverage? • Your legal spouse by marriage. Common law spouses are also eligible. A Common Law Marriage Affidavit is required and is considered a binding legal agreement. • Dependent children under the age of 26. • An unmarried child of any age who is medically certified as disabled and dependent upon you for their total support. • Children placed for adoption or for whom you have obtained legal guardianship. • A child for whom health care coverage is required through a Qualified Medical Support Order.

4. Where can I find a list of my current benefits? You can find a list of your current benefits on the ADP portal , and you can view them when you make your Open Enrollment elections.

5. How do I find out if I qualified for the Wellness (discounted) Rate? If you qualified, it will be indicated when you pull up your personal benefits record during open enrollment. The discounted rates will be shown when you are selecting your medical coverage. IMPORTANT: Final cut-off date for contacting Human Resources with a dispute, if you aren’t receiving the Wellness Rate in 2017, and you feel you qualify: January 27, 2017.

6. What do I need to do if I’m enrolled in Aflac? If you have no changes, you don’t need to do anything. Your current benefits will carry over to the new plan year. Contact Amy Griffin, the Aflac associate, at 530-1208 to add, drop, or change any Aflac coverage.

Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

Page 3 of 32

Open Enrollment Meetings OPEN ENROLLMENT MEETINGS WILL NOT BE HELD THIS YEAR DUE TO PAST LOW PARTICIPATION. However, Benefits staff will have open office hours on the following days to meet with employees to answer any questions.

TOPIC

PREMIUMS

MEDICAL INSURANCE

What's Changing in 2017

OVERVIEW OF CHANGES

Medical Insurance: Rates will increase, due in large part to substantial increases in prescription drug costs and medical treatment for chronic diseases. See Benefits Cost Summary, page 7.   Delta Dental Plan: Rates will increase slightly. See Benefits Cost Summary.   No Change in Rates for: Vision Service Plan Supplemental Term Life Insurance Voluntary Accidental Death & Dismemberment

Copay changes: Office Visit: $25 - Includes primary care physician, vision exam, and out-patient physical therapy, speech, hearing and occupational therapy, and out-patient mental health/substance abuse. Specialist Office Visit: $50 Urgent Care: $50 Emergency Room: $200, doesn’t include x-ray Specialty Rx: $100, limited to 30-day supply

HEALTHCARE FLEXIBLE Contribution maximum will increase to IRS allowable amount of $2,550 (currently $2,500). SPENDING ACCOUNT Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

Page 4 of 32

Where can I can find more benefits information? The Bulletin Board/Benefits Page should be your first stop for looking up benefits information.

THE BULLETIN BOARD IS THE PLACE TO GO TO: • View a Benefits Cost Summary and what each plan covers. • Find contact information for our benefit providers, including phone numbers and website addresses. • Find forms, policies, and plan documents, such as the benefit forms to change your benefits, a copy of a policy, or a plan document. • Find forms to make changes in your retirement plan or deferred compensation contributions.

REMINDER: OPEN ENROLLMENT RUNS FROM NOVEMBER 2-18, 2016. Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

Page 5 of 32

2017 Benefits Cost Summary SCHEDULE FOR FULL-TIME EMPLOYEES

EMPLOYEE EMPLOYEE PAYS EMPLOYEE PAYS WELLNESS RATE (monthly) (semi-monthly)** (semi-monthly)**

TOTAL COST (monthly)

COUNTY PAYS (monthly)*

Employee Only

$

796.52

$

733.52

$

63.00

$

31.50

$

11.50

Employee and Spouse

$ 1,491.04

$

1,129.10

$

361.94

$

180.97

$

160.97

Employee and 1 Child

$ 1,070.14

$

810.22

$

259.92

$

129.96

$

109.96

Employee and Children

$ 1,376.30

$ 1,042.20

$

334.10

$

167.05

$

147.05

Employee and Family

$ 1,919.28

$ 1,453.54

$

465.74

$

232.87

$

212.87

Employee Only

$

835.08

$

733.52

$

101.56

$

50.78

$

30.78

Employee and Spouse

$ 1,651.24

$

1,129.10

$

522.14

$

261.07

$

241.07

Employee and 1 Child

$ 1,185.32

$

810.22

$

375.10

$

187.55

$

167.55

Employee and Children

$ 1,524.20

$ 1,042.20

$

482.00

$

241.00

$

221.00

Employee and Family

$ 2,124.06

$ 1,453.54

$

670.52

$

335.26

$

315.26

Employee Only

$

36.86

$

36.86

$

0.00

$

0.00

Employee and 1 Dependent

$

71.70

$

36.86

$

34.84

$

17.42

Employee and Family

$

103.74

$

36.86

$

66.88

$

33.44

STANDARD PPO PLAN - UMR

CHOICE PPO PLAN - UMR

DENTAL PLAN - DELTA DENTAL

VISION INSURANCE - VISION SERVICE PLAN Employee Only

$

9.00

$

0.00

$

9.00

$

4.50

Employee and 1 Dependent

$

17.04

$

0.00

$

17.04

$

8.52

Employee and Family

$

24.90

$

0.00

$

24.90

$

12.45

$

0.00

$

0.00

LIFE INSURANCE - VOYA Employee Only

varies

Employee and Family

varies

$0.00

$

0.76

$

0.38

Short-Term Disability

varies

.235% of salary

$

0.00

$

0.00

Long-Term Disability

varies

.36% of salary

$

0.00

$

0.00

$.11/1000 of salary

DISABILITY BENEFITS - VOYA

OTHER VOLUNTARY POLICIES The costs for Supplemental Term Life Insurance, Voluntary Accidental Death & Dismemberment, and the AFLAC plans are based on the coverage selected. See the individual brochures for current premiums. * This is the amount the County pays for a full-time employee. Part-time employees share the cost for the health and dental coverages on a proportional basis. See the "Schedule for Part-Time Employees." ** Premiums will be deducted from the first 2 paychecks of each month. When there is a month with three paychecks, they will not be deducted from the 3rd check.

Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

Page 6 of 32

2017 Benefits Cost Summary

SCHEDULE FOR PART-TIME EMPLOYEES

Costs below don’t reflect the “Wellness Rate.” A monthly $40 medical insurance premium reduction will be applied for eligible participants. See the next page for more information.

MEDICAL INSURANCE:

Premiums are shown in semi-monthly* amounts. Depending on the plan option and number of dependents to be covered, a part-time employee's health insurance premium will vary, as shown below.

STANDARD PPO - EMPLOYEE'S COST PER PAYCHECK Number of Hours Worked per Week

Employee Only

Employee & Spouse

Employee & 1 Child

Employee & Children

Employee & Family

20 - 29

$123.19

$322.11

$231.24

$297.32

$414.56

30 - 39

$77.34

$251.54

$180.58

$232.19

$323.72

Full-Time

$31.50

$180.97

$129.96

$167.05

$232.87

CHOICE PPO - EMPLOYEE'S COST PER PAYCHECK Number of Hours Worked per Week

Employee Only

Employee & Spouse

Employee & 1 Child

Employee & Children

Employee & Family

20 - 29

$142.47

$402.21

$288.83

$371.27

$516.95

30 - 39

$96.62

$331.64

$238.18

$306.14

$426.11

Full-Time

$50.78

$261.07

$187.55

$241.00

$335.26

DENTAL INSURANCE:

Premiums are shown in semi-monthly* amounts. Depending on the plan option and number of dependents to be covered, a part-time employee's health insurance premium will vary, as shown below. # of Hours Worked per Week

Employee Only

Employee + 1 Dependent

Employee & Family

20 - 29

$4.60

$22.02

$38.04

30 - 39

$2.30

$19.72

$35.74

Full-Time

$0.00

$17.42

$33.44

* Premiums will be deducted from the first 2 paychecks of each month. When there is a month with three paychecks, they will not be deducted from the 3rd check.

Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

Page 7 of 32

Wellness Rate Criteria

INTRODUCTION

Larimer County provides a reduced insurance premium, known as the “wellness rate”, to medical plan members who are committed to maintaining or improving their health. The wellness rate for the 2017 Plan Year is a $40 reduction in monthly medical insurance plan premiums for members who qualify based on criteria outlined below. Criteria is based on outcomes from a plan member’s Biometric Screening Assessment, with these goals in mind: • Encourage plan members to be engaged in their health • Make the criteria attainable and realistic for plan member

CRITERIA TO RECEIVE WELLNESS RATE ON 2017 MEDICAL INSURANCE PLAN To receive the wellness rate in 2017, it is required that the employee AND any spouse on the plan BOTH have to meet these criteria:

• Have participated in the 2016 Biometric Screening Event (Aug 17-26) • Have three or more (out of six) biometric results in the following range: • Self Reported Non-Tobacco User (or Complete Tobacco Cessation Program since last year’s screening. Proof of program completion needs to be turned into Human Resources by deadlines listed below.) • BMI below 30 • Blood Pressure below 130/85 mmHg • Total Cholesterol below 200 mg/dL • Triglycerides below 150 mg/dL • Blood Glucose below 100 mg/dL Please be assured that the only information Larimer County will receive is whether or not a participant meets the overall incentive requirement, not how a person meets it or which criteria they’ve met. The County has asked for a list of Plan members who have met three or more of the criteria listed above without any specifics regarding the number or type of factors met. Larimer County will not receive any identified medical information. Hence, Larimer County will remain HIPAA compliant.

EMPLOYEES & NEW ENROLLEES IN THE COUNTY’S MEDICAL INSURANCE PLAN To be eligible for the Wellness Rate in 2017, you must get a Biometric Screening (for you and covered spouse on the plan), and submit the required documentation​by the appropriate deadlines, as outlined below. ELIGIBILITY CATEGORY New Employees: Hired between July 16 - November 15 New Employees: Hired between Nov 16 - December 15 New Enrollees in Medical Plan (through Open Enrollment/Status Change) Employees Currently Enrolled in Medical Plan

DOCUMENTATION DEADLINE 12/15/2016 1/16/2017 12/15/2016 8/26/2016

New employees hired between July 16 and November 15:

Employees hired after July 16 would not be eligible for benefits until September 1, thus would not be able to participate in the mass screening events which are held in August. Employees hired during this time frame who enroll themselves or spouse in the County’s Medical Insurance Plan, can either… a. Get a Biometric Screening done at The Wellness Clinic, after date that medical insurance is effective (submit the Physician’s Statement on page 10). b. Get a Biometric Assessment completed by a different medical provider and submit a signed Physician’s Statement (found on page

Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

Page 8 of 32

Wellness Rate Criteria (cont'd).

10), indicating that they (employee, spouse) qualify for the Wellness Rate based on the criteria outlined in this document. Medical provider must indicate that he or she is basing the statement on the patient’s biometric screening results recent as of 90 days. Signed statement would need to be submitted by December 15. (Please make sure to allow time for results to be obtained after your blood draw.)

New employees hired between November 16 and December 15:

The above criteria applies. These employees will not be eligible for benefits until January 1, but will be able to use The Wellness Clinic to get their Biometric Screening completed after January 1, 2017. Employees may submit a Physician’s Statement (for employee and covered spouse) by January 16, 2017. (Please make sure to allow time for the results to be obtained after your blood draw.)

New enrollees (employees and/or covered spouse) in the medical insurance plan due to:

(A) OPEN ENROLLMENT (B) QUALIFIED STATUS CHANGE, EFFECTIVE BETWEEN SEPTEMBER 1, 2016 AND NOVEMBER 30, 2016. Employees who enroll themselves or their spouse in the County’s Medical Insurance at open enrollment (or through qualified status change) may be eligible for the Wellness Rate in 2017, if they meet the criteria and submit a Physician’s Statement (for employee and covered spouse), as outlined above. Signed statement would need to be submitted by December 15. (Please make sure to allow time for the results to be obtained after your blood draw.) If you have a status change in December, please contact Human Resources.

New employees hired after December 15:

Because these employees are not eligible for benefits until after January 1, they are not eligible for the Wellness Rate until the following year.

Your Wellness Rate qualification status will be effective for the 2017 plan year. Thus, you will not gain or lose the Wellness Rate incentive due to any mid-year plan changes in 2017. Please contact Human Resources for additional information.

Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

Page 9 of 32

PHYSICIAN’S STATEMENT AND MEDICAL WAIVER FORM For employees and/or covered spouses who do NOT attend the mass screening events, which took place August 2016. (Both the employee and covered spouse must meet biometric criteria to be eligible for the Wellness Rate.) EMPLOYEE/SPOUSE: Complete this section only. Please print.

 Employee or  Spouse (please check only one)

First, Middle, Last Name: Date of Birth: Phone: Email (for receipt confirmation): If Spouse, please list Employee’s Full Name: * for Employees Only - ADP Employee ID: Do you use tobacco? Yes  No NOTE: Pregnant or postpartum women (up to 3 months postpartum) qualify to complete a medical waiver, as lipid levels increase during pregnancy and may not return to normal levels until several months postpartum. PERSONAL PHYSICIAN/PHYSICIAN ASSISTANT: Complete this section OR the Waiver below. Blood Pressure: Systolic: Diastolic: Height (inches): Weight (pounds): Glucose: mg/dL Total Cholesterol: mg/dL Triglycerides: Low Density Lipoprotein (LDL): mg/dL High Density Lipoprotein (HDL):

mg/dL mg/dL

MEDICAL WAIVER: To be completed by physician.  I consider it to be unreasonably difficult due to a medical condition (such as pregnancy or other), or medically inadvisable for this patient to achieve the following standard. Have three or more, out of six, biometric scores/results in the following range: • Self-Reported Non-Tobacco User (or completed cessation program in 2016) • BMI below 30 • Blood Pressure below 130/85 mmHg • Total Cholesterol below 200mg/dL • Triglycerides below 150mg/dL • Blood Glucose below 100mg/dL PHYSICIAN NAME (please print): PHONE NUMBER: PHYSICIAN SIGNATURE: DATE:

FAX this form to Preventive Health Now, LLC at (720) 221-0708. Or SECURE UPLOAD at www.incentivetracking.com/co/securedrop.aspx ELIGIBILITY CATEGORY New Employees: Hired between July 16 - November 15 New Employees: Hired between Nov 16 - December 15 New Enrollees in Medical Plan (through Open Enrollment/Status Change) Employees Currently Enrolled in Medical Plan

Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

DOCUMENTATION DEADLINE 12/15/2016 1/16/2017 12/15/2016 8/26/2016

Page 10 of 32

Medical Insurance Plans BENEFIT OVERVIEW

STANDARD PPO

CHOICE PPO

In-Network

Out-of-Network

In-Network

Out-of-Network

$1,000 $2,000

$2,000 $4,000

$500 $1,000

$1,000 $2,000

80%

60%

90%

70%

$6,000 $12,000

$12,000 $24,000

$3,500 $7,000

$7,000 $14,000

OFFICE VISIT

$25 Copay

60%**

$25 Copay

70%**

SPECIALIST OFFICE VISIT

$50 Copay

60%**

$50 Copay

70%**

80%**

$500copay/occurrence; 60%**

90%**

$500copay/occurrence; 70%**

CALENDAR YEAR DEDUCTIBLE

Individual Family

COINSURANCE OUT-OF-POCKET MAXIMUM*

Individual Family

INPATIENT HOSPITAL

($250 penalty if not precertified)

80%** OUTPATIENT HOSPITAL

($250 penalty if not precertified)

(Additional $500 penalty if not precertified)

($250 penalty if not precertified)

$250copay/occurrence; 60%**

90%**

(Additional $500 penalty if not precertified)

(Additional $500 penalty if not precertified)

$250copay/occurrence; 70%**

($250 penalty if not precertified)

(Additional $500 penalty if not precertified)

PRESCRIPTIONS Generic

$10 max copay

$10 max copay

20% coinsurance

Preferred Brand

(minimum $25 copay & maximum $50 copay)

Non-Preferred Brand

(minimum $50 copay & maximum $100 copay)

Mail Order (90-Day Supply) Specialty Drugs ALLERGY INJECTIONS EMERGENCY ROOM URGENT CARE

50% coinsurance

OUTPATIENT PHYSICAL THERAPY

50% coinsurance

(minimum $50 copay & maximum $100 copay)

2 months cost

$100/30-day supply

$100/30-day supply

No copay for injections rendered without an office visit.

60%**

$200 Copay - Not including X-ray. $50 Copay

60%**

$200 Copay - Not including X-ray. $50 Copay

60%**

100%

Bone Scan/Mammogram

90%**

70%**

60%**

100%

70%**

60%**

$25 Copay/Initial Visit Then 90%**

60%**

$25 Copay

All Other

$25 Copay

70%**

100%

80%**

$25 Copay/Initial Visit Then 80%**

70%**

90%**

100%

Bone Scan/Mammogram

Network copay/ coinsurance + 50% of remaining cost.

No copay for injections rendered without an office visit.

80%**

LABORATORY MATERNITY

Network copay/ coinsurance + 50% of remaining cost.

2 months cost

AMBULANCE X-RAY (Including CAT/MRI/PET/EKG)

20% coinsurance

(minimum $25 copay & maximum $50 copay)

All Other

$500 Copay/Occurrence, 60%**

70%**

$500 Copay/Occurrence, 70%**

70%**

* Including deductible. ** Subject to the deductible/coinsurance.

Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

Page 11 of 32

Medical Insurance Plans

BENEFIT OVERVIEW

STANDARD PPO

CHOICE PPO

In-Network

Out-of-Network

In-Network

Out-of-Network

OUTPATIENT PHYSICAL THERAPY

$25 Copay

60%**

$25 Copay

70%**

SPEECH, HEARING, AND OCCUPATIONAL THERAPY

$25 Copay

60%**

$25 Copay

70%**

DURABLE MEDICAL EQUIPMENT

80%**

60%**

90%**

70%**

HUMAN ORGAN TRANSPLANT

80%**

Not Covered Out-of-Network

90%**

Not Covered Out-of-Network

80%**

60%**

90%**

70%**

HOME HEALTH CARE

(100 visits/calendar year; combined in-and-out-of-network.) (100 visits/calendar year; combined in-and-out-of-network.)

HOSPICE SKILLED NURSING FACILITY VISION CARE

CHIROPRACTIC CARE

PREVENTATIVE CARE

90%**

70%**

80%**

60%**

90%**

70%**

100 days/calendar year

$25 Copay/Visit; 1 visit/calendar year; $130 payable

$25 Copay/Visit; 1 visit/calendar year; $130 payable

Payable up to $2,500 every 3 years.

Payable up to $2,500 every 3 years.

$25 Copay

$25 Copay

$1,000 total calendar year maximum

$25 Copay

60%**

$1,000 total calendar year maximum

MENTAL HEALTH/ SUBSTANCE ABUSE (INPATIENT) MENTAL HEALTH/ SUBSTANCE ABUSE (OUTPATIENT)

60%**

100 days/calendar year

HEARING AIDS MASSAGE THERAPY/ ACUPUNCTURE

80%**

$25 Copay

$25 Copay

$1,000 total calendar year maximum

$25 Copay

70%**

$1,000 total calendar year maximum

80%**

60%**

90%**

70%**

$25 Copay

60%**

$25 Copay

70%**

100% for Routine Preventative Services

60%** for Routine Preventative Services

100% for Routine Preventative Services

70%** for Routine Preventative Services

(such as well child, routine (such as well child, routine (such as well child, routine (such as well child, routine physicals, mammograms, physicals, mammograms, physicals, mammograms, physicals, mammograms, and colonoscopies) and colonoscopies) and colonoscopies) and colonoscopies)

* Including deductible. ** Subject to the deductible/coinsurance.

Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

Page 12 of 32

LOCATION 2601 Midpoint Drive Suite 100 Fort Collins, CO 80525

THE WELLNESS CLINIC T

he Wellness Clinic, operated by Marathon Health, focuses on helping people live the healthiest life possible. Services include primary care, health coaching, group wellness programs, more time with your provider, little to no CENTER HOURS wait time before your scheduled appointment, onsite medication dispensing, Mon, Wed, Fri and online appointment scheduling.

7:00am - 4:00pm Tues, Thurs Services are provided at no additional cost and available to employees, spouses, 8:30am - 5:30pm and dependents (ages 2 years and older) enrolled in the County medical plan. PHONE (970) 980-2425

PRIMARY CARE SERVICES

CHRONIC CONDITION COACHING

PREVENTION

• • • • • • • •

call (970) 980-2425 TO SCHEDULE APPOINTMENTS Please Go online at www.marathonhealth.com/myphr.

Bronchitis Common cold Constipation Cough Diarrhea Ear pain Eye infections Headache

• • • • • • • •

Hip pain Knee pain Nausea and vomiting Nosebleed Shoulder pain Sinus infections Skin infections/rash Strep throat

EXAMPLES • Asthma • Coronary artery disease • COPD • Congestive heart failure • Depression • Diabetes

• Gastroesophageal reflux disease • Hypertension • Low back pain • Metabolic syndrome • Osteoarthritis • Rheumatoid arthritis • Sleep Apnea

HEALTH SCREENINGS • Blood Pressure • Body Mass Index • Cholesterol • Glucose

HEALTH COACHING • Nutrition • Physical activity • Tobacco cessation • Stress management • Weight loss

EXAMPLES EXAMPLES

Who can use The Wellness Clinic? Services are available to employees, spouses, and dependents (ages 2 and older) enrolled in the County medical plan. Do I need an appointment to use these services? The Wellness Clinic operates on an appointment basis. Marathon Health offers the convenience of online appointment scheduling or by phone. (See above.) If you would like to be seen as soon as possible, we recommend calling to discuss your symptoms and find out if a same-day appointment is available. How long should an appointment take? Most appointments for sick care will take about 20-30 minutes. Appointment times vary. Physical exams are scheduled for one hour, a Comprehensive Health Review (CHR) can last up to 45 minutes, while health coaching and chronic condition coaching visits are generally 30 minutes. Will I have to complete a new Health Risk Assessment (HRA)? Employees and spouses who wish to use The Wellness Clinic for the first time are required to schedule an appointment for a biometric screening to assess blood pressure, height, weight, glucose and cholesterol levels, as well as complete an online Health History and Risk Assessment (HHRA).

Dental Insurance

ADVANTAGES OF THE DELTA DENTAL PPO PLUS PREMIER PLAN SAVINGS: Delta Dental PPO dentists offer members the greatest savings so your annual maximum will go further. And you still save money if you need a service that is not covered. Non-covered services will be billed at a discounted rate if you go to a PPO dentist. CHOICE: If you choose to visit a Premier dentist, you will still see savings because Premier dentists also accept discounted fees (however, discounts are greatest when you see a PPO dentist. NETWORK: To find a participating dentist, visit www.deltadentalco.com . Make sure you’re searching for a PPO dentist. You may also call Customer Relations at 1-800-610-0201.

Coverage

Description

PPO Plus Premier Dentist

Non-Participating Dentist

TYPE A

DIAGNOSTIC & PREVENTATIVE SERVICES* (Exams, x-rays, cleanings)

100%**

100%**

TYPE B

BASIC SERVICES (Fillings and other standard dental procedures)

80%**

80%**

$50 $100

$50 $150

ANNUAL MAXIMUM BENEFIT (per person)

$1,500

$1,500

TMJ LIFETIME MAXIMUM (per person)

$1,000

$1,000

$1,000

$1,000

MAJOR SERVICES (Bridges, dentures, implants, TMJ, and other complex issues) TYPE C

DEDUCTIBLE*** Individual Family

ORTHODONTIA LIFETIME MAXIMUM (for children and adults) * Diagnostic and preventative care services do not count against the annual maximum.

** You and your family members may visit any licensed dentist, but will enjoy the greatest out-of-pocket savings if you see a Delta Dental PPO dentist. There are three levels of dentists to choose from: • PPO Dentist — Payment is based on the PPO dentist’s allowable fee, or the actual fee charged, whichever is less. • Premier Dentist — Payment is based on the Premier Maximum Plan Allowance (MPA), or the fee actually charged, whichever is less. • Non-Participating Dentist — Payment is based on the non-participating MPA. Members are responsible for the difference between the non-participating MPA and the full fee charged by the dentist. *** A pplies only to Type B & C Services

YOUR VISION CARE PROGRAM As a Delta Dental member, you are eligible for vision care savings offered through EyeMed Vision Care. The program is available to all subscribers and eligible dependents. However this plan cannot be combined, or used in conjuction, with any other vision care plans. If you are enrolled in a funded vision care program, the discount plan can only be utilized separate from your funded program. For more information on this program, please go to the Benefits page on the Bulletin Board. Look for Delta Dental, Employee Education Packet.

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Benefit

Vision Insurance VSP Provider Network: VSP Choice Copay Frequency

Description

Your Coverage with a VSP Provider WellVision Exam

Focuses on your eyes and overall wellness

$15

Every 12 months

Included in Prescription Glasses

Every 24 months

Included in Prescription Glasses

Every 12 months

This is a voluntary, employee-paid supplemental vision care plan. Note that this $15 policy is completely separate Prescription Glasses See frame and lenses from the$175 one eye exam a year thatofisframes available through the medical insurance. allowance for a wide selection Frame

$195 allowance for featured frame brands 20% savings on the amount over your allowance $95 Costco® frame allowance

Your VSP Vision Benefits Summary Lenses

Single vision, lined bifocal, and lined trifocal lenses Polycarbonate lenses for dependent children

LARIMER COUNTY GOVERNMENT and VSP provide you with an affordable eye care plan. Standard progressive lenses Lens Enhancements

Benefit

Premium progressive lenses Custom progressive lenses Average savings of 20-25% on other lens enhancements Description

Contacts (instead of WellVision Exam glasses)

Yourcopay Coverage a VSP Provider $175 allowance for contacts; doeswith not apply Focuses on your eyes and overall wellness Contact lens exam (fitting and evaluation)

Prescription Glasses Diabetic Eyecare Plus Program Frame

Services related to diabetic eye disease, glaucoma and age-related macular degeneration (AMD). Retinalofscreening $175 allowance for a wide selection frames for eligible members with diabetes. Limitations and coordination $195 allowance for featured frame brands with medical coverage may VSP doctor details. 20% apply. savingsAsk on your the amount overfor your allowance

Extra Savings Lens Enhancements

Copay

Every 12 VSP months Network: Choice Frequency

Up to $60 $15

Every 12 months Every 12 months

$15

See frame and lenses

$20 in Included Prescription Glasses

As needed Every 24 months

$95 Costco frame allowance Glasses and Sunglasses Included in Extra to spend on featured frametrifocal brands. Go to vsp.com/specialoffers for details. Single$20 vision, lined bifocal, and lined lenses Prescription Every 12 months 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 Polycarbonate lenses for dependent children Glasses months of your last WellVision Exam. $55 Standard progressive lenses Retinal Screening Premium progressive lenses $95 No more than a $39 copay on routine retinal screening as an enhancement to- a$105 WellVision Exam Every 12 months Custom progressive lenses $150 - $175 Laser Visionsavings Correction Average of 20-25% on other lens enhancements Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities ®

Lenses

$55 $95 - $105 VSP- Provider $150 $175

$175 allowance for contacts; copay does not apply Contacts (instead of Up to $60 Every 12 months Coverage with Out-of-Network Providers Contact lens examYour (fitting and evaluation) glasses) Visit vsp.com for details, if you plan to see a provider other than a VSP network provider. Services related to diabetic eye disease, glaucoma and age-related Exam .............................................................................. up to $45 Lined Bifocal Lenses ........................................... up to $50 Progressive Lenses ............................................. up to $50 macular degeneration (AMD). Retinal screening for eligible members Contacts .................................................................... up to $105 Diabetic Eyecare Plus Frame ............................................................................ up to $70 Lined Trifocal Lenses ......................................... up to $65 $20 As needed with diabetes. Program Single Vision Lenses ........................................... up to $30 Limitations and coordination with medical coverage may apply. Ask your VSP doctor for details. Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, theSunglasses terms of the contract will prevail. Based on applicable laws, benefits may vary by location. Glasses and

Extra Savings

Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details. 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam.

Retinal Screening No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam Laser Vision Correction Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities Your Coverage with Out-of-Network Providers

Visit vsp.com for details, if you plan to see a provider other than a VSP network provider. Exam .............................................................................. up to $45 Frame ............................................................................ up to $70 Single Vision Lenses ........................................... up to $30

Lined Bifocal Lenses ........................................... up to $50 Lined Trifocal Lenses ......................................... up to $65

Progressive Lenses ............................................. up to $50 Contacts .................................................................... up to $105

Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location.

Contact us. 800.877.7195 | vsp.com 1

Brands/Promotion subject to change.

2014 Vision Service Plan. All rights reserved. VSP, VSP Vision care for life, and WellVision Exam are registered trademarks of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear, Inc. All other company names and brands are trademarks or registered trademarks of their respective owners. ©

Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

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Short-Term Disability

Group Disability Income Insurance provides you with benefits to replace part of your paycheck when you can’t work because of a sickness or injury. When your claim is approved, you will receive either a weekly benefit (Short Term Disability) or monthly benefit (Long Term Disability).

EMPLOYEE COST

• 100% Employer Paid

WAITING PERIOD

• Greater of 14-day waiting period, or the exhaustion of your accrued sick leave. During this time, you may use your available vacation and/or sick time.

AMOUNT PAID

• 60% of Weekly Earnings, with a weekly benefit minimum of $25, and a maximum of $1,250. • Provides coverage for up to 11 weeks, as approved.

Long-Term Disability

Group Disability Income Insurance provides you with benefits to replace part of your paycheck when you can’t work because of a sickness or injury. When your claim is approved, you will receive either a weekly benefit (Short Term Disability) or monthly benefit (Long Term Disability). EMPLOYEE COST

• 100% Employer Paid

WAITING PERIOD

• 90-day waiting period before benefits begin.

AMOUNT PAID

• 60% of Weekly Earnings, with a weekly benefit minimum of $25, and a maximum of $1,250. • Will pay up to 2 years (up to a max of $5,000 per month), if you are disabled that long.

AMOUNT PAID (AFTER 2 YEARS)

• After 2 years, the definition of disability will change from “unable to perform your job” to “totally disabled from any job for which you are reasonably trained”. • If your disability still qualifies, the policy would continue to pay you until you reach Social Security Age or until you are no longer disabled. (if your disability does not qualify, the payments will stop).

NOTE ABOUT OTHER GROUP DISABILITY BENEFITS

• This policy pays secondary to other group disability benefits (i.e., Workers Compensation, Social Security), if applicable. If you are receiving other qualifying payments, those payments will be subtracted from the amount that this policy will pay.

PRE-EXISTING CONDITION CLAUSE

• If you have been treated for any medical condition in the 3 months immediately prior to your effective date, and if that condition causes your disability in the first 12 months of your coverage, then no benefits will be payable under this policy. Once you have been covered for 12 months, the pre-existing condition limitation will no longer apply to you.

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Basic Life Insurance w/ Accidental Death & Dismemberment The charts on the next two pages provide an overview of your Life/AD&D insurance benefits. These plans offer your family financial protection in the event of your death. Basic Life/AD&D is provided by Larimer County at no cost to you. You also may purchase optional life insurance for your dependents. EMPLOYEE COST EMPLOYEE COVERAGE

COVERAGE AMOUNT

REDUCTION IN COVERAGE

Your annual salary or $10,000 whichever is greater. (Adjusts as salary changes.) Benefit coverage reduces

100% Employer Paid

SPOUSE COVERAGE

$0.76/month CHILD COVERAGE Children between the ages of 14 days and 6 months. (Regardless of number of dependents covered.) Unmarried dependent children over the age of 6 months, up to age 26 years.

$5,000 $500

at the following ages: Age 65: to 65% Age 75: to 45% Age 80: to 30%

$2,000

Supplemental Term Life Insurance

This is a voluntary, employee-paid supplemental term life insurance policy. Supplemental life insurance coverage is portable, so if you leave employment, you can take this coverage with you and continue to pay the same premium as if you were an active employee. All rates are guaranteed through 12/31/2017.

SPOUSE COVERAGE

(Employee must be enrolled to obtain coverage for spouse.)

CHILD COVERAGE

(Employee must be enrolled to obtain coverage for children.)

SUPPLEMENTAL LIFE RATE CHART

COVERAGE INCREMENTS

$10,000 - $500,000

$10,000

$10,000 - $500,000

$10,000

Up to $20,000

Age of Employee or Spouse (Cost per month/ per $1,000 coverage) Less than 30 30 - 34 HOW TO USE THIS CHART 35 - 39 To determine your monthly premium: 40 - 44 1. Select the total amount of coverage you want. 45 - 49 2. Divide by 1,000. 50 - 54 3. Multiply by the rate shown on the 55 - 59 chart for your age. 4. The rate changes as you move 60 - 64 the age bands. 65 - 69 70+

Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

Rate (Standard) 0.05 0.08 0.09 0.13 0.20 0.33 0.57 0.87 1.68 2.72

$2,000

RATES

REDUCTION IN COVERAGE

See Chart

Benefit coverage reduces at the following ages:

$0.05 per $1,000 of coverage

Age 65: to 65% Age 75: to 45% Age 80: to 30%

GUARANTEE ISSUE FOR INCREASES AVAILABLE FOR CURRENT ENROLLEES DURING OPEN ENROLLMENT:

Employee: At Open Enrollment, you can elect to increase your current coverage amount the lesser of $20,000, not to exceed $200,000, without providing proof of good health. Spouse: At Open Enrollment, you can elect to increase current spouse coverage the lesser of $10,000, not to exceed $30,000, without providing proof of good health. Children: At open enrollment, you can elect to increase your current child(ren) coverage up to $14,000 without providing proof of good health.

EVIDENCE OF INSURABILITY (Proof of Good Health)

EMPLOYEE COVERAGE

COVERAGE AMOUNT

All new applications or applications for an increase in coverage beyond the Guaranteed Issue Coverage offered require the completion of an Evidence of Insurability form, which is available on the Bulletin Board/Benefits page. Any coverage beyond the Guaranteed Issue amount will be subject to approval by Voya based on the health information listed on the Evidence of Insurability form. Voya may contact you for further medical information, blood tests, physicals, etc., based on their review of your health statement. Page 17 of 32

Voluntary Accidental Death + Dismemberment

Voluntary Accidental Death and Dismemberment (AD&D) insurance pays your beneficiary a death benefit if you die due to a covered accident, and also pays you a benefit for certain accidental losses. AD&D covers losses that occur away from work or at work. Benefits are paid in addition to any life insurance or Worker’s Compensation benefits you collect. This plan can be added, dropped, or changed at any time.

NUMEROUS BENEFITS, INCLUDING: 100% of the amount of coverage purchased in the event of accidental loss of life, two limbs, the sight of both eyes, one limb and the sight of one eye, or speech and hearing in both ears. 50% for accidental loss of one limb, sight of one eye, or speech or hearing in both ears. 25% for accidental loss of thumb and index finger of the same hand.

RATE CHART - EMPLOYEE & SPOUSE Amounts of Insurance $25,000 $50,000 $75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000 $275,000 $300,000 $325,000 $350,000 $375,000 $400,000 $425,000 $450,000 $475,000 $500,000

Your Cost

Spouse Cost

$0.50 $1.00 $1.50 $2.00 $2.50 $3.00 $3.50 $4.00 $4.50 $5.00 $5.50 $6.00 $6.50 $7.00 $7.50 $8.00 $8.50 $9.00 $9.50 $10.00

$0.50 $1.00 $1.50 $2.00 $2.50 $3.00 $3.50 $4.00 $4.50 $5.00

Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

FAMILY MEMBER

COVERAGE AMOUNTS

Employee

Increments of $25,000, to a maximum of $500,000

Spouse

Increments of $25,000, to a maximum of $250,000

Children

Increments of $5,000, not to exceed $25,000

REDUCTION IN COVERAGE Benefit coverage reduces at the following ages: Age 65: to 65% Age 75: to 45% Age 80: to 30%

RATE CHART - CHILD(REN) Amounts of Insurance $5,000 $10,000 $15,000 $20,000 $25,000

Child(ren) $0.20 $0.40 $0.60 $0.80 $1.00

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Flexible Spending Accounts

There are two types of Flexible Spending Accounts (FSA). The first is a Health Care Flexible Spending Account and the second is a Dependent Care Flexible Spending Account. Your participation in a FSA plan allows a portion of your salary to be redirected on a pre-tax basis to provide reimbursement for these types of expenses. WHAT CAN A WAGEWORKS FLEXIBLE SPENDING ACCOUNT DO FOR ME? Save between 25% & 40% on everyday expenses. Open a WageWorks Flexible Spending Account (FSA) during Open Enrollment and good things happen. You have money ready for eligible expenses not covered by your insurance, saving you 25% - 40%. HOW DOES IT WORK? You can sign up for an FSA during open enrollment. Each paycheck, you set aside some of your pay, before taxes, to use for eligible expenses. This is how you save money: $100 put into your FSA is $100 to spend on eligible expenses. Without an FSA, you pay taxes, leaving $60 or $75 to pay for the same eligible expenses. WHAT IS THE take care® CARD? Use your take care® Card instead of cash or credit at health care providers and pharmacies for eligible services, goods, and prescriptions. Typical expenses include co-pays for doctor visits and prescriptions, dental and orthodontia expenses, vision care, prescribed over-the-counter (OTC) drugs and medications, and non-drug OTC items and devices. IS IT HARD TO USE MY FSA? Using your FSA is easy. When you elect a health care FSA, your account is funded with the full amount you’ve chosen at the beginning of the year. As soon as that happens, it’s ready to use for eligible expenses. Throughout the year, you ‘pay your account back’ with pre-tax contributions from your paycheck. Accessing your account is easy: 1. take care® Card. Use it instead of cash at health care providers and wherever accepted for health-related services and health expenses. 2. Pay Me Back. File a claim online, by fax, or mail for reimbursement. 3. On The Go. Use our mobile website to view your account or file a claim. You can also choose a WageWorks Dependent Care FSA to help with the cost of care for eligible children or aging parents while you are at work. A dependent care FSA works a lot like a health care FSA, but your account is funded each payroll period, so funds are available as contributions are taken from your paycheck.

HEALTH CARE FSA

DEPENDENT CARE FSA

WHAT IT COVERS

CONTRIBUTION MAXIMUMS

Expense must be incurred for medical care that is not reimbursed from any other source. Medical care means the drug or service is needed to treat a medical condition.

$2,550

Work-related day care expenses for a qualifying dependent.

$2,500 (if married, filing separately) $5000 (if married, filing jointly, or single)

OVER-THE-COUNTER MEDICATIONS In March 2010 the Patient Protection and Affordable Care Act was signed into law. As a result of this new Act, effective January 1, 2011, it is required that reimbursement for OTC medicines and drugs be accompanied by a physician’s prescription in order to be reimbursed under Health Flexible Spending Accounts (FSA’s), Health Reimbursement Arrangements (HRA’s), and Health Savings Accounts (HSA’s). OTC drugs and medicines will continue to be eligible for reimbursement from these benefit plans as long as the reimbursement request is accompanied by a doctor’s prescription. As a general rule, any OTC drug or medicine that you take orally or topically will require a doctor’s prescription. For example, cough medicines, pain relievers, acid controllers, and diaper rash ointments will require a doctor’s prescription.

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NOTE: You can use the take care® Card to pay for OTC drugs and medicines only if a valid prescription is presented at the time of purchase, and the purchase is made at a pharmacy counter and dispensed as a prescription item. To learn more and to view a list of common items that can and cannot be reimbursed without a doctor’s prescription, go to takecareWageWorks.com, click on the employee tab, then click on the New Rules Regarding Over the Counter drugs link. YOUR FLEXIBLE SPENDING ACCOUNT FEATURES A $500 CARRYOVER

On October 31, 2013, the U.S. Department of the Treasury modified the “Use It or Lose It” rule which required any leftover balance in a Healthcare FSA to be forfeited at the end of the plan year. Under the rule, you can carryover up to $500 of your unused WageWorks Healthcare FSA balance remaining at the end of a plan year, so you don’t lose all of your unused funds. WHAT DOES THIS RULE MEAN FOR YOU? This rule limits your risk of losing some unused funds and gives you more control and flexibility in managing your out-of-pocket healthcare expenses. NO MORE… • Trying to precisely predict what your healthcare expenses might be for the year • Worrying about losing money left unspent in your FSA at the end of the plan year • Rushing to spend the remaining balance in your FSA at the end of the plan year or grace period WHAT SHOULD YOU DO? • Review your current balance and your planned expenses for the remainder of this year. Note that up to $500 of any remaining balance from the current plan year will be carried over into the next plan year account. • It will not affect your election limit for the next plan year – you can carry a total balance of the full election amount ($2,550), plus any carryover from (up to $500) for a total balance of up to $3,050.

Go to takecareWageWorks.com for more information.

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Aflac-Supplemental Insurance

In case of an accident or illness, Aflac insurance policies pay cash benefits directly to you, unless assigned, regardless of any other insurance you may have. Use the cash benefits for such expenses as: • Deductibles, co-payments, out of network charges, and any other expenses not picked up by your major medical coverage • Travel related expenses for treatment in distant medical centers, including airfare, hotels, and meals. • Everyday living expenses like house (or rent) payments, car notes, groceries, and utility bills. • Lost income, resulting in a “double whammy” if the healthy spouse has to leave work to care for the recuperating one. THE PRODUCT

THE BENEFIT

THE NECESSITY

ACCIDENT INSURANCE POLICY

Helps provide a financial cushion if an accident occurs

An injury can be just as debilitating as an extended illness – suspending or stopping the physical capacity to earn a living.

CANCER/SPECIFIED DISEASE INSURANCE POLICY

Helps with medical expenses related to cancer treatment

In the United states, men have slightly less than a 1-in2 lifetime risk of developing cancer; for women, the risk is a little more than 1-in-3. About 1,479,350 new cancer cases were expected to be diagnosed in 2009.

HOSPITAL INTENSIVE CARE INSURANCE POLICY

Helps cover expenses related to confinement in a hospital intensive care unit (ICU)

ICU costs can soar well above those of a general room as well as above the benefit levels of major medical health insurance policies.

HOSPITAL CONFINEMENT INDEMNITY INSURANCE POLICY

Helps with the non-covered expenses of a hospital stay

In 2008, the average hospital expense, adjusted per inpatient day, was $1,782.28 and 63% of all surgeries were outpatient surgeries.

SPECIFIED HEALTH EVENT INSURANCE POLICY

Certain life-threatening events pose special financial Helps with the medical expenses related to risks because of their statistically high levels of a covered life-threatening health event. incidence and cost.

Provides a physician feature that covers HOSPITAL CONFINEMENT SICKNESS sickness, accident, and wellness visits in addition to the plan’s basic sickness-only INDEMNITY INSURANCE POLICY benefits

Illness rather than injury is the leading cause of emergency room visits.

For more information and rates, contact our Aflac Associate: Amy Griffin, Phone: (970) 530-1208, Email: [email protected]

Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

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Annual Notices LARIMER COUNTY 2017 HEALTH PLAN NOTICES TABLE OF CONTENTS

1. Medicare Part D Creditable Coverage Notice 2. HIPAA Comprehensive Notice of Privacy Policy and Procedures 3. Notice of Special Enrollment Rights 4. Women’s Health and Cancer Rights Notice 5. Notice of No Obligation for Pre-Authorization for Ob/Gyn 6. Medicaid and the Children’s Health Insurance Program (CHIP) Offer of Free or Low-Cost Health Coverage to Children and Families

IMPORTANT NOTICE This packet of notices related to our health care plan includes a notice regarding how the plan’s prescription drug coverage compares to Medicare Part D. If you or a covered family member is also enrolled in Medicare Parts A or B, but not Part D, you should read the Medicare Part D notice carefully. It is titled, “Important Notice from Larimer County About Your Prescription Drug Coverage and Medicare.”

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Annual Notices

MEDICARE PART D CREDITABLE COVERAGE NOTICE

IMPORTANT NOTICE FROM LARIMER COUNTY ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND MEDICARE Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Larimer County and about your options under Medicare’s prescription drug coverage. This information can help you decide whether 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. If neither you nor any of your covered dependents are eligible for or have Medicare, this notice does not apply to you or your dependents, as the case may be. However, you should still keep a copy of this notice in the event you or a dependent should qualify for coverage under Medicare in the future. Please note, however, that later notices might supersede this notice. 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. Larimer County has determined that the prescription drug coverage offered by the Larimer County Employee Health Care Plan (“Plan”) is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is considered “creditable” prescription drug coverage. This is important for the reasons described below. ____________________________________________________________________ Because your existing coverage is, on average, at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to enroll in a Medicare drug plan, as long as you later enroll within specific time periods. Enrolling in Medicare – General Rules As some background, you can join a Medicare drug plan when you first become eligible for Medicare. If you qualify for Medicare due to age, you may enroll in a Medicare drug plan during a seven-month initial enrollment period. That period begins three months prior to your 65th birthday, includes the month you turn 65, and continues for the ensuing three months. If you qualify for Medicare due to disability or end-stage renal disease, your initial Medicare Part D enrollment period depends on the date your disability or treatment began. For more information you should contact Medicare at the telephone number or web address listed below. Late Enrollment and the Late Enrollment Penalty If you decide to wait to enroll in a Medicare drug plan you may enroll later, during Medicare Part D’s annual enrollment period, which runs each year from October 15th through December 7th. But as a general rule, if you delay your enrollment in Medicare Part D, after first becoming eligible to enroll, you may have to pay a higher premium (a penalty). If after your initial Medicare Part D enrollment period you go 63 continuous days or longer without “creditable” prescription drug coverage (that is, prescription drug coverage that’s at least as good as Medicare’s prescription drug coverage), your monthly Part D premium may go up by at least 1% of the premium you would have paid had you enrolled timely, for every month that you did not have creditable coverage. For example, if after your Medicare Part D initial enrollment period you go nineteen months without coverage, your premium may be at least 19% higher than the premium you otherwise would have paid. You may have to pay this higher premium for as long as you have Medicare prescription drug coverage. However, there are some important exceptions to the late enrollment penalty. Special Enrollment Period Exceptions to the Late Enrollment Penalty There are “special enrollment periods” that allow you to add Medicare Part D coverage months or even years after you first became eligible to do so, without a penalty. For example, if after your Medicare Part D initial enrollment period you lose or decide to leave employer-sponsored or union-sponsored health coverage that includes “creditable” prescription drug coverage, you will be eligible to join a Medicare drug plan at that time. In addition, if you otherwise lose other creditable prescription drug coverage (such as under an individual policy) through no fault of your own, you will be able to join a Medicare drug plan, again without penalty. These special enrollment periods end two months after the month in which your other coverage ends. Compare Coverage 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. See the Plan’s summary plan description for a summary of the Plan’s prescription drug coverage. If you don’t have a copy, you can get one by contacting us at the telephone number or address listed below.

Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

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Annual Notices

MEDICARE PART D CREDITABLE COVERAGE NOTICE (cont'd).

Coordinating Other Coverage with Medicare Part D Generally speaking, if you decide to join a Medicare drug plan while covered under the Larimer County Plan due to your employment (or someone else’s employment, such as a spouse or parent), your coverage under the Larimer County Plan will not be affected. For most persons covered under the Plan, the Plan will pay prescription drug benefits first, and Medicare will determine its payments second. For more information about this issue of what program pays first and what program pays second, see the Plan’s summary plan description or contact Medicare at the telephone number or web address listed below. If you do decide to join a Medicare drug plan and drop your Larimer County prescription drug coverage, be aware that you and your dependents may not be able to get this coverage back. To regain coverage you would have to re-enroll in the Plan, pursuant to the Plan’s eligibility and enrollment rules. You should review the Plan's summary plan description to determine if and when you are allowed to add coverage. 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 Larimer County changes. You also may request a copy. 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: • Visit www.medicare.gov • Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help, • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). 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 whether or not you are required to pay a higher premium (a penalty).

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

October 12, 2016 Larimer County / Pam Stultz Benefits Manager 200 W. Oak Street, Suite 3200 Fort Collins, CO 80521 (970) 498-5983

Nothing in this notice gives you or your dependents a right to coverage under the Plan. Your (or your dependents’) right to coverage under the Plan is determined solely under the terms of the Plan.

Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

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Annual Notices

HIPAA COMPREHENSIVE NOTICE OF PRIVACY POLICY & PROCEDURES

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.

This Notice is provided to you on behalf of: Larimer County Medical Plan Larimer County Dental Plan Larimer County Vision Plan Larimer County Flexible Benefits Plan This notice pertains only to healthcare coverage provided under the plan. These plans comprise what is called an “Affiliated Covered Entity,” and are treated as a single plan for purposes of this Notice and the privacy rules that require it. For purposes of this Notice, we’ll refer to these plans as a single “Plan.” The Plan’s Duty to Safeguard Your Protected Health Information Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for the health care is considered “Protected Health Information” (“PHI”). The Plan is required to extend certain protections to your PHI, and to give you this Notice about its privacy practices that explains how, when and why the Plan may use or disclose your PHI. Except in specified circumstances, the Plan may use or disclose only the minimum necessary PHI to accomplish the purpose of the use or disclosure. The Plan is required to follow the privacy practices described in this Notice, though it reserves the right to change those practices and the terms of this Notice at any time. If it does so, and the change is material, you will receive a revised version of this Notice either by hand delivery, mail delivery to your last known address, or some other fashion. This Notice, and any material revisions of it, will also be provided to you in writing upon your request (ask your Human Resources representative, or contact the Plan’s Privacy Official, described below), and will be posted on any website maintained by Larimer County that describes benefits available to employees and dependents. You may also receive one or more other privacy notices, from insurance companies that provide benefits under the Plan. Those notices will describe how the insurance companies use and disclose PHI, and your rights with respect to the PHI they maintain. How the Plan May Use and Disclose Your Protected Health Information The Plan uses and discloses PHI for a variety of reasons. For its routine uses and disclosures it does not require your authorization, but for other uses and disclosures, your authorization (or the authorization of your personal representative (e.g., a person who is your custodian, guardian, or has your power-of-attorney) may be required. The following offers more description and examples of the Plan’s uses and disclosures of your PHI.

Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations. • Treatment: Generally, and as you would expect, the Plan is permitted to disclose your PHI for purposes of your medical treatment. Thus, it may disclose your PHI to doctors, nurses, hospitals, emergency medical technicians, pharmacists and other health care professionals where the disclosure is for your medical treatment. For example, if you are injured in an accident, and it’s important for your treatment team to know your blood type, the Plan could disclose that PHI to the team in order to allow it to more effectively provide treatment to you. • Payment: Of course, the Plan’s most important function, as far as you are concerned, is that it pays for all or some of the medical care you receive (provided the care is covered by the Plan). In the course of its payment operations, the Plan receives a substantial amount of PHI about you. For example, doctors, hospitals and pharmacies that provide you care send the Plan detailed information about the care they provided, so that they can be paid for their services. The Plan may also share your PHI with other plans, in certain cases. For example, if you are covered by more than one health care plan (e.g., covered by this Plan, and your spouse’s plan, or covered by the plans covering your father and mother), we may share your PHI with the other plans to coordinate payment of your claims. • Health care operations: The Plan may use and disclose your PHI in the course of its “health care operations.” For example, it may use your PHI in evaluating the quality of services you received, or disclose your PHI to an accountant or attorney for audit purposes. In some cases, the Plan may disclose your PHI to insurance companies for purposes of obtaining various insurance coverage. However, the Plan will not disclose, for underwriting purposes, PHI that is genetic information. Other Uses and Disclosures of Your PHI Not Requiring Authorization. The law provides that the Plan may use and disclose your PHI without authorization in the following circumstances: • To the Plan Sponsor: The Plan may disclose PHI to the employers (such as Larimer County) who sponsor or maintain the Plan for the benefit of employees and dependents. However, the PHI may only be used for limited purposes, and may not be used for purposes of employment-related actions or decisions or in connection with any other benefit or employee benefit plan of the employers. PHI

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Annual Notices

HIPAA COMPREHENSIVE NOTICE OF PRIVACY POLICY & PROCEDURES (cont''d)

• • • • • • • •

may be disclosed to: the human resources or employee benefits department for purposes of enrollments and disenrollments, census, claim resolutions, and other matters related to Plan administration; payroll department for purposes of ensuring appropriate payroll deductions and other payments by covered persons for their coverage; information technology department, as needed for preparation of data compilations and reports related to Plan administration; finance department for purposes of reconciling appropriate payments of premium to and benefits from the Plan, and other matters related to Plan administration; internal legal counsel to assist with resolution of claim, coverage and other disputes related to the Plan’s provision of benefits. To the Plan’s Service Providers: The Plan may disclose PHI to its service providers (“business associates) who perform claim payment and plan management services. The plan requires a written contract that obligates the business associate to safeguard and limit the use of PHI. Required by law: The Plan may disclose PHI when a law requires that it report information about suspected abuse, neglect or domestic violence, or relating to suspected criminal activity, or in response to a court order. It must also disclose PHI to authorities that monitor compliance with these privacy requirements. For public health activities: The Plan may disclose PHI when required to collect information about disease or injury, or to report vital statistics to the public health authority. For health oversight activities: The Plan may disclose PHI to agencies or departments responsible for monitoring the health care system for such purposes as reporting or investigation of unusual incidents. Relating to decedents: The Plan may disclose PHI relating to an individual's death to coroners, medical examiners or funeral directors, and to organ procurement organizations relating to organ, eye, or tissue donations or transplants. For research purposes: In certain circumstances, and under strict supervision of a privacy board, the Plan may disclose PHI to assist medical and psychiatric research. To avert threat to health or safety: In order to avoid a serious threat to health or safety, the Plan may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm. For specific government functions: The Plan may disclose PHI of military personnel and veterans in certain situations, to correctional facilities in certain situations, to government programs relating to eligibility and enrollment, and for national security reasons.

Uses and Disclosures Requiring Authorization: For uses and disclosures beyond treatment, payment and operations purposes, and for reasons not included in one of the exceptions described above, the Plan is required to have your written authorization. For example, uses and disclosures of psychotherapy notes, uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI would require your authorization. Your authorizations can be revoked at any time to stop future uses and disclosures, except to the extent that the Plan has already undertaken an action in reliance upon your authorization. Uses and Disclosures Requiring You to have an Opportunity to Object: The Plan may share PHI with your family, friend or other person involved in your care, or payment for your care. We may also share PHI with these people to notify them about your location, general condition, or death. However, the Plan may disclose your PHI only if it informs you about the disclosure in advance and you do not object (but if there is an emergency situation and you cannot be given your opportunity to object, disclosure may be made if it is consistent with any prior expressed wishes and disclosure is determined to be in your best interests; you must be informed and given an opportunity to object to further disclosure as soon as you are able to do so). Your Rights Regarding Your Protected Health Information You have the following rights relating to your protected health information: • To request restrictions on uses and disclosures: You have the right to ask that the Plan limit how it uses or discloses your PHI. The Plan will consider your request, but is not legally bound to agree to the restriction. To the extent that it agrees to any restrictions on its use or disclosure of your PHI, it will put the agreement in writing and abide by it except in emergency situations. The Plan cannot agree to limit uses or disclosures that are required by law. • To choose how the Plan contacts you: You have the right to ask that the Plan send you information at an alternative address or by an alternative means. To request confidential communications, you must make your request in writing to the Privacy Official. We will not ask you the reason for your request. Your request must specify how or where you wish to be contacted. The Plan must agree to your request as long as it is reasonably easy for it to accommodate the request. • To inspect and copy your PHI: Unless your access is restricted for clear and documented treatment reasons, you have a right to see your PHI in the possession of the Plan or its vendors if you put your request in writing. The Plan, or someone on behalf of the Plan, will respond to your request, normally within 30 days. If your request is denied, you will receive written reasons for the denial and an explanation of any right to have the denial reviewed. If you want copies of your PHI, a charge for copying may be imposed but may be waived, depending on your circumstances. You have a right to choose what portions of your information you want copied and to receive, upon request, prior information on the cost of copying. • To request amendment of your PHI: If you believe that there is a mistake or missing information in a record of your PHI held by the Plan or one of its vendors, you may request, in writing, that the record be corrected or supplemented. The Plan or someone on its behalf will respond, normally within 60 days of receiving your request. The Plan may deny the request if it is determined that the PHI is: (i) correct and

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Annual Notices

HIPAA COMPREHENSIVE NOTICE OF PRIVACY POLICY & PROCEDURES (cont'd)

complete; (ii) not created by the Plan or its vendor and/or not part of the Plan’s or vendor’s records; or (iii) not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response that you provide, appended to your PHI. If the request for amendment is approved, the Plan or vendor, as the case may be, will change the PHI and so inform you, and tell others that need to know about the change in the PHI. • To find out what disclosures have been made: You have a right to get a list of when, to whom, for what purpose, and what portion of your PHI has been released by the Plan and its vendors, other than instances of disclosure for which you gave authorization, or instances where the disclosure was made to you or your family. In addition, the disclosure list will not include disclosures for treatment, payment, or health care operations. The list also will not include any disclosures made for national security purposes, to law enforcement officials or correctional facilities, or before the date the federal privacy rules applied to the Plan. You will normally receive a response to your written request for such a list within 60 days after you make the request in writing. Your request can relate to disclosures going as far back as six years. There will be no charge for up to one such list each year. There may be a charge for more frequent requests.

How to Complain about the Plan’s Privacy Practices If you think the Plan or one of its vendors may have violated your privacy rights, or if you disagree with a decision made by the Plan or a vendor about access to your PHI, you may file a complaint with the person listed in the section immediately below. You also may file a written complaint with the Secretary of the U.S. Department of Health and Human Services. The law does not permit anyone to take retaliatory action against you if you make such complaints. Notification of a Privacy Breach Any individual whose unsecured PHI has been, or is reasonably believed to have been used, accessed, acquired or disclosed in an unauthorized manner will receive written notification from the Plan within 60 days of the discovery of the breach. If the breach involves 500 or more residents of a state, the Plan will notify prominent media outlets in the state. The Plan will maintain a log of security breaches and will report this information to HHS on an annual basis. Immediate reporting from the Plan to HHS is required if a security breach involves 500 or more people. Contact Person for Information, or to Submit a Complaint If you have questions about this Notice please contact the Plan’s Privacy Official or Deputy Privacy Official(s) (see below). If you have any complaints about the Plan’s privacy practices, handling of your PHI, or breach notification process, please contact the Privacy Official or an authorized Deputy Privacy Official. Privacy Official The Plan’s Privacy Official, the personal responsible for ensuring compliance with this Notice, is: Bridget Paris Human Resources Director 970-498-5976 Organized Health Care Arrangement Designation The Plan participates in what the federal privacy rules call an “Organized Health Care Arrangement.” The purpose of that participation is that it allows PHI to be shared between the members of the Arrangement, without authorization by the persons whose PHI is shared, for health care operations. Primarily, the designation is useful to the Plan because it allows the insurers who participate in the Arrangement to share PHI with the Plan for purposes such as shopping for other insurance bids. The members of the Organized Health Care Arrangement are: UMR Medical Plan Delta Dental Dental Care Plan Vision Service Plan Vision Plan WageWorks Flexible Benefits Plan Effective Date

The effective date of this Notice is: January 1, 2017

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Annual Notices

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 later 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 towards your or your dependents’ other coverage). Loss of eligibility includes but is not limited to: • Loss of eligibility for coverage as a result of ceasing to meet the plan’s eligibility requirements (i.e., legal separation, divorce, cessation of dependent status, death of an employee, termination of employment, reduction in the number of hours of employment); • Loss of HMO coverage because the person no longer resides or works in the HMO service area and no other coverage option is available through the HMO plan sponsor; • Elimination of the coverage option a person was enrolled in, and another option is not offered in its place; • Failing to return from an FMLA leave of absence; and • Loss of coverage under Medicaid or the Children’s Health Insurance Program (CHIP). Unless the event giving rise to your special enrollment right is a loss of coverage under Medicaid or CHIP, you must request enrollment within 31 days after your or your dependent’s(s’) other coverage ends (or after the employer that sponsors that coverage stops contributing toward the coverage). If the event giving rise to your special enrollment right is a loss of coverage under Medicaid or the CHIP, you may request enrollment under this plan within 60 days of the date you or your dependent(s) lose such coverage under Medicaid or CHIP. Similarly, if you or your dependent(s) become eligible for a state-granted premium subsidy towards this plan, you may request enrollment under this plan within 60 days after the date Medicaid or CHIP determine that you or the dependent(s) qualify for the subsidy. 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 within 31 days after the marriage, birth, adoption, or placement for adoption. To request special enrollment or obtain more information, contact: Pam Stultz Benefits Manager (970) 498-5983 * This notice is relevant for healthcare coverages subject to the HIPAA portability rules.

WOMEN'S HEALTH AND CANCER RIGHTS NOTICE

Larimer County Employee Health Care Plan is required by law to provide you with the following notice: The Women’s Health and Cancer Rights Act of 1998 (“WHCRA”) provides certain protections for individuals receiving mastectomy-related benefits. Coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: • • • •

All stages of reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; Prostheses; and Treatment of physical complications of the mastectomy, including lymphedemas.

The Larimer County Employee Health Care Plan provide(s) medical coverage for mastectomies and the related procedures listed above, subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. Therefore, the following deductibles and coinsurance apply: Standard PPO: In-Network: $1,000/$2,000 individual/ family deductible; 20% coinsurance Choice PPO: $500/$1,000 individual / family deductible; 10% coinsurance If you would like more information on WHCRA benefits, please refer to your Summary Plan Description or contact your Plan Administrator, UMR, at 800-826-9781.

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Annual Notices

NOTICE OF NO OBLIGATION FOR PRE-AUTHORIZATION FOR OB/GYN CARE

You do not need prior authorization from Larimer County Employee Health Care Plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact UMR at (800) 826-9781.

Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

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Annual Notices

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). ALABAMA - Medicaid

ALASKA - Medicaid

web: www.myalhipp.com phone: 1-855-692-5447

web: http://health.hss.state.ak/us/dpa/programs/medicaid phone: 1-888-318-8890 (outside of Anchorage) phone: 907-269-6529 (Anchorage)

COLORADO - Medicaid

FLORIDA - Medicaid

web: www.colorado.gov/hcpf phone: 1-800-221-3943

web: www.flmedicaidtplrecovery.com phone: 1-877-357-3268

GEORGIA - Medicaid

INDIANA - Medicaid

Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP).

web: http://dch.georgia.gov phone: 404-656-4507

web: www.in.gov/fssa phone: 1-800-889-9949

IOWA - Medicaid

KANSAS - Medicaid

web: www.dhs.state.ia.us/hipp phone: 1-888-346-9562

web: www.kdheks.gov/hcf phone: 1-800-792-4884

KENTUCKY - Medicaid

LOUISIANA - Medicaid

web: http://chfs.ky.gov/dms/default.htm phone: 1-800-635-2570

web: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 phone: 1-888-695-2447

MAINE - Medicaid

MASSACHUSETTS - Medicaid

web: www.maine.gov/dhhs/ofi/public-assistance/index.html phone: 1-800-977-6740 TTY: 1-800-977-6741

web: www.mass.gov/MassHealth phone: 1-800-462-1120

MINNESOTA - Medicaid

MISSOURI - Medicaid

web: www.dhs.state.mn.us/id_006254 Click on Health Care, then Medical Assistance. phone: 1-800-657-3739

web: www.dss.mo.gov/mhd/participants/pages/hipp.htm phone: 573-751-2005

MONTANA - Medicaid

NEBRASKA - Medicaid

web: http://medicaid.mt.gov/member phone: 1-800-694-3084

web: www.ACCESSNebraska.ne.gov phone: 1-855-632-7633

NEVADA - Medicaid

NEW HAMPSHIRE - Medicaid

web: http://dwss.nv.gov phone: 1-800-992-0900

web: www.dhhs.nh.gov/oii/documents/hippapp.pdf phone: 603-271-5218

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NEW JERSEY - Medicaid & CHIP

Annual Notices NEW YORK - Medicaid

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

web: www.nyhealth.gov/health_care/medicaid phone: 1-800-541-2831

NORTH CAROLINA - Medicaid

NORTH DAKOTA - Medicaid

web: www.ncdhhs.gov/dma phone: 919-855-4100

web: www.nd.gov/dhs/services/medicalserv/medicaid phone: 1-800-755-2604

OKLAHOMA - Medicaid & CHIP

OREGON - Medicaid

web: www.insureoklahoma.org phone: 1-888-365-3742

web: www.oregonhealthykids.gov web: www.hijossaludablesoregon.gov phone: 1-800-699-9075

PENNSYLVANIA - Medicaid

RHODE ISLAND - Medicaid

web: www.dhs.state.pa.us/hipp phone: 1-800-692-7462

web: www.eohhs.ri.gov phone: 401-462-5300

SOUTH CAROLINA - Medicaid

SOUTH DAKOTA - Medicaid

web: www.scdhhs.gov phone: 1-888-549-0820

web: www.dss.sd.gov phone: 1-888-828-0059

TEXAS - Medicaid

UTAH - Medicaid

web: www.gethipptexas.com phone: 1-800-440-0493

web (Medicaid): http://health.utah.gov/medicaid web (CHIP): http://health.utah.gov/chip phone: 1-866-435-7414

VERMONT - Medicaid

VIRGINIA - Medicaid & CHIP

web: www.greenmountaincare.org phone: 1-800-250-8427

web: www.coverva.org/programs_premium_assistance.cfm Medicaid phone: 1-800-432-5924 CHIP phone: 1-855-242-8282

WASHINGTON - Medicaid

WEST VIRGINIA - Medicaid

web: www.hea.wa.gov/medicaid/premiumpymt/pages/index.aspx phone: 1-800-562-3022 ext. 15473

web: www.dhhr.wv.gov/bms/medicaid%20Expansion/Pages/default.aspx phone: 1-877-598-5820, HMS Third Party Liability

WISCONSIN - Medicaid & CHIP

WYOMING - Medicaid

web: www.dhs.wisconsin.gov/badgercareplus/p-10095.htm phone: 1-800-362-3002

web: https://wyequalitycare.acs-inc.com phone: 307-777-7531

To see if any other states have added a premium assistance program since July 31, 2015, or for more information on special enrollment rights, contact either: US Department of Labor US Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 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 [email protected] and reference the OMB Control Number 1210-0137 OMB Control Number 1210-0137 (expires 10/31/2016)

Your health.Your money. Your choice. 2017 Benefits Open Enrollment Booklet

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Benefit Vendor Contact Information GROUP NUMBER

CONTACT NUMBER

BASIC LIFE INSURANCE

679054

(970) 498-5983 (970) 498-5986

Contact County Benefits Staff

DEFERRED COMPENSATION (457)

406342

1-800-842-2252

www.tiaa-cref.org/larimer

11386

1-800-610-0201

www.deltadentalco.com

EMPLOYEE ASSISTANCE PROGRAM

COM589

1-800-272-7255

www.guidanceresources.com

FLEXIBLE SPENDING ACCOUNTS

3214

1-800-950-0105

www.takecareWageWorks.com

1-866-956-5400

www.epichearing.com

679054

(970) 498-5983 (970) 498-5986

Contact County Benefits Staff

76-411073

1-800-320-3206

www.umr.com

1-800-424-0472

www.magellanrx.com

INSURANCE TYPE

BENEFIT VENDOR

DENTAL INSURANCE

HEARING SERVICES PLAN

LONG-TERM DISABILITY

MEDICAL INSURANCE

PRESCRIPTION PLAN

WEBSITE

RETIREMENT PLAN (401A)

406341

1-800-842-2252

www.tiaa-cref.org/larimer

SHORT-TERM DISABILITY

679054

1-866-228-8742

n/a

Amy Griffin (970) 530-1208

www.aflac.com

12065186

1-800-877-7195

www.vsp.com

VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT

679054

(970) 498-5983 (970) 498-5986

Contact County Benefits Staff

SUPPLEMENTAL LIFE INSURANCE

679054

(970) 498-5983 (970) 498-5986

Contact County Benefits Staff

SUPPLEMENTAL INSURANCE POLICIES VISION INSURANCE

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Benefits Open Enrollment -

Nov 2, 2016 - dentist. You may also call Customer Relations at 1-800-610-0201. Coverage ..... Travel related expenses for treatment in distant medical centers, including airfare, hotels, and meals. ...... web: https://wyequalitycare.acs-inc.com.

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signature on the Weekly Order Pickup List indicates you have received your ... 7) You must sign a WAIVER OF RESPONSIBILITY form before certificates will be ...

Enrollment Form.pdf
Home Phone Cell Phone Home Phone Cell Phone. Email Email. Place of Employment Work Phone Place of Employment Work Phone. If parents reside at ...

Enrollment Form.pdf
Student Lives with: Y N OK to pick up: Y N Legal Custody: Y N Receives Mail: Y N. First Name Last Name Relationship. Street Address. City Zip Code.

pdf-1433\friends-wanting-benefits-friends-with-benefits-prequel ...
... of the apps below to open or edit this item. pdf-1433\friends-wanting-benefits-friends-with-benefits-prequel-series-book-1-volume-1-by-luke-young.pdf.

Running head: BENEFITS OF MUSIC 1 BENEFITS ...
several occasions in which students were singing along with the music and moving their bodies in response to what they were hearing on the software. The researchers concluded that the enjoyment levels of students who participated in the web-based pro

Fringe Benefits
Page 1 of 8. US Department of Labor DBRA Compliance. Davis-Bacon Resource Book 11/2002 Principles. FRINGE BENEFITS. Definition (29 CFR 5.2(p)):.

Employee Benefits
(c) Other long-term employee benefits, which may include long-service leave or sabbatical leave, jubilee or other long-service benefits, long-term disability ...