36
Benefits Enrollment Guide 2021-2022
Benefits Enrollment Guide
2021-2022
The following descriptions of available benefit elections options are purely informational and have been provided to you for illustrative purposes only Payment of benefits will vary from claim to claim within a particular benefit option and will be paid at the sole discretion of the applicable insurance provider for each benefit option The terms and conditions of each applicable policy or certificate of coverage will provide specific details and will govern in all matters relating to each particular benefit option described in this summary In no case will any information in this summary amend modify expand enhance improve or otherwise change any term condition or element of the policies or certificates of coverage that govern the benefit options described in this summary
2
TABLE OF CONTENTS
Presented by
Enrollment and Eligibility 3
Advanced Resolution Team 4
Medical Plans 6
LiveHealth Online 7
Health Savings Accounts 8
Flexible Spending Accounts 9
Dental Plans 10
Vision Plans 11
Medical Dental Vision Rates 12
Sydney App 13
Voluntary Term Life Insurance 14
Voluntary Whole Life Insurance 15
Voluntary Short Term Disability 16
Voluntary Accident Insurance 17
Voluntary Critical Illness 18
Voluntary Hospital Plan 19
Employee Assistance Program 20
Voluntary Pet Insurance 21
Required Notices 22
Confidentiality Notice 27
Carrier Contact Information 28
Glossary of Insurance Terms 29
3
Qualifying EventGenerally you may enroll in the plan or make changes to your benefits when you are first eligible However you can make changesenroll during the plan year if you experience a qualifying event As with a new enrollee you must submit your paperwork within 30 days of the change or you will be considered a late enrollee and you may not be eligible to enroll
Examples of qualifying events
bull You get married or divorced
bull You have a baby or adopt a child
bull You or your spouse takes an unpaid leave of absence
bull You or your spouse has a change in employment status
bull Your spouse dies
bull You become eligible for or lose Medicaid coverage
bull Significant increase or decrease in plan benefits or cost
How to Enroll in the PlansRead your materials and make sure you understand all of the options available
bull Contact HR for the enrollment forms
bull Fill out any necessary personal information
bull Make your benefit choices
bull If you have questions or concerns please contact your HR department
Whom Can You Add to Your PlanEligible
bull Legally married spouse
bull Natural or adopted children up to age 26 regardless of student and marital status
bull Children under your legal guardianship
bull Stepchildren
bull Children under a qualified medical child support order
bull Disabled children 19 years or older
bull Children placed in your physical custody for adoption
Ineligible
bull Divorced or legally separated spouse
bull Common law spouse even if recognized by your state
bull Domestic partners unless your employer states otherwise
bull Foster children
bull Sisters brothers parents or in-laws grandchildren etc
Offering a comprehensive and competitive benefits package is one way we recognize your contribution to the success of the organization and our role in helping you and your family to be healthy feel secure and maintain worklife balance This enrollment guide has been designed to provide you with information about the benefit choices available to you Remember open enrollment is your only opportunity each year to make changes to your elections unless you or your family members experience an eligible ldquoqualifying eventldquo New hires are eligible for benefits on the first of the month following their date of hire
ENROLLMENT AND ELIGIBILITY
Open Enrollment is the only chance to make changes unless you experience a ldquoqualifying eventrdquo
4
ADVANCED RESOLUTION TEAM
Through our Advanced Resolution Team you have access to live representatives who will help you get the most out of your benefits and answer your questions
The OneDigital Advanced Resolution Team can help educate you about your benefits and teach you how to navigate within the healthcare system
bull Help you with enrollment changes including ID card requests
bull Coverage assistance
bull Facilitate resolution on billing issues
bull Assist you with claims
bull Locate in-network providers
bull And much much more
Advanced Resolution TeamWe are available by phone or email
Call (866) 802-6311Email artonedigitalcom
Monday through Friday 8am to 5pm (EST)
5
PACKAGE OVERVIEW
New Kent County offers eligible employees a comprehensive benefit package that provides both financial stability and protection Our offering provides flexibility for employees to design a package to meet their unique needs
bull Anthem Medical and Vision Delta Dental plans through The Local Choice
bull Voluntary Whole Life Voluntary Short Term Disability Voluntary Accident Voluntary Critical Illness Voluntary Hospital Plan through Aflac
bull Anthem Employee Assistance Program through The Local Choice
bull Voluntary Pet Insurance through Nationwide
After you have enrolled in coverage you will receive additional information in the mail from the insurance carriers This information will contain your personal identification cards In the meantime you can look up the appropriate participating providers online Please see page 28 of this guide for a list of carrier websites
6
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
MEDICAL PLAN OPTIONS ndash ANTHEM
For this plan year you can choose from the following medical plans Refer to the carrier benefit summaries for the exact benefit level associated with your plan
In Network Benefits Key Advantage $250 Key Advantage $500 HDHP $2800
Referrals Required No No No
Plan Accumulator Plan Year Plan Year Plan Year
Annual Deductible(embedded)
$250 individual$500 family
$500 individual$1000 family
$2800 individual $5600 family
Coinsurance 20 20 20
Maximum Out-of-Pocket$3000 individual
$6000 family$4000 individual
$8000 family$5000 individual $10000 family
Preventive Care Covered 100 Covered 100 Covered 100
Physicianrsquos Office VisitsPCP $20
Specialist $35Virtual Visit $0
PCP $25Specialist $40Virtual Visit $0
20 after deductibleVirtual Visit
determined by services rendered
Urgent CarePCP $20
Specialist $35PCP $25
Specialist $4020 after deductible
Emergency Room Facility $350 copay per visit 20 after deductible 20 after deductible
Inpatient Facility $400 copay per stay 20 after deductible 20 after deductible
Outpatient Facility $150 copay 20 after deductible 20 after deductible
Diagnostic Lab Services 20 after deductible 20 after deductible 20 after deductible
Advanced Imaging Services
20 after deductible 20 after deductible 20 after deductible
Pharmacy Prescription Drugs
$10$30$45$55 $10$30$45$55 20 after deductible
Mail Order Prescription Drugs
$20$60$90$110 $20$60$90$110 20 after deductible
Out of Network Benefits Key Advantage $250 Key Advantage $500 HDHP $2800
Annual Deductible$500 individual$1000 family
$1000 individual$2000 family
Deductible is combined for In and Out of
Network
Maximum Out-of-Pocket$5000 individual$10000 family
$7000 individual$14000 family
$10000 individual$20000 family
Coinsurance 30 30 40
7
TELEMEDICINE ndash LIVEHEALTH ONLINE
What is Telemedicine bull Telemedicine uses technology to facilitate communication
between a doctor and patient who are not in the same physical location for medical evaluation diagnosis and treatment
bull Speak to a real live doctor 247365
bull All doctors are US Board Certified licensed to practice medicine and write prescriptions in the state the caller is located in
bull 100 HIPAA Compliant
bull Designed for non-emergency care 71 of all medical visits today are non-emergency
Common issues treated via LiveHealth Onlinebull Allergies
bull CoughCold or Flu
bull Pinkeye
bull Sore throat
bull Sinus Infection
bull Stomachache
Enroll for free at wwwlivehealthonlinecom
8
HEALTH SAVINGS ACCOUNT (HSA) ndash WEXDISCOVERY BENEFITS
Option for theHigh Deductible Health Plan
Employees who enroll in the High Deductible Health Plan offered through New Kent County have the option of opening a Health Savings Account (HSA) This HSA eligible plan provides a way to save money that is available in future years for health care expensesbull For 2021 New Kent County will contribute
$1000 for individuals who enroll in the HDHP and $2000 for employees with any dependents enrolled You will receive half of the employer contribution in the July 15 2021 pay period and the other half in the January 15 2022 pay period
bull In 2021 individuals can contribute up to $3600 and families can contribute up to $7200 to their HSA
bull If you are 55 or older you can make a $1000 catch-up contribution
bull Contributions to an HSA can be made on a pre-tax or post-tax basis and funds within the HSA grow without incurring taxes Funds are withdrawn tax-free for healthcare related needs without having to file receipts although you should keep your receipts in case you are ever audited
bull Money deposited in the HSA by the employee AND employer immediately become the employeersquos asset and is portable
The benefit plan information shown in this guide is illustrative only This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
Pre-Tax PlanWhat is this account
and how does it work Maximum Contribution
AllowedCan money in accounts
be ldquorolled overrdquo
Health Savings Account (HSA)
A HSA can be funded with pre-tax dollars to
help pay for eligible medical expenses
Employee only coverage $3600
Family coverage $7200
Catch up contribution (55 year of age or
older) $1000
Yes amounts left in your HSA can be rolled over year to year and are portable if your employment ends
9
FLEXIBLE SPENDING ACCOUNTS (FSA) ndash WEXDISCOVERY BENEFITS
If you are enrolling in the High Deductible Health Plan and contributing to a Health Savings Account you cannot open a Flexible Spending Account
Who is Eligible
All Full-Time Employees working at least 30 hours each week
Benefits You Receive
FSAs provide you with an important tax advantage that can help you pay health care and dependent care expenses on a pretax basis By anticipating your familyrsquos health care and dependent care costs for the next year you can actually lower your taxable income
Health Care Reimbursement FSA
This program lets employees pay for certain IRS-approved medical care expenses and prescriptions not covered by their insurance plan with pretax dollars The annual pretax maximum amount you may contribute to the Health Care Reimbursement FSA is $2750This limit will be indexed for cost-of-living adjustments You can rollover up to $550 into the following plan year Some examples of eligible expenses include
bull Hearing services including hearing aids and batteries
bull Vision services including contact lenses contact lens solution eye examinations and eyeglasses
bull Dental services and orthodontia
bull Chiropractic services
bull Acupuncture
bull Prescription contraceptives
Dependent Care FSA
The Dependent Care FSA lets employees use pretax dollars toward qualified dependent care such as caring for children under the age 13 or caring for elders The annual maximum amount you may contribute to the Dependent Care FSA is $5000 (or $2500 if married and filing separately) per calendar year Examples include
bull The cost of child or adult dependent care
bull The cost for an individual to provide care either in or out of your house
bull Nursery schools and preschools (excluding kindergarten)
The benefit plan information shown in this guide is illustrative only This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
10
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
DENTAL PLAN ndash DELTA DENTAL
One can of soda is the amount of sugar
recommended for three days for a child
Sugary Sodas are a major risk factor for
tooth decay
Source American Dental Association (ADA)
For this plan year dental coverage is offered through The Local Choice and administered by Delta Dental Refer to the carrier benefit summary for the exact benefit level associated with your plan
In Network Benefits Comprehensive
DentalPreventive Dental
Individual Annual Maximum
$1500 None
Annual Deductible$25 Individual
$50 Two People$75 Family
None
Preventive Services (exams cleaning x-rays
fluoride etc)100 100
Basic Services(fillings root canals periodontics simple
extractions etc)
80 afterdeductible
Not covered
Major Services(crowns dentures
bridges etc)
50 after deductible
Not covered
Orthodontic Services(Adult and Child)
50 to $1500 lifetime maximum
Not covered
Out of Network BenefitsOut of network benefits mirror in network benefits However out of
network providers may balance bill
11
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VISION PLAN ndash ANTHEM
Your eyes need a rest even while yoursquore awake Use the 20-20-20 rule to reduce eyestrain After
working for 20 minutes look away about 20 feet in front of you for
about 20 seconds
Source National Eye Institute httpsneinihgovhealthhealthyeyes
For this plan year vision coverage is offered through The Local Choice and administered by Anthem Blue View Vision Refer to the carrier benefit summary for the exact benefit level associated with your plan
In-NetworkOut of
Network
Key Advantage
$250
Key Advantage
$500HDHP $2800
Allowance for All Plans
Annual Exam
$35 copay $40 copay $15 copay$50
allowance
LensesSingleBifocalTrifocal
$20 copay $20 copay $20 copay
$50$75
$100
ContactLensesin lieu of glasses lenses
$100 allowance+ 15 off remaining
balance
$100 allowance + 15 off remaining
balance
$100 allowance+ 15 off remaining
balance
$80
Frames
$100 allowance+ 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$80
FrequencyExamLensesFrames
Once every 12 monthsOnce every 12 monthsOnce every 12 months
12
2021-2022 MEDICAL DENTAL AND VISION PER PAY DEDUCTIONS
Key Advantage $250 Plan
ComprehensiveDental amp Vision
Key Advantage $500 Plan
ComprehensiveDental amp Vision
HDHP $2800 ComprehensiveDental amp Vision
Employee Only $2500 $000 $000
Employee + One $21800 $19500 $16600
Employee Family $43600 $39000 $33250
Dual Enrollment Spouse
$5000 $000 $11150
Dual Enrollment Family
$31775 $29000 $22300
Key Advantage $250 Plan
Preventive Dentalamp Vision
Key Advantage $500 Plan
Preventive Dental amp Vision
HDHP $2800 Preventive Dental
amp Vision
Employee Only $2150 $000 $000
Employee + One $21150 $19000 $15800
Employee Family $42650 $38000 $31600
Dual Enrollment Spouse
$4300 $000 $10800
Dual Enrollment Family
$30900 $28000 $21600
Dual Enrollment = Both eligible employees work for New Kent County
Say hi to SydneyAnthemrsquos new app is s imple
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benefits -- personalized and all in one place Sydney makes it easier to get
things done so you can spend more time focused on your health
Get started with Sydney
Download the app today
Ready for you to use quickly easily
seamlessly mdash with one-click access
to benefits info Member Services
wellness resources and more
Sydney acts like a personal health
guide answering your questions
and connecting you to the right
resources at the right time And
you can use the chatbot to get
answers quickly
Get alerts reminders and tips
directly from Sydney Get doctor
suggestions based on your needs
The more you use it the more
Sydney can help you stay healthy
and save money
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Find care and check costs
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See claims
Already using one of our apps
Itrsquos easy to make the switch Simply
download the Sydney app and log in
with your Anthem username and password
Get answers even faster with
our chatbot
View and use digital ID cards
AnthemBlueCrossandBlueShield is the trade name of InColorado RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc InConnecticut AnthemHealth Plans Inc InGeorgia BlueCross BlueShield Healthcare Planof Georgia Inc In IndianaAnthemInsurance Companies Inc InKentuckyAnthemHealth Plans of Kentucky Inc InMaine AnthemHealth Plans of Maine Inc InMissouri (excluding 30 counties in the Kansas City area) RightCHOICEregManaged Care Inc (RIT)Healthy Alliancereg Life Insurance Company(HALIC) andHMOMissouri Inc RITandcertain affiliates administer non-HMObenefits underwritten byHALICandHMObenefits underwritten byHMOMissouri Inc RITandcertain affiliates onlyprovide administrative services for self-funded plans anddonot underwrite benefits InNevada RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc dba HMONevada InNewHampshire AnthemHealth Plans of NewHampshire Inc HMOplans are administered byAnthemHealth Plans of NewHampshire Inc andunderwritten byMatthewThorntonHealthPlan Inc In Ohio Community Insurance Company In Virginia Anthem Health Plans of Virginia Inc trades as Anthem Blue Cross and Blue Shield6in V4irginia and its service area is all of Virginia except for the City of Fairfax the Town of Vienna and the area east
of State Route 123 In Wisconsin
Blue Cross Blue Shield of Wisconsin (BCBSWI) underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC) Compcare underwrites or administers HMO or POS policies WCIC underwrites or administers Well Priority HMO or POS policies Independent licensees of the Blue Cross and Blue Shield Association Anthem is a registered trademark of Anthem Insurance Companies Inc
115993MUMENABS 0619
13
14
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life
You may purchase 15 or 30 year coverage up to $100000
Guaranteed Issue for new hires $25000
Spouse LifeYou may purchase up to $50000 Guaranteed
Issue $10000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
VOLUNTARY TERM LIFE ndash AFLAC
Voluntary Life coverage provides an additional benefit to the beneficiaries It provides a benefit to your
designated beneficiary in the event of your death and you can choose the term of coverage To be eligible
for coverage you must qualify as an eligible member (working at least 30 hours per week) and be
considered actively at work If you are not currently enrolled and make a Voluntary Life election for 2021
you will be subject to underwriting and required to answer medical questions to enroll If you have questions
or would like to enroll in coverage contact Rebecca Smith at Aflacsmithagencyinccom or 804-422-3522
15
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life You may purchase up to $300000Guaranteed Issue for new hires
$40000
Spouse LifeYou may purchase up to $100000
Guaranteed Issue $5000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
If you are not currently enrolled and make a Voluntary Life election for 2021 you will be subject to underwriting and required to answer medical questions to enroll Employees must enroll in order to elect dependent coverage If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
VOLUNTARY WHOLE LIFE ndash AFLAC
16
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY SHORT TERM DISABILITY INSURANCE
Only 48 percent of American adults indicate they have enough savings to cover three months of living expenses in the event they become disabled
Source Council for Disability Awareness httpdisabilitycanhappenorgdisability-statistic
3 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income ReplacedUp to 60 of base monthly earnings
Guarantee Issue up to $3000 per month
Maximum Benefit $6000 per week
Duration of Benefits 3 months
6 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income Replaced Up to 60 of base monthly earnings
Maximum Benefit$6000 per month
Guaranteed Issue up to $3000 per month
Duration of Benefits 6 months
All benefit eligible employees can choose to enroll in one of two Voluntary Short Term Disability plans Should you have an accident or an illness your benefit will be paid for either 3 or 6 months If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
12 month pre-existing clause still applies
17
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY ACCIDENT ndash AFLAC
This is not a complete list of all covered accidents Please consult the plan summary for more details If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
24 Hour On or Off Job Accident
Annual Wellness Benefit
Year 1 $25 per insuredYear 2-4 $50 per insuredYear 5+ $75 per insured
Does not include children
Initial Treatment
Doctorrsquos office or other facility $75Doctorrsquos office or other facility
with x-ray $100ERUrgent Care $150
ERUrgent Care with X-ray $200
Hospital Admission$900
Additional $225 per dayAdditional $525 per day
AmbulanceGround $300
Air $900
Burns Lacerations Fractures Dislocations Concussion etc
$75-$15000
Accidental Death $50000
Accidental Dismemberment Up to $17500
18
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY CRITICAL ILLNESS ndash AFLAC
Voluntary Critical Illness
Wellness Benefit$50 per year ndash Employeeand Spouse (if applicable)
Coverage Amount Options
New Employee Guaranteed Issue up to $20000If a spousedependent is covered under the employees
plan they can elect 50 of the employees coverageChildren are automatically covered at 50 with no
charge
Included Illness at 100Cancer heart attack stroke major organ transplant
end stage renal failure paralysis coma and major third-degree burns ndash and more
Pre-existing Conditions
12 month exclusion for pre-existing cancerNo pre-existing exclusions on other health benefits as
long as diagnosis is made after the plan is in effect
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
The following descriptions of available benefit elections options are purely informational and have been provided to you for illustrative purposes only Payment of benefits will vary from claim to claim within a particular benefit option and will be paid at the sole discretion of the applicable insurance provider for each benefit option The terms and conditions of each applicable policy or certificate of coverage will provide specific details and will govern in all matters relating to each particular benefit option described in this summary In no case will any information in this summary amend modify expand enhance improve or otherwise change any term condition or element of the policies or certificates of coverage that govern the benefit options described in this summary
2
TABLE OF CONTENTS
Presented by
Enrollment and Eligibility 3
Advanced Resolution Team 4
Medical Plans 6
LiveHealth Online 7
Health Savings Accounts 8
Flexible Spending Accounts 9
Dental Plans 10
Vision Plans 11
Medical Dental Vision Rates 12
Sydney App 13
Voluntary Term Life Insurance 14
Voluntary Whole Life Insurance 15
Voluntary Short Term Disability 16
Voluntary Accident Insurance 17
Voluntary Critical Illness 18
Voluntary Hospital Plan 19
Employee Assistance Program 20
Voluntary Pet Insurance 21
Required Notices 22
Confidentiality Notice 27
Carrier Contact Information 28
Glossary of Insurance Terms 29
3
Qualifying EventGenerally you may enroll in the plan or make changes to your benefits when you are first eligible However you can make changesenroll during the plan year if you experience a qualifying event As with a new enrollee you must submit your paperwork within 30 days of the change or you will be considered a late enrollee and you may not be eligible to enroll
Examples of qualifying events
bull You get married or divorced
bull You have a baby or adopt a child
bull You or your spouse takes an unpaid leave of absence
bull You or your spouse has a change in employment status
bull Your spouse dies
bull You become eligible for or lose Medicaid coverage
bull Significant increase or decrease in plan benefits or cost
How to Enroll in the PlansRead your materials and make sure you understand all of the options available
bull Contact HR for the enrollment forms
bull Fill out any necessary personal information
bull Make your benefit choices
bull If you have questions or concerns please contact your HR department
Whom Can You Add to Your PlanEligible
bull Legally married spouse
bull Natural or adopted children up to age 26 regardless of student and marital status
bull Children under your legal guardianship
bull Stepchildren
bull Children under a qualified medical child support order
bull Disabled children 19 years or older
bull Children placed in your physical custody for adoption
Ineligible
bull Divorced or legally separated spouse
bull Common law spouse even if recognized by your state
bull Domestic partners unless your employer states otherwise
bull Foster children
bull Sisters brothers parents or in-laws grandchildren etc
Offering a comprehensive and competitive benefits package is one way we recognize your contribution to the success of the organization and our role in helping you and your family to be healthy feel secure and maintain worklife balance This enrollment guide has been designed to provide you with information about the benefit choices available to you Remember open enrollment is your only opportunity each year to make changes to your elections unless you or your family members experience an eligible ldquoqualifying eventldquo New hires are eligible for benefits on the first of the month following their date of hire
ENROLLMENT AND ELIGIBILITY
Open Enrollment is the only chance to make changes unless you experience a ldquoqualifying eventrdquo
4
ADVANCED RESOLUTION TEAM
Through our Advanced Resolution Team you have access to live representatives who will help you get the most out of your benefits and answer your questions
The OneDigital Advanced Resolution Team can help educate you about your benefits and teach you how to navigate within the healthcare system
bull Help you with enrollment changes including ID card requests
bull Coverage assistance
bull Facilitate resolution on billing issues
bull Assist you with claims
bull Locate in-network providers
bull And much much more
Advanced Resolution TeamWe are available by phone or email
Call (866) 802-6311Email artonedigitalcom
Monday through Friday 8am to 5pm (EST)
5
PACKAGE OVERVIEW
New Kent County offers eligible employees a comprehensive benefit package that provides both financial stability and protection Our offering provides flexibility for employees to design a package to meet their unique needs
bull Anthem Medical and Vision Delta Dental plans through The Local Choice
bull Voluntary Whole Life Voluntary Short Term Disability Voluntary Accident Voluntary Critical Illness Voluntary Hospital Plan through Aflac
bull Anthem Employee Assistance Program through The Local Choice
bull Voluntary Pet Insurance through Nationwide
After you have enrolled in coverage you will receive additional information in the mail from the insurance carriers This information will contain your personal identification cards In the meantime you can look up the appropriate participating providers online Please see page 28 of this guide for a list of carrier websites
6
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
MEDICAL PLAN OPTIONS ndash ANTHEM
For this plan year you can choose from the following medical plans Refer to the carrier benefit summaries for the exact benefit level associated with your plan
In Network Benefits Key Advantage $250 Key Advantage $500 HDHP $2800
Referrals Required No No No
Plan Accumulator Plan Year Plan Year Plan Year
Annual Deductible(embedded)
$250 individual$500 family
$500 individual$1000 family
$2800 individual $5600 family
Coinsurance 20 20 20
Maximum Out-of-Pocket$3000 individual
$6000 family$4000 individual
$8000 family$5000 individual $10000 family
Preventive Care Covered 100 Covered 100 Covered 100
Physicianrsquos Office VisitsPCP $20
Specialist $35Virtual Visit $0
PCP $25Specialist $40Virtual Visit $0
20 after deductibleVirtual Visit
determined by services rendered
Urgent CarePCP $20
Specialist $35PCP $25
Specialist $4020 after deductible
Emergency Room Facility $350 copay per visit 20 after deductible 20 after deductible
Inpatient Facility $400 copay per stay 20 after deductible 20 after deductible
Outpatient Facility $150 copay 20 after deductible 20 after deductible
Diagnostic Lab Services 20 after deductible 20 after deductible 20 after deductible
Advanced Imaging Services
20 after deductible 20 after deductible 20 after deductible
Pharmacy Prescription Drugs
$10$30$45$55 $10$30$45$55 20 after deductible
Mail Order Prescription Drugs
$20$60$90$110 $20$60$90$110 20 after deductible
Out of Network Benefits Key Advantage $250 Key Advantage $500 HDHP $2800
Annual Deductible$500 individual$1000 family
$1000 individual$2000 family
Deductible is combined for In and Out of
Network
Maximum Out-of-Pocket$5000 individual$10000 family
$7000 individual$14000 family
$10000 individual$20000 family
Coinsurance 30 30 40
7
TELEMEDICINE ndash LIVEHEALTH ONLINE
What is Telemedicine bull Telemedicine uses technology to facilitate communication
between a doctor and patient who are not in the same physical location for medical evaluation diagnosis and treatment
bull Speak to a real live doctor 247365
bull All doctors are US Board Certified licensed to practice medicine and write prescriptions in the state the caller is located in
bull 100 HIPAA Compliant
bull Designed for non-emergency care 71 of all medical visits today are non-emergency
Common issues treated via LiveHealth Onlinebull Allergies
bull CoughCold or Flu
bull Pinkeye
bull Sore throat
bull Sinus Infection
bull Stomachache
Enroll for free at wwwlivehealthonlinecom
8
HEALTH SAVINGS ACCOUNT (HSA) ndash WEXDISCOVERY BENEFITS
Option for theHigh Deductible Health Plan
Employees who enroll in the High Deductible Health Plan offered through New Kent County have the option of opening a Health Savings Account (HSA) This HSA eligible plan provides a way to save money that is available in future years for health care expensesbull For 2021 New Kent County will contribute
$1000 for individuals who enroll in the HDHP and $2000 for employees with any dependents enrolled You will receive half of the employer contribution in the July 15 2021 pay period and the other half in the January 15 2022 pay period
bull In 2021 individuals can contribute up to $3600 and families can contribute up to $7200 to their HSA
bull If you are 55 or older you can make a $1000 catch-up contribution
bull Contributions to an HSA can be made on a pre-tax or post-tax basis and funds within the HSA grow without incurring taxes Funds are withdrawn tax-free for healthcare related needs without having to file receipts although you should keep your receipts in case you are ever audited
bull Money deposited in the HSA by the employee AND employer immediately become the employeersquos asset and is portable
The benefit plan information shown in this guide is illustrative only This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
Pre-Tax PlanWhat is this account
and how does it work Maximum Contribution
AllowedCan money in accounts
be ldquorolled overrdquo
Health Savings Account (HSA)
A HSA can be funded with pre-tax dollars to
help pay for eligible medical expenses
Employee only coverage $3600
Family coverage $7200
Catch up contribution (55 year of age or
older) $1000
Yes amounts left in your HSA can be rolled over year to year and are portable if your employment ends
9
FLEXIBLE SPENDING ACCOUNTS (FSA) ndash WEXDISCOVERY BENEFITS
If you are enrolling in the High Deductible Health Plan and contributing to a Health Savings Account you cannot open a Flexible Spending Account
Who is Eligible
All Full-Time Employees working at least 30 hours each week
Benefits You Receive
FSAs provide you with an important tax advantage that can help you pay health care and dependent care expenses on a pretax basis By anticipating your familyrsquos health care and dependent care costs for the next year you can actually lower your taxable income
Health Care Reimbursement FSA
This program lets employees pay for certain IRS-approved medical care expenses and prescriptions not covered by their insurance plan with pretax dollars The annual pretax maximum amount you may contribute to the Health Care Reimbursement FSA is $2750This limit will be indexed for cost-of-living adjustments You can rollover up to $550 into the following plan year Some examples of eligible expenses include
bull Hearing services including hearing aids and batteries
bull Vision services including contact lenses contact lens solution eye examinations and eyeglasses
bull Dental services and orthodontia
bull Chiropractic services
bull Acupuncture
bull Prescription contraceptives
Dependent Care FSA
The Dependent Care FSA lets employees use pretax dollars toward qualified dependent care such as caring for children under the age 13 or caring for elders The annual maximum amount you may contribute to the Dependent Care FSA is $5000 (or $2500 if married and filing separately) per calendar year Examples include
bull The cost of child or adult dependent care
bull The cost for an individual to provide care either in or out of your house
bull Nursery schools and preschools (excluding kindergarten)
The benefit plan information shown in this guide is illustrative only This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
10
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
DENTAL PLAN ndash DELTA DENTAL
One can of soda is the amount of sugar
recommended for three days for a child
Sugary Sodas are a major risk factor for
tooth decay
Source American Dental Association (ADA)
For this plan year dental coverage is offered through The Local Choice and administered by Delta Dental Refer to the carrier benefit summary for the exact benefit level associated with your plan
In Network Benefits Comprehensive
DentalPreventive Dental
Individual Annual Maximum
$1500 None
Annual Deductible$25 Individual
$50 Two People$75 Family
None
Preventive Services (exams cleaning x-rays
fluoride etc)100 100
Basic Services(fillings root canals periodontics simple
extractions etc)
80 afterdeductible
Not covered
Major Services(crowns dentures
bridges etc)
50 after deductible
Not covered
Orthodontic Services(Adult and Child)
50 to $1500 lifetime maximum
Not covered
Out of Network BenefitsOut of network benefits mirror in network benefits However out of
network providers may balance bill
11
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VISION PLAN ndash ANTHEM
Your eyes need a rest even while yoursquore awake Use the 20-20-20 rule to reduce eyestrain After
working for 20 minutes look away about 20 feet in front of you for
about 20 seconds
Source National Eye Institute httpsneinihgovhealthhealthyeyes
For this plan year vision coverage is offered through The Local Choice and administered by Anthem Blue View Vision Refer to the carrier benefit summary for the exact benefit level associated with your plan
In-NetworkOut of
Network
Key Advantage
$250
Key Advantage
$500HDHP $2800
Allowance for All Plans
Annual Exam
$35 copay $40 copay $15 copay$50
allowance
LensesSingleBifocalTrifocal
$20 copay $20 copay $20 copay
$50$75
$100
ContactLensesin lieu of glasses lenses
$100 allowance+ 15 off remaining
balance
$100 allowance + 15 off remaining
balance
$100 allowance+ 15 off remaining
balance
$80
Frames
$100 allowance+ 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$80
FrequencyExamLensesFrames
Once every 12 monthsOnce every 12 monthsOnce every 12 months
12
2021-2022 MEDICAL DENTAL AND VISION PER PAY DEDUCTIONS
Key Advantage $250 Plan
ComprehensiveDental amp Vision
Key Advantage $500 Plan
ComprehensiveDental amp Vision
HDHP $2800 ComprehensiveDental amp Vision
Employee Only $2500 $000 $000
Employee + One $21800 $19500 $16600
Employee Family $43600 $39000 $33250
Dual Enrollment Spouse
$5000 $000 $11150
Dual Enrollment Family
$31775 $29000 $22300
Key Advantage $250 Plan
Preventive Dentalamp Vision
Key Advantage $500 Plan
Preventive Dental amp Vision
HDHP $2800 Preventive Dental
amp Vision
Employee Only $2150 $000 $000
Employee + One $21150 $19000 $15800
Employee Family $42650 $38000 $31600
Dual Enrollment Spouse
$4300 $000 $10800
Dual Enrollment Family
$30900 $28000 $21600
Dual Enrollment = Both eligible employees work for New Kent County
Say hi to SydneyAnthemrsquos new app is s imple
smart mdash and al l about you
With Sydney you can find everything you need to know about your Anthem
benefits -- personalized and all in one place Sydney makes it easier to get
things done so you can spend more time focused on your health
Get started with Sydney
Download the app today
Ready for you to use quickly easily
seamlessly mdash with one-click access
to benefits info Member Services
wellness resources and more
Sydney acts like a personal health
guide answering your questions
and connecting you to the right
resources at the right time And
you can use the chatbot to get
answers quickly
Get alerts reminders and tips
directly from Sydney Get doctor
suggestions based on your needs
The more you use it the more
Sydney can help you stay healthy
and save money
With just one click you can
Find care and check costs
Check all benefits
See claims
Already using one of our apps
Itrsquos easy to make the switch Simply
download the Sydney app and log in
with your Anthem username and password
Get answers even faster with
our chatbot
View and use digital ID cards
AnthemBlueCrossandBlueShield is the trade name of InColorado RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc InConnecticut AnthemHealth Plans Inc InGeorgia BlueCross BlueShield Healthcare Planof Georgia Inc In IndianaAnthemInsurance Companies Inc InKentuckyAnthemHealth Plans of Kentucky Inc InMaine AnthemHealth Plans of Maine Inc InMissouri (excluding 30 counties in the Kansas City area) RightCHOICEregManaged Care Inc (RIT)Healthy Alliancereg Life Insurance Company(HALIC) andHMOMissouri Inc RITandcertain affiliates administer non-HMObenefits underwritten byHALICandHMObenefits underwritten byHMOMissouri Inc RITandcertain affiliates onlyprovide administrative services for self-funded plans anddonot underwrite benefits InNevada RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc dba HMONevada InNewHampshire AnthemHealth Plans of NewHampshire Inc HMOplans are administered byAnthemHealth Plans of NewHampshire Inc andunderwritten byMatthewThorntonHealthPlan Inc In Ohio Community Insurance Company In Virginia Anthem Health Plans of Virginia Inc trades as Anthem Blue Cross and Blue Shield6in V4irginia and its service area is all of Virginia except for the City of Fairfax the Town of Vienna and the area east
of State Route 123 In Wisconsin
Blue Cross Blue Shield of Wisconsin (BCBSWI) underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC) Compcare underwrites or administers HMO or POS policies WCIC underwrites or administers Well Priority HMO or POS policies Independent licensees of the Blue Cross and Blue Shield Association Anthem is a registered trademark of Anthem Insurance Companies Inc
115993MUMENABS 0619
13
14
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life
You may purchase 15 or 30 year coverage up to $100000
Guaranteed Issue for new hires $25000
Spouse LifeYou may purchase up to $50000 Guaranteed
Issue $10000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
VOLUNTARY TERM LIFE ndash AFLAC
Voluntary Life coverage provides an additional benefit to the beneficiaries It provides a benefit to your
designated beneficiary in the event of your death and you can choose the term of coverage To be eligible
for coverage you must qualify as an eligible member (working at least 30 hours per week) and be
considered actively at work If you are not currently enrolled and make a Voluntary Life election for 2021
you will be subject to underwriting and required to answer medical questions to enroll If you have questions
or would like to enroll in coverage contact Rebecca Smith at Aflacsmithagencyinccom or 804-422-3522
15
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life You may purchase up to $300000Guaranteed Issue for new hires
$40000
Spouse LifeYou may purchase up to $100000
Guaranteed Issue $5000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
If you are not currently enrolled and make a Voluntary Life election for 2021 you will be subject to underwriting and required to answer medical questions to enroll Employees must enroll in order to elect dependent coverage If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
VOLUNTARY WHOLE LIFE ndash AFLAC
16
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY SHORT TERM DISABILITY INSURANCE
Only 48 percent of American adults indicate they have enough savings to cover three months of living expenses in the event they become disabled
Source Council for Disability Awareness httpdisabilitycanhappenorgdisability-statistic
3 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income ReplacedUp to 60 of base monthly earnings
Guarantee Issue up to $3000 per month
Maximum Benefit $6000 per week
Duration of Benefits 3 months
6 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income Replaced Up to 60 of base monthly earnings
Maximum Benefit$6000 per month
Guaranteed Issue up to $3000 per month
Duration of Benefits 6 months
All benefit eligible employees can choose to enroll in one of two Voluntary Short Term Disability plans Should you have an accident or an illness your benefit will be paid for either 3 or 6 months If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
12 month pre-existing clause still applies
17
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY ACCIDENT ndash AFLAC
This is not a complete list of all covered accidents Please consult the plan summary for more details If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
24 Hour On or Off Job Accident
Annual Wellness Benefit
Year 1 $25 per insuredYear 2-4 $50 per insuredYear 5+ $75 per insured
Does not include children
Initial Treatment
Doctorrsquos office or other facility $75Doctorrsquos office or other facility
with x-ray $100ERUrgent Care $150
ERUrgent Care with X-ray $200
Hospital Admission$900
Additional $225 per dayAdditional $525 per day
AmbulanceGround $300
Air $900
Burns Lacerations Fractures Dislocations Concussion etc
$75-$15000
Accidental Death $50000
Accidental Dismemberment Up to $17500
18
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY CRITICAL ILLNESS ndash AFLAC
Voluntary Critical Illness
Wellness Benefit$50 per year ndash Employeeand Spouse (if applicable)
Coverage Amount Options
New Employee Guaranteed Issue up to $20000If a spousedependent is covered under the employees
plan they can elect 50 of the employees coverageChildren are automatically covered at 50 with no
charge
Included Illness at 100Cancer heart attack stroke major organ transplant
end stage renal failure paralysis coma and major third-degree burns ndash and more
Pre-existing Conditions
12 month exclusion for pre-existing cancerNo pre-existing exclusions on other health benefits as
long as diagnosis is made after the plan is in effect
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
3
Qualifying EventGenerally you may enroll in the plan or make changes to your benefits when you are first eligible However you can make changesenroll during the plan year if you experience a qualifying event As with a new enrollee you must submit your paperwork within 30 days of the change or you will be considered a late enrollee and you may not be eligible to enroll
Examples of qualifying events
bull You get married or divorced
bull You have a baby or adopt a child
bull You or your spouse takes an unpaid leave of absence
bull You or your spouse has a change in employment status
bull Your spouse dies
bull You become eligible for or lose Medicaid coverage
bull Significant increase or decrease in plan benefits or cost
How to Enroll in the PlansRead your materials and make sure you understand all of the options available
bull Contact HR for the enrollment forms
bull Fill out any necessary personal information
bull Make your benefit choices
bull If you have questions or concerns please contact your HR department
Whom Can You Add to Your PlanEligible
bull Legally married spouse
bull Natural or adopted children up to age 26 regardless of student and marital status
bull Children under your legal guardianship
bull Stepchildren
bull Children under a qualified medical child support order
bull Disabled children 19 years or older
bull Children placed in your physical custody for adoption
Ineligible
bull Divorced or legally separated spouse
bull Common law spouse even if recognized by your state
bull Domestic partners unless your employer states otherwise
bull Foster children
bull Sisters brothers parents or in-laws grandchildren etc
Offering a comprehensive and competitive benefits package is one way we recognize your contribution to the success of the organization and our role in helping you and your family to be healthy feel secure and maintain worklife balance This enrollment guide has been designed to provide you with information about the benefit choices available to you Remember open enrollment is your only opportunity each year to make changes to your elections unless you or your family members experience an eligible ldquoqualifying eventldquo New hires are eligible for benefits on the first of the month following their date of hire
ENROLLMENT AND ELIGIBILITY
Open Enrollment is the only chance to make changes unless you experience a ldquoqualifying eventrdquo
4
ADVANCED RESOLUTION TEAM
Through our Advanced Resolution Team you have access to live representatives who will help you get the most out of your benefits and answer your questions
The OneDigital Advanced Resolution Team can help educate you about your benefits and teach you how to navigate within the healthcare system
bull Help you with enrollment changes including ID card requests
bull Coverage assistance
bull Facilitate resolution on billing issues
bull Assist you with claims
bull Locate in-network providers
bull And much much more
Advanced Resolution TeamWe are available by phone or email
Call (866) 802-6311Email artonedigitalcom
Monday through Friday 8am to 5pm (EST)
5
PACKAGE OVERVIEW
New Kent County offers eligible employees a comprehensive benefit package that provides both financial stability and protection Our offering provides flexibility for employees to design a package to meet their unique needs
bull Anthem Medical and Vision Delta Dental plans through The Local Choice
bull Voluntary Whole Life Voluntary Short Term Disability Voluntary Accident Voluntary Critical Illness Voluntary Hospital Plan through Aflac
bull Anthem Employee Assistance Program through The Local Choice
bull Voluntary Pet Insurance through Nationwide
After you have enrolled in coverage you will receive additional information in the mail from the insurance carriers This information will contain your personal identification cards In the meantime you can look up the appropriate participating providers online Please see page 28 of this guide for a list of carrier websites
6
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
MEDICAL PLAN OPTIONS ndash ANTHEM
For this plan year you can choose from the following medical plans Refer to the carrier benefit summaries for the exact benefit level associated with your plan
In Network Benefits Key Advantage $250 Key Advantage $500 HDHP $2800
Referrals Required No No No
Plan Accumulator Plan Year Plan Year Plan Year
Annual Deductible(embedded)
$250 individual$500 family
$500 individual$1000 family
$2800 individual $5600 family
Coinsurance 20 20 20
Maximum Out-of-Pocket$3000 individual
$6000 family$4000 individual
$8000 family$5000 individual $10000 family
Preventive Care Covered 100 Covered 100 Covered 100
Physicianrsquos Office VisitsPCP $20
Specialist $35Virtual Visit $0
PCP $25Specialist $40Virtual Visit $0
20 after deductibleVirtual Visit
determined by services rendered
Urgent CarePCP $20
Specialist $35PCP $25
Specialist $4020 after deductible
Emergency Room Facility $350 copay per visit 20 after deductible 20 after deductible
Inpatient Facility $400 copay per stay 20 after deductible 20 after deductible
Outpatient Facility $150 copay 20 after deductible 20 after deductible
Diagnostic Lab Services 20 after deductible 20 after deductible 20 after deductible
Advanced Imaging Services
20 after deductible 20 after deductible 20 after deductible
Pharmacy Prescription Drugs
$10$30$45$55 $10$30$45$55 20 after deductible
Mail Order Prescription Drugs
$20$60$90$110 $20$60$90$110 20 after deductible
Out of Network Benefits Key Advantage $250 Key Advantage $500 HDHP $2800
Annual Deductible$500 individual$1000 family
$1000 individual$2000 family
Deductible is combined for In and Out of
Network
Maximum Out-of-Pocket$5000 individual$10000 family
$7000 individual$14000 family
$10000 individual$20000 family
Coinsurance 30 30 40
7
TELEMEDICINE ndash LIVEHEALTH ONLINE
What is Telemedicine bull Telemedicine uses technology to facilitate communication
between a doctor and patient who are not in the same physical location for medical evaluation diagnosis and treatment
bull Speak to a real live doctor 247365
bull All doctors are US Board Certified licensed to practice medicine and write prescriptions in the state the caller is located in
bull 100 HIPAA Compliant
bull Designed for non-emergency care 71 of all medical visits today are non-emergency
Common issues treated via LiveHealth Onlinebull Allergies
bull CoughCold or Flu
bull Pinkeye
bull Sore throat
bull Sinus Infection
bull Stomachache
Enroll for free at wwwlivehealthonlinecom
8
HEALTH SAVINGS ACCOUNT (HSA) ndash WEXDISCOVERY BENEFITS
Option for theHigh Deductible Health Plan
Employees who enroll in the High Deductible Health Plan offered through New Kent County have the option of opening a Health Savings Account (HSA) This HSA eligible plan provides a way to save money that is available in future years for health care expensesbull For 2021 New Kent County will contribute
$1000 for individuals who enroll in the HDHP and $2000 for employees with any dependents enrolled You will receive half of the employer contribution in the July 15 2021 pay period and the other half in the January 15 2022 pay period
bull In 2021 individuals can contribute up to $3600 and families can contribute up to $7200 to their HSA
bull If you are 55 or older you can make a $1000 catch-up contribution
bull Contributions to an HSA can be made on a pre-tax or post-tax basis and funds within the HSA grow without incurring taxes Funds are withdrawn tax-free for healthcare related needs without having to file receipts although you should keep your receipts in case you are ever audited
bull Money deposited in the HSA by the employee AND employer immediately become the employeersquos asset and is portable
The benefit plan information shown in this guide is illustrative only This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
Pre-Tax PlanWhat is this account
and how does it work Maximum Contribution
AllowedCan money in accounts
be ldquorolled overrdquo
Health Savings Account (HSA)
A HSA can be funded with pre-tax dollars to
help pay for eligible medical expenses
Employee only coverage $3600
Family coverage $7200
Catch up contribution (55 year of age or
older) $1000
Yes amounts left in your HSA can be rolled over year to year and are portable if your employment ends
9
FLEXIBLE SPENDING ACCOUNTS (FSA) ndash WEXDISCOVERY BENEFITS
If you are enrolling in the High Deductible Health Plan and contributing to a Health Savings Account you cannot open a Flexible Spending Account
Who is Eligible
All Full-Time Employees working at least 30 hours each week
Benefits You Receive
FSAs provide you with an important tax advantage that can help you pay health care and dependent care expenses on a pretax basis By anticipating your familyrsquos health care and dependent care costs for the next year you can actually lower your taxable income
Health Care Reimbursement FSA
This program lets employees pay for certain IRS-approved medical care expenses and prescriptions not covered by their insurance plan with pretax dollars The annual pretax maximum amount you may contribute to the Health Care Reimbursement FSA is $2750This limit will be indexed for cost-of-living adjustments You can rollover up to $550 into the following plan year Some examples of eligible expenses include
bull Hearing services including hearing aids and batteries
bull Vision services including contact lenses contact lens solution eye examinations and eyeglasses
bull Dental services and orthodontia
bull Chiropractic services
bull Acupuncture
bull Prescription contraceptives
Dependent Care FSA
The Dependent Care FSA lets employees use pretax dollars toward qualified dependent care such as caring for children under the age 13 or caring for elders The annual maximum amount you may contribute to the Dependent Care FSA is $5000 (or $2500 if married and filing separately) per calendar year Examples include
bull The cost of child or adult dependent care
bull The cost for an individual to provide care either in or out of your house
bull Nursery schools and preschools (excluding kindergarten)
The benefit plan information shown in this guide is illustrative only This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
10
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
DENTAL PLAN ndash DELTA DENTAL
One can of soda is the amount of sugar
recommended for three days for a child
Sugary Sodas are a major risk factor for
tooth decay
Source American Dental Association (ADA)
For this plan year dental coverage is offered through The Local Choice and administered by Delta Dental Refer to the carrier benefit summary for the exact benefit level associated with your plan
In Network Benefits Comprehensive
DentalPreventive Dental
Individual Annual Maximum
$1500 None
Annual Deductible$25 Individual
$50 Two People$75 Family
None
Preventive Services (exams cleaning x-rays
fluoride etc)100 100
Basic Services(fillings root canals periodontics simple
extractions etc)
80 afterdeductible
Not covered
Major Services(crowns dentures
bridges etc)
50 after deductible
Not covered
Orthodontic Services(Adult and Child)
50 to $1500 lifetime maximum
Not covered
Out of Network BenefitsOut of network benefits mirror in network benefits However out of
network providers may balance bill
11
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VISION PLAN ndash ANTHEM
Your eyes need a rest even while yoursquore awake Use the 20-20-20 rule to reduce eyestrain After
working for 20 minutes look away about 20 feet in front of you for
about 20 seconds
Source National Eye Institute httpsneinihgovhealthhealthyeyes
For this plan year vision coverage is offered through The Local Choice and administered by Anthem Blue View Vision Refer to the carrier benefit summary for the exact benefit level associated with your plan
In-NetworkOut of
Network
Key Advantage
$250
Key Advantage
$500HDHP $2800
Allowance for All Plans
Annual Exam
$35 copay $40 copay $15 copay$50
allowance
LensesSingleBifocalTrifocal
$20 copay $20 copay $20 copay
$50$75
$100
ContactLensesin lieu of glasses lenses
$100 allowance+ 15 off remaining
balance
$100 allowance + 15 off remaining
balance
$100 allowance+ 15 off remaining
balance
$80
Frames
$100 allowance+ 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$80
FrequencyExamLensesFrames
Once every 12 monthsOnce every 12 monthsOnce every 12 months
12
2021-2022 MEDICAL DENTAL AND VISION PER PAY DEDUCTIONS
Key Advantage $250 Plan
ComprehensiveDental amp Vision
Key Advantage $500 Plan
ComprehensiveDental amp Vision
HDHP $2800 ComprehensiveDental amp Vision
Employee Only $2500 $000 $000
Employee + One $21800 $19500 $16600
Employee Family $43600 $39000 $33250
Dual Enrollment Spouse
$5000 $000 $11150
Dual Enrollment Family
$31775 $29000 $22300
Key Advantage $250 Plan
Preventive Dentalamp Vision
Key Advantage $500 Plan
Preventive Dental amp Vision
HDHP $2800 Preventive Dental
amp Vision
Employee Only $2150 $000 $000
Employee + One $21150 $19000 $15800
Employee Family $42650 $38000 $31600
Dual Enrollment Spouse
$4300 $000 $10800
Dual Enrollment Family
$30900 $28000 $21600
Dual Enrollment = Both eligible employees work for New Kent County
Say hi to SydneyAnthemrsquos new app is s imple
smart mdash and al l about you
With Sydney you can find everything you need to know about your Anthem
benefits -- personalized and all in one place Sydney makes it easier to get
things done so you can spend more time focused on your health
Get started with Sydney
Download the app today
Ready for you to use quickly easily
seamlessly mdash with one-click access
to benefits info Member Services
wellness resources and more
Sydney acts like a personal health
guide answering your questions
and connecting you to the right
resources at the right time And
you can use the chatbot to get
answers quickly
Get alerts reminders and tips
directly from Sydney Get doctor
suggestions based on your needs
The more you use it the more
Sydney can help you stay healthy
and save money
With just one click you can
Find care and check costs
Check all benefits
See claims
Already using one of our apps
Itrsquos easy to make the switch Simply
download the Sydney app and log in
with your Anthem username and password
Get answers even faster with
our chatbot
View and use digital ID cards
AnthemBlueCrossandBlueShield is the trade name of InColorado RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc InConnecticut AnthemHealth Plans Inc InGeorgia BlueCross BlueShield Healthcare Planof Georgia Inc In IndianaAnthemInsurance Companies Inc InKentuckyAnthemHealth Plans of Kentucky Inc InMaine AnthemHealth Plans of Maine Inc InMissouri (excluding 30 counties in the Kansas City area) RightCHOICEregManaged Care Inc (RIT)Healthy Alliancereg Life Insurance Company(HALIC) andHMOMissouri Inc RITandcertain affiliates administer non-HMObenefits underwritten byHALICandHMObenefits underwritten byHMOMissouri Inc RITandcertain affiliates onlyprovide administrative services for self-funded plans anddonot underwrite benefits InNevada RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc dba HMONevada InNewHampshire AnthemHealth Plans of NewHampshire Inc HMOplans are administered byAnthemHealth Plans of NewHampshire Inc andunderwritten byMatthewThorntonHealthPlan Inc In Ohio Community Insurance Company In Virginia Anthem Health Plans of Virginia Inc trades as Anthem Blue Cross and Blue Shield6in V4irginia and its service area is all of Virginia except for the City of Fairfax the Town of Vienna and the area east
of State Route 123 In Wisconsin
Blue Cross Blue Shield of Wisconsin (BCBSWI) underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC) Compcare underwrites or administers HMO or POS policies WCIC underwrites or administers Well Priority HMO or POS policies Independent licensees of the Blue Cross and Blue Shield Association Anthem is a registered trademark of Anthem Insurance Companies Inc
115993MUMENABS 0619
13
14
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life
You may purchase 15 or 30 year coverage up to $100000
Guaranteed Issue for new hires $25000
Spouse LifeYou may purchase up to $50000 Guaranteed
Issue $10000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
VOLUNTARY TERM LIFE ndash AFLAC
Voluntary Life coverage provides an additional benefit to the beneficiaries It provides a benefit to your
designated beneficiary in the event of your death and you can choose the term of coverage To be eligible
for coverage you must qualify as an eligible member (working at least 30 hours per week) and be
considered actively at work If you are not currently enrolled and make a Voluntary Life election for 2021
you will be subject to underwriting and required to answer medical questions to enroll If you have questions
or would like to enroll in coverage contact Rebecca Smith at Aflacsmithagencyinccom or 804-422-3522
15
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life You may purchase up to $300000Guaranteed Issue for new hires
$40000
Spouse LifeYou may purchase up to $100000
Guaranteed Issue $5000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
If you are not currently enrolled and make a Voluntary Life election for 2021 you will be subject to underwriting and required to answer medical questions to enroll Employees must enroll in order to elect dependent coverage If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
VOLUNTARY WHOLE LIFE ndash AFLAC
16
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY SHORT TERM DISABILITY INSURANCE
Only 48 percent of American adults indicate they have enough savings to cover three months of living expenses in the event they become disabled
Source Council for Disability Awareness httpdisabilitycanhappenorgdisability-statistic
3 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income ReplacedUp to 60 of base monthly earnings
Guarantee Issue up to $3000 per month
Maximum Benefit $6000 per week
Duration of Benefits 3 months
6 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income Replaced Up to 60 of base monthly earnings
Maximum Benefit$6000 per month
Guaranteed Issue up to $3000 per month
Duration of Benefits 6 months
All benefit eligible employees can choose to enroll in one of two Voluntary Short Term Disability plans Should you have an accident or an illness your benefit will be paid for either 3 or 6 months If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
12 month pre-existing clause still applies
17
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY ACCIDENT ndash AFLAC
This is not a complete list of all covered accidents Please consult the plan summary for more details If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
24 Hour On or Off Job Accident
Annual Wellness Benefit
Year 1 $25 per insuredYear 2-4 $50 per insuredYear 5+ $75 per insured
Does not include children
Initial Treatment
Doctorrsquos office or other facility $75Doctorrsquos office or other facility
with x-ray $100ERUrgent Care $150
ERUrgent Care with X-ray $200
Hospital Admission$900
Additional $225 per dayAdditional $525 per day
AmbulanceGround $300
Air $900
Burns Lacerations Fractures Dislocations Concussion etc
$75-$15000
Accidental Death $50000
Accidental Dismemberment Up to $17500
18
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY CRITICAL ILLNESS ndash AFLAC
Voluntary Critical Illness
Wellness Benefit$50 per year ndash Employeeand Spouse (if applicable)
Coverage Amount Options
New Employee Guaranteed Issue up to $20000If a spousedependent is covered under the employees
plan they can elect 50 of the employees coverageChildren are automatically covered at 50 with no
charge
Included Illness at 100Cancer heart attack stroke major organ transplant
end stage renal failure paralysis coma and major third-degree burns ndash and more
Pre-existing Conditions
12 month exclusion for pre-existing cancerNo pre-existing exclusions on other health benefits as
long as diagnosis is made after the plan is in effect
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
4
ADVANCED RESOLUTION TEAM
Through our Advanced Resolution Team you have access to live representatives who will help you get the most out of your benefits and answer your questions
The OneDigital Advanced Resolution Team can help educate you about your benefits and teach you how to navigate within the healthcare system
bull Help you with enrollment changes including ID card requests
bull Coverage assistance
bull Facilitate resolution on billing issues
bull Assist you with claims
bull Locate in-network providers
bull And much much more
Advanced Resolution TeamWe are available by phone or email
Call (866) 802-6311Email artonedigitalcom
Monday through Friday 8am to 5pm (EST)
5
PACKAGE OVERVIEW
New Kent County offers eligible employees a comprehensive benefit package that provides both financial stability and protection Our offering provides flexibility for employees to design a package to meet their unique needs
bull Anthem Medical and Vision Delta Dental plans through The Local Choice
bull Voluntary Whole Life Voluntary Short Term Disability Voluntary Accident Voluntary Critical Illness Voluntary Hospital Plan through Aflac
bull Anthem Employee Assistance Program through The Local Choice
bull Voluntary Pet Insurance through Nationwide
After you have enrolled in coverage you will receive additional information in the mail from the insurance carriers This information will contain your personal identification cards In the meantime you can look up the appropriate participating providers online Please see page 28 of this guide for a list of carrier websites
6
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
MEDICAL PLAN OPTIONS ndash ANTHEM
For this plan year you can choose from the following medical plans Refer to the carrier benefit summaries for the exact benefit level associated with your plan
In Network Benefits Key Advantage $250 Key Advantage $500 HDHP $2800
Referrals Required No No No
Plan Accumulator Plan Year Plan Year Plan Year
Annual Deductible(embedded)
$250 individual$500 family
$500 individual$1000 family
$2800 individual $5600 family
Coinsurance 20 20 20
Maximum Out-of-Pocket$3000 individual
$6000 family$4000 individual
$8000 family$5000 individual $10000 family
Preventive Care Covered 100 Covered 100 Covered 100
Physicianrsquos Office VisitsPCP $20
Specialist $35Virtual Visit $0
PCP $25Specialist $40Virtual Visit $0
20 after deductibleVirtual Visit
determined by services rendered
Urgent CarePCP $20
Specialist $35PCP $25
Specialist $4020 after deductible
Emergency Room Facility $350 copay per visit 20 after deductible 20 after deductible
Inpatient Facility $400 copay per stay 20 after deductible 20 after deductible
Outpatient Facility $150 copay 20 after deductible 20 after deductible
Diagnostic Lab Services 20 after deductible 20 after deductible 20 after deductible
Advanced Imaging Services
20 after deductible 20 after deductible 20 after deductible
Pharmacy Prescription Drugs
$10$30$45$55 $10$30$45$55 20 after deductible
Mail Order Prescription Drugs
$20$60$90$110 $20$60$90$110 20 after deductible
Out of Network Benefits Key Advantage $250 Key Advantage $500 HDHP $2800
Annual Deductible$500 individual$1000 family
$1000 individual$2000 family
Deductible is combined for In and Out of
Network
Maximum Out-of-Pocket$5000 individual$10000 family
$7000 individual$14000 family
$10000 individual$20000 family
Coinsurance 30 30 40
7
TELEMEDICINE ndash LIVEHEALTH ONLINE
What is Telemedicine bull Telemedicine uses technology to facilitate communication
between a doctor and patient who are not in the same physical location for medical evaluation diagnosis and treatment
bull Speak to a real live doctor 247365
bull All doctors are US Board Certified licensed to practice medicine and write prescriptions in the state the caller is located in
bull 100 HIPAA Compliant
bull Designed for non-emergency care 71 of all medical visits today are non-emergency
Common issues treated via LiveHealth Onlinebull Allergies
bull CoughCold or Flu
bull Pinkeye
bull Sore throat
bull Sinus Infection
bull Stomachache
Enroll for free at wwwlivehealthonlinecom
8
HEALTH SAVINGS ACCOUNT (HSA) ndash WEXDISCOVERY BENEFITS
Option for theHigh Deductible Health Plan
Employees who enroll in the High Deductible Health Plan offered through New Kent County have the option of opening a Health Savings Account (HSA) This HSA eligible plan provides a way to save money that is available in future years for health care expensesbull For 2021 New Kent County will contribute
$1000 for individuals who enroll in the HDHP and $2000 for employees with any dependents enrolled You will receive half of the employer contribution in the July 15 2021 pay period and the other half in the January 15 2022 pay period
bull In 2021 individuals can contribute up to $3600 and families can contribute up to $7200 to their HSA
bull If you are 55 or older you can make a $1000 catch-up contribution
bull Contributions to an HSA can be made on a pre-tax or post-tax basis and funds within the HSA grow without incurring taxes Funds are withdrawn tax-free for healthcare related needs without having to file receipts although you should keep your receipts in case you are ever audited
bull Money deposited in the HSA by the employee AND employer immediately become the employeersquos asset and is portable
The benefit plan information shown in this guide is illustrative only This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
Pre-Tax PlanWhat is this account
and how does it work Maximum Contribution
AllowedCan money in accounts
be ldquorolled overrdquo
Health Savings Account (HSA)
A HSA can be funded with pre-tax dollars to
help pay for eligible medical expenses
Employee only coverage $3600
Family coverage $7200
Catch up contribution (55 year of age or
older) $1000
Yes amounts left in your HSA can be rolled over year to year and are portable if your employment ends
9
FLEXIBLE SPENDING ACCOUNTS (FSA) ndash WEXDISCOVERY BENEFITS
If you are enrolling in the High Deductible Health Plan and contributing to a Health Savings Account you cannot open a Flexible Spending Account
Who is Eligible
All Full-Time Employees working at least 30 hours each week
Benefits You Receive
FSAs provide you with an important tax advantage that can help you pay health care and dependent care expenses on a pretax basis By anticipating your familyrsquos health care and dependent care costs for the next year you can actually lower your taxable income
Health Care Reimbursement FSA
This program lets employees pay for certain IRS-approved medical care expenses and prescriptions not covered by their insurance plan with pretax dollars The annual pretax maximum amount you may contribute to the Health Care Reimbursement FSA is $2750This limit will be indexed for cost-of-living adjustments You can rollover up to $550 into the following plan year Some examples of eligible expenses include
bull Hearing services including hearing aids and batteries
bull Vision services including contact lenses contact lens solution eye examinations and eyeglasses
bull Dental services and orthodontia
bull Chiropractic services
bull Acupuncture
bull Prescription contraceptives
Dependent Care FSA
The Dependent Care FSA lets employees use pretax dollars toward qualified dependent care such as caring for children under the age 13 or caring for elders The annual maximum amount you may contribute to the Dependent Care FSA is $5000 (or $2500 if married and filing separately) per calendar year Examples include
bull The cost of child or adult dependent care
bull The cost for an individual to provide care either in or out of your house
bull Nursery schools and preschools (excluding kindergarten)
The benefit plan information shown in this guide is illustrative only This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
10
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
DENTAL PLAN ndash DELTA DENTAL
One can of soda is the amount of sugar
recommended for three days for a child
Sugary Sodas are a major risk factor for
tooth decay
Source American Dental Association (ADA)
For this plan year dental coverage is offered through The Local Choice and administered by Delta Dental Refer to the carrier benefit summary for the exact benefit level associated with your plan
In Network Benefits Comprehensive
DentalPreventive Dental
Individual Annual Maximum
$1500 None
Annual Deductible$25 Individual
$50 Two People$75 Family
None
Preventive Services (exams cleaning x-rays
fluoride etc)100 100
Basic Services(fillings root canals periodontics simple
extractions etc)
80 afterdeductible
Not covered
Major Services(crowns dentures
bridges etc)
50 after deductible
Not covered
Orthodontic Services(Adult and Child)
50 to $1500 lifetime maximum
Not covered
Out of Network BenefitsOut of network benefits mirror in network benefits However out of
network providers may balance bill
11
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VISION PLAN ndash ANTHEM
Your eyes need a rest even while yoursquore awake Use the 20-20-20 rule to reduce eyestrain After
working for 20 minutes look away about 20 feet in front of you for
about 20 seconds
Source National Eye Institute httpsneinihgovhealthhealthyeyes
For this plan year vision coverage is offered through The Local Choice and administered by Anthem Blue View Vision Refer to the carrier benefit summary for the exact benefit level associated with your plan
In-NetworkOut of
Network
Key Advantage
$250
Key Advantage
$500HDHP $2800
Allowance for All Plans
Annual Exam
$35 copay $40 copay $15 copay$50
allowance
LensesSingleBifocalTrifocal
$20 copay $20 copay $20 copay
$50$75
$100
ContactLensesin lieu of glasses lenses
$100 allowance+ 15 off remaining
balance
$100 allowance + 15 off remaining
balance
$100 allowance+ 15 off remaining
balance
$80
Frames
$100 allowance+ 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$80
FrequencyExamLensesFrames
Once every 12 monthsOnce every 12 monthsOnce every 12 months
12
2021-2022 MEDICAL DENTAL AND VISION PER PAY DEDUCTIONS
Key Advantage $250 Plan
ComprehensiveDental amp Vision
Key Advantage $500 Plan
ComprehensiveDental amp Vision
HDHP $2800 ComprehensiveDental amp Vision
Employee Only $2500 $000 $000
Employee + One $21800 $19500 $16600
Employee Family $43600 $39000 $33250
Dual Enrollment Spouse
$5000 $000 $11150
Dual Enrollment Family
$31775 $29000 $22300
Key Advantage $250 Plan
Preventive Dentalamp Vision
Key Advantage $500 Plan
Preventive Dental amp Vision
HDHP $2800 Preventive Dental
amp Vision
Employee Only $2150 $000 $000
Employee + One $21150 $19000 $15800
Employee Family $42650 $38000 $31600
Dual Enrollment Spouse
$4300 $000 $10800
Dual Enrollment Family
$30900 $28000 $21600
Dual Enrollment = Both eligible employees work for New Kent County
Say hi to SydneyAnthemrsquos new app is s imple
smart mdash and al l about you
With Sydney you can find everything you need to know about your Anthem
benefits -- personalized and all in one place Sydney makes it easier to get
things done so you can spend more time focused on your health
Get started with Sydney
Download the app today
Ready for you to use quickly easily
seamlessly mdash with one-click access
to benefits info Member Services
wellness resources and more
Sydney acts like a personal health
guide answering your questions
and connecting you to the right
resources at the right time And
you can use the chatbot to get
answers quickly
Get alerts reminders and tips
directly from Sydney Get doctor
suggestions based on your needs
The more you use it the more
Sydney can help you stay healthy
and save money
With just one click you can
Find care and check costs
Check all benefits
See claims
Already using one of our apps
Itrsquos easy to make the switch Simply
download the Sydney app and log in
with your Anthem username and password
Get answers even faster with
our chatbot
View and use digital ID cards
AnthemBlueCrossandBlueShield is the trade name of InColorado RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc InConnecticut AnthemHealth Plans Inc InGeorgia BlueCross BlueShield Healthcare Planof Georgia Inc In IndianaAnthemInsurance Companies Inc InKentuckyAnthemHealth Plans of Kentucky Inc InMaine AnthemHealth Plans of Maine Inc InMissouri (excluding 30 counties in the Kansas City area) RightCHOICEregManaged Care Inc (RIT)Healthy Alliancereg Life Insurance Company(HALIC) andHMOMissouri Inc RITandcertain affiliates administer non-HMObenefits underwritten byHALICandHMObenefits underwritten byHMOMissouri Inc RITandcertain affiliates onlyprovide administrative services for self-funded plans anddonot underwrite benefits InNevada RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc dba HMONevada InNewHampshire AnthemHealth Plans of NewHampshire Inc HMOplans are administered byAnthemHealth Plans of NewHampshire Inc andunderwritten byMatthewThorntonHealthPlan Inc In Ohio Community Insurance Company In Virginia Anthem Health Plans of Virginia Inc trades as Anthem Blue Cross and Blue Shield6in V4irginia and its service area is all of Virginia except for the City of Fairfax the Town of Vienna and the area east
of State Route 123 In Wisconsin
Blue Cross Blue Shield of Wisconsin (BCBSWI) underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC) Compcare underwrites or administers HMO or POS policies WCIC underwrites or administers Well Priority HMO or POS policies Independent licensees of the Blue Cross and Blue Shield Association Anthem is a registered trademark of Anthem Insurance Companies Inc
115993MUMENABS 0619
13
14
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life
You may purchase 15 or 30 year coverage up to $100000
Guaranteed Issue for new hires $25000
Spouse LifeYou may purchase up to $50000 Guaranteed
Issue $10000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
VOLUNTARY TERM LIFE ndash AFLAC
Voluntary Life coverage provides an additional benefit to the beneficiaries It provides a benefit to your
designated beneficiary in the event of your death and you can choose the term of coverage To be eligible
for coverage you must qualify as an eligible member (working at least 30 hours per week) and be
considered actively at work If you are not currently enrolled and make a Voluntary Life election for 2021
you will be subject to underwriting and required to answer medical questions to enroll If you have questions
or would like to enroll in coverage contact Rebecca Smith at Aflacsmithagencyinccom or 804-422-3522
15
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life You may purchase up to $300000Guaranteed Issue for new hires
$40000
Spouse LifeYou may purchase up to $100000
Guaranteed Issue $5000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
If you are not currently enrolled and make a Voluntary Life election for 2021 you will be subject to underwriting and required to answer medical questions to enroll Employees must enroll in order to elect dependent coverage If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
VOLUNTARY WHOLE LIFE ndash AFLAC
16
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY SHORT TERM DISABILITY INSURANCE
Only 48 percent of American adults indicate they have enough savings to cover three months of living expenses in the event they become disabled
Source Council for Disability Awareness httpdisabilitycanhappenorgdisability-statistic
3 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income ReplacedUp to 60 of base monthly earnings
Guarantee Issue up to $3000 per month
Maximum Benefit $6000 per week
Duration of Benefits 3 months
6 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income Replaced Up to 60 of base monthly earnings
Maximum Benefit$6000 per month
Guaranteed Issue up to $3000 per month
Duration of Benefits 6 months
All benefit eligible employees can choose to enroll in one of two Voluntary Short Term Disability plans Should you have an accident or an illness your benefit will be paid for either 3 or 6 months If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
12 month pre-existing clause still applies
17
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY ACCIDENT ndash AFLAC
This is not a complete list of all covered accidents Please consult the plan summary for more details If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
24 Hour On or Off Job Accident
Annual Wellness Benefit
Year 1 $25 per insuredYear 2-4 $50 per insuredYear 5+ $75 per insured
Does not include children
Initial Treatment
Doctorrsquos office or other facility $75Doctorrsquos office or other facility
with x-ray $100ERUrgent Care $150
ERUrgent Care with X-ray $200
Hospital Admission$900
Additional $225 per dayAdditional $525 per day
AmbulanceGround $300
Air $900
Burns Lacerations Fractures Dislocations Concussion etc
$75-$15000
Accidental Death $50000
Accidental Dismemberment Up to $17500
18
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY CRITICAL ILLNESS ndash AFLAC
Voluntary Critical Illness
Wellness Benefit$50 per year ndash Employeeand Spouse (if applicable)
Coverage Amount Options
New Employee Guaranteed Issue up to $20000If a spousedependent is covered under the employees
plan they can elect 50 of the employees coverageChildren are automatically covered at 50 with no
charge
Included Illness at 100Cancer heart attack stroke major organ transplant
end stage renal failure paralysis coma and major third-degree burns ndash and more
Pre-existing Conditions
12 month exclusion for pre-existing cancerNo pre-existing exclusions on other health benefits as
long as diagnosis is made after the plan is in effect
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
5
PACKAGE OVERVIEW
New Kent County offers eligible employees a comprehensive benefit package that provides both financial stability and protection Our offering provides flexibility for employees to design a package to meet their unique needs
bull Anthem Medical and Vision Delta Dental plans through The Local Choice
bull Voluntary Whole Life Voluntary Short Term Disability Voluntary Accident Voluntary Critical Illness Voluntary Hospital Plan through Aflac
bull Anthem Employee Assistance Program through The Local Choice
bull Voluntary Pet Insurance through Nationwide
After you have enrolled in coverage you will receive additional information in the mail from the insurance carriers This information will contain your personal identification cards In the meantime you can look up the appropriate participating providers online Please see page 28 of this guide for a list of carrier websites
6
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
MEDICAL PLAN OPTIONS ndash ANTHEM
For this plan year you can choose from the following medical plans Refer to the carrier benefit summaries for the exact benefit level associated with your plan
In Network Benefits Key Advantage $250 Key Advantage $500 HDHP $2800
Referrals Required No No No
Plan Accumulator Plan Year Plan Year Plan Year
Annual Deductible(embedded)
$250 individual$500 family
$500 individual$1000 family
$2800 individual $5600 family
Coinsurance 20 20 20
Maximum Out-of-Pocket$3000 individual
$6000 family$4000 individual
$8000 family$5000 individual $10000 family
Preventive Care Covered 100 Covered 100 Covered 100
Physicianrsquos Office VisitsPCP $20
Specialist $35Virtual Visit $0
PCP $25Specialist $40Virtual Visit $0
20 after deductibleVirtual Visit
determined by services rendered
Urgent CarePCP $20
Specialist $35PCP $25
Specialist $4020 after deductible
Emergency Room Facility $350 copay per visit 20 after deductible 20 after deductible
Inpatient Facility $400 copay per stay 20 after deductible 20 after deductible
Outpatient Facility $150 copay 20 after deductible 20 after deductible
Diagnostic Lab Services 20 after deductible 20 after deductible 20 after deductible
Advanced Imaging Services
20 after deductible 20 after deductible 20 after deductible
Pharmacy Prescription Drugs
$10$30$45$55 $10$30$45$55 20 after deductible
Mail Order Prescription Drugs
$20$60$90$110 $20$60$90$110 20 after deductible
Out of Network Benefits Key Advantage $250 Key Advantage $500 HDHP $2800
Annual Deductible$500 individual$1000 family
$1000 individual$2000 family
Deductible is combined for In and Out of
Network
Maximum Out-of-Pocket$5000 individual$10000 family
$7000 individual$14000 family
$10000 individual$20000 family
Coinsurance 30 30 40
7
TELEMEDICINE ndash LIVEHEALTH ONLINE
What is Telemedicine bull Telemedicine uses technology to facilitate communication
between a doctor and patient who are not in the same physical location for medical evaluation diagnosis and treatment
bull Speak to a real live doctor 247365
bull All doctors are US Board Certified licensed to practice medicine and write prescriptions in the state the caller is located in
bull 100 HIPAA Compliant
bull Designed for non-emergency care 71 of all medical visits today are non-emergency
Common issues treated via LiveHealth Onlinebull Allergies
bull CoughCold or Flu
bull Pinkeye
bull Sore throat
bull Sinus Infection
bull Stomachache
Enroll for free at wwwlivehealthonlinecom
8
HEALTH SAVINGS ACCOUNT (HSA) ndash WEXDISCOVERY BENEFITS
Option for theHigh Deductible Health Plan
Employees who enroll in the High Deductible Health Plan offered through New Kent County have the option of opening a Health Savings Account (HSA) This HSA eligible plan provides a way to save money that is available in future years for health care expensesbull For 2021 New Kent County will contribute
$1000 for individuals who enroll in the HDHP and $2000 for employees with any dependents enrolled You will receive half of the employer contribution in the July 15 2021 pay period and the other half in the January 15 2022 pay period
bull In 2021 individuals can contribute up to $3600 and families can contribute up to $7200 to their HSA
bull If you are 55 or older you can make a $1000 catch-up contribution
bull Contributions to an HSA can be made on a pre-tax or post-tax basis and funds within the HSA grow without incurring taxes Funds are withdrawn tax-free for healthcare related needs without having to file receipts although you should keep your receipts in case you are ever audited
bull Money deposited in the HSA by the employee AND employer immediately become the employeersquos asset and is portable
The benefit plan information shown in this guide is illustrative only This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
Pre-Tax PlanWhat is this account
and how does it work Maximum Contribution
AllowedCan money in accounts
be ldquorolled overrdquo
Health Savings Account (HSA)
A HSA can be funded with pre-tax dollars to
help pay for eligible medical expenses
Employee only coverage $3600
Family coverage $7200
Catch up contribution (55 year of age or
older) $1000
Yes amounts left in your HSA can be rolled over year to year and are portable if your employment ends
9
FLEXIBLE SPENDING ACCOUNTS (FSA) ndash WEXDISCOVERY BENEFITS
If you are enrolling in the High Deductible Health Plan and contributing to a Health Savings Account you cannot open a Flexible Spending Account
Who is Eligible
All Full-Time Employees working at least 30 hours each week
Benefits You Receive
FSAs provide you with an important tax advantage that can help you pay health care and dependent care expenses on a pretax basis By anticipating your familyrsquos health care and dependent care costs for the next year you can actually lower your taxable income
Health Care Reimbursement FSA
This program lets employees pay for certain IRS-approved medical care expenses and prescriptions not covered by their insurance plan with pretax dollars The annual pretax maximum amount you may contribute to the Health Care Reimbursement FSA is $2750This limit will be indexed for cost-of-living adjustments You can rollover up to $550 into the following plan year Some examples of eligible expenses include
bull Hearing services including hearing aids and batteries
bull Vision services including contact lenses contact lens solution eye examinations and eyeglasses
bull Dental services and orthodontia
bull Chiropractic services
bull Acupuncture
bull Prescription contraceptives
Dependent Care FSA
The Dependent Care FSA lets employees use pretax dollars toward qualified dependent care such as caring for children under the age 13 or caring for elders The annual maximum amount you may contribute to the Dependent Care FSA is $5000 (or $2500 if married and filing separately) per calendar year Examples include
bull The cost of child or adult dependent care
bull The cost for an individual to provide care either in or out of your house
bull Nursery schools and preschools (excluding kindergarten)
The benefit plan information shown in this guide is illustrative only This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
10
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
DENTAL PLAN ndash DELTA DENTAL
One can of soda is the amount of sugar
recommended for three days for a child
Sugary Sodas are a major risk factor for
tooth decay
Source American Dental Association (ADA)
For this plan year dental coverage is offered through The Local Choice and administered by Delta Dental Refer to the carrier benefit summary for the exact benefit level associated with your plan
In Network Benefits Comprehensive
DentalPreventive Dental
Individual Annual Maximum
$1500 None
Annual Deductible$25 Individual
$50 Two People$75 Family
None
Preventive Services (exams cleaning x-rays
fluoride etc)100 100
Basic Services(fillings root canals periodontics simple
extractions etc)
80 afterdeductible
Not covered
Major Services(crowns dentures
bridges etc)
50 after deductible
Not covered
Orthodontic Services(Adult and Child)
50 to $1500 lifetime maximum
Not covered
Out of Network BenefitsOut of network benefits mirror in network benefits However out of
network providers may balance bill
11
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VISION PLAN ndash ANTHEM
Your eyes need a rest even while yoursquore awake Use the 20-20-20 rule to reduce eyestrain After
working for 20 minutes look away about 20 feet in front of you for
about 20 seconds
Source National Eye Institute httpsneinihgovhealthhealthyeyes
For this plan year vision coverage is offered through The Local Choice and administered by Anthem Blue View Vision Refer to the carrier benefit summary for the exact benefit level associated with your plan
In-NetworkOut of
Network
Key Advantage
$250
Key Advantage
$500HDHP $2800
Allowance for All Plans
Annual Exam
$35 copay $40 copay $15 copay$50
allowance
LensesSingleBifocalTrifocal
$20 copay $20 copay $20 copay
$50$75
$100
ContactLensesin lieu of glasses lenses
$100 allowance+ 15 off remaining
balance
$100 allowance + 15 off remaining
balance
$100 allowance+ 15 off remaining
balance
$80
Frames
$100 allowance+ 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$80
FrequencyExamLensesFrames
Once every 12 monthsOnce every 12 monthsOnce every 12 months
12
2021-2022 MEDICAL DENTAL AND VISION PER PAY DEDUCTIONS
Key Advantage $250 Plan
ComprehensiveDental amp Vision
Key Advantage $500 Plan
ComprehensiveDental amp Vision
HDHP $2800 ComprehensiveDental amp Vision
Employee Only $2500 $000 $000
Employee + One $21800 $19500 $16600
Employee Family $43600 $39000 $33250
Dual Enrollment Spouse
$5000 $000 $11150
Dual Enrollment Family
$31775 $29000 $22300
Key Advantage $250 Plan
Preventive Dentalamp Vision
Key Advantage $500 Plan
Preventive Dental amp Vision
HDHP $2800 Preventive Dental
amp Vision
Employee Only $2150 $000 $000
Employee + One $21150 $19000 $15800
Employee Family $42650 $38000 $31600
Dual Enrollment Spouse
$4300 $000 $10800
Dual Enrollment Family
$30900 $28000 $21600
Dual Enrollment = Both eligible employees work for New Kent County
Say hi to SydneyAnthemrsquos new app is s imple
smart mdash and al l about you
With Sydney you can find everything you need to know about your Anthem
benefits -- personalized and all in one place Sydney makes it easier to get
things done so you can spend more time focused on your health
Get started with Sydney
Download the app today
Ready for you to use quickly easily
seamlessly mdash with one-click access
to benefits info Member Services
wellness resources and more
Sydney acts like a personal health
guide answering your questions
and connecting you to the right
resources at the right time And
you can use the chatbot to get
answers quickly
Get alerts reminders and tips
directly from Sydney Get doctor
suggestions based on your needs
The more you use it the more
Sydney can help you stay healthy
and save money
With just one click you can
Find care and check costs
Check all benefits
See claims
Already using one of our apps
Itrsquos easy to make the switch Simply
download the Sydney app and log in
with your Anthem username and password
Get answers even faster with
our chatbot
View and use digital ID cards
AnthemBlueCrossandBlueShield is the trade name of InColorado RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc InConnecticut AnthemHealth Plans Inc InGeorgia BlueCross BlueShield Healthcare Planof Georgia Inc In IndianaAnthemInsurance Companies Inc InKentuckyAnthemHealth Plans of Kentucky Inc InMaine AnthemHealth Plans of Maine Inc InMissouri (excluding 30 counties in the Kansas City area) RightCHOICEregManaged Care Inc (RIT)Healthy Alliancereg Life Insurance Company(HALIC) andHMOMissouri Inc RITandcertain affiliates administer non-HMObenefits underwritten byHALICandHMObenefits underwritten byHMOMissouri Inc RITandcertain affiliates onlyprovide administrative services for self-funded plans anddonot underwrite benefits InNevada RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc dba HMONevada InNewHampshire AnthemHealth Plans of NewHampshire Inc HMOplans are administered byAnthemHealth Plans of NewHampshire Inc andunderwritten byMatthewThorntonHealthPlan Inc In Ohio Community Insurance Company In Virginia Anthem Health Plans of Virginia Inc trades as Anthem Blue Cross and Blue Shield6in V4irginia and its service area is all of Virginia except for the City of Fairfax the Town of Vienna and the area east
of State Route 123 In Wisconsin
Blue Cross Blue Shield of Wisconsin (BCBSWI) underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC) Compcare underwrites or administers HMO or POS policies WCIC underwrites or administers Well Priority HMO or POS policies Independent licensees of the Blue Cross and Blue Shield Association Anthem is a registered trademark of Anthem Insurance Companies Inc
115993MUMENABS 0619
13
14
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life
You may purchase 15 or 30 year coverage up to $100000
Guaranteed Issue for new hires $25000
Spouse LifeYou may purchase up to $50000 Guaranteed
Issue $10000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
VOLUNTARY TERM LIFE ndash AFLAC
Voluntary Life coverage provides an additional benefit to the beneficiaries It provides a benefit to your
designated beneficiary in the event of your death and you can choose the term of coverage To be eligible
for coverage you must qualify as an eligible member (working at least 30 hours per week) and be
considered actively at work If you are not currently enrolled and make a Voluntary Life election for 2021
you will be subject to underwriting and required to answer medical questions to enroll If you have questions
or would like to enroll in coverage contact Rebecca Smith at Aflacsmithagencyinccom or 804-422-3522
15
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life You may purchase up to $300000Guaranteed Issue for new hires
$40000
Spouse LifeYou may purchase up to $100000
Guaranteed Issue $5000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
If you are not currently enrolled and make a Voluntary Life election for 2021 you will be subject to underwriting and required to answer medical questions to enroll Employees must enroll in order to elect dependent coverage If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
VOLUNTARY WHOLE LIFE ndash AFLAC
16
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY SHORT TERM DISABILITY INSURANCE
Only 48 percent of American adults indicate they have enough savings to cover three months of living expenses in the event they become disabled
Source Council for Disability Awareness httpdisabilitycanhappenorgdisability-statistic
3 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income ReplacedUp to 60 of base monthly earnings
Guarantee Issue up to $3000 per month
Maximum Benefit $6000 per week
Duration of Benefits 3 months
6 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income Replaced Up to 60 of base monthly earnings
Maximum Benefit$6000 per month
Guaranteed Issue up to $3000 per month
Duration of Benefits 6 months
All benefit eligible employees can choose to enroll in one of two Voluntary Short Term Disability plans Should you have an accident or an illness your benefit will be paid for either 3 or 6 months If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
12 month pre-existing clause still applies
17
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY ACCIDENT ndash AFLAC
This is not a complete list of all covered accidents Please consult the plan summary for more details If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
24 Hour On or Off Job Accident
Annual Wellness Benefit
Year 1 $25 per insuredYear 2-4 $50 per insuredYear 5+ $75 per insured
Does not include children
Initial Treatment
Doctorrsquos office or other facility $75Doctorrsquos office or other facility
with x-ray $100ERUrgent Care $150
ERUrgent Care with X-ray $200
Hospital Admission$900
Additional $225 per dayAdditional $525 per day
AmbulanceGround $300
Air $900
Burns Lacerations Fractures Dislocations Concussion etc
$75-$15000
Accidental Death $50000
Accidental Dismemberment Up to $17500
18
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY CRITICAL ILLNESS ndash AFLAC
Voluntary Critical Illness
Wellness Benefit$50 per year ndash Employeeand Spouse (if applicable)
Coverage Amount Options
New Employee Guaranteed Issue up to $20000If a spousedependent is covered under the employees
plan they can elect 50 of the employees coverageChildren are automatically covered at 50 with no
charge
Included Illness at 100Cancer heart attack stroke major organ transplant
end stage renal failure paralysis coma and major third-degree burns ndash and more
Pre-existing Conditions
12 month exclusion for pre-existing cancerNo pre-existing exclusions on other health benefits as
long as diagnosis is made after the plan is in effect
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
6
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
MEDICAL PLAN OPTIONS ndash ANTHEM
For this plan year you can choose from the following medical plans Refer to the carrier benefit summaries for the exact benefit level associated with your plan
In Network Benefits Key Advantage $250 Key Advantage $500 HDHP $2800
Referrals Required No No No
Plan Accumulator Plan Year Plan Year Plan Year
Annual Deductible(embedded)
$250 individual$500 family
$500 individual$1000 family
$2800 individual $5600 family
Coinsurance 20 20 20
Maximum Out-of-Pocket$3000 individual
$6000 family$4000 individual
$8000 family$5000 individual $10000 family
Preventive Care Covered 100 Covered 100 Covered 100
Physicianrsquos Office VisitsPCP $20
Specialist $35Virtual Visit $0
PCP $25Specialist $40Virtual Visit $0
20 after deductibleVirtual Visit
determined by services rendered
Urgent CarePCP $20
Specialist $35PCP $25
Specialist $4020 after deductible
Emergency Room Facility $350 copay per visit 20 after deductible 20 after deductible
Inpatient Facility $400 copay per stay 20 after deductible 20 after deductible
Outpatient Facility $150 copay 20 after deductible 20 after deductible
Diagnostic Lab Services 20 after deductible 20 after deductible 20 after deductible
Advanced Imaging Services
20 after deductible 20 after deductible 20 after deductible
Pharmacy Prescription Drugs
$10$30$45$55 $10$30$45$55 20 after deductible
Mail Order Prescription Drugs
$20$60$90$110 $20$60$90$110 20 after deductible
Out of Network Benefits Key Advantage $250 Key Advantage $500 HDHP $2800
Annual Deductible$500 individual$1000 family
$1000 individual$2000 family
Deductible is combined for In and Out of
Network
Maximum Out-of-Pocket$5000 individual$10000 family
$7000 individual$14000 family
$10000 individual$20000 family
Coinsurance 30 30 40
7
TELEMEDICINE ndash LIVEHEALTH ONLINE
What is Telemedicine bull Telemedicine uses technology to facilitate communication
between a doctor and patient who are not in the same physical location for medical evaluation diagnosis and treatment
bull Speak to a real live doctor 247365
bull All doctors are US Board Certified licensed to practice medicine and write prescriptions in the state the caller is located in
bull 100 HIPAA Compliant
bull Designed for non-emergency care 71 of all medical visits today are non-emergency
Common issues treated via LiveHealth Onlinebull Allergies
bull CoughCold or Flu
bull Pinkeye
bull Sore throat
bull Sinus Infection
bull Stomachache
Enroll for free at wwwlivehealthonlinecom
8
HEALTH SAVINGS ACCOUNT (HSA) ndash WEXDISCOVERY BENEFITS
Option for theHigh Deductible Health Plan
Employees who enroll in the High Deductible Health Plan offered through New Kent County have the option of opening a Health Savings Account (HSA) This HSA eligible plan provides a way to save money that is available in future years for health care expensesbull For 2021 New Kent County will contribute
$1000 for individuals who enroll in the HDHP and $2000 for employees with any dependents enrolled You will receive half of the employer contribution in the July 15 2021 pay period and the other half in the January 15 2022 pay period
bull In 2021 individuals can contribute up to $3600 and families can contribute up to $7200 to their HSA
bull If you are 55 or older you can make a $1000 catch-up contribution
bull Contributions to an HSA can be made on a pre-tax or post-tax basis and funds within the HSA grow without incurring taxes Funds are withdrawn tax-free for healthcare related needs without having to file receipts although you should keep your receipts in case you are ever audited
bull Money deposited in the HSA by the employee AND employer immediately become the employeersquos asset and is portable
The benefit plan information shown in this guide is illustrative only This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
Pre-Tax PlanWhat is this account
and how does it work Maximum Contribution
AllowedCan money in accounts
be ldquorolled overrdquo
Health Savings Account (HSA)
A HSA can be funded with pre-tax dollars to
help pay for eligible medical expenses
Employee only coverage $3600
Family coverage $7200
Catch up contribution (55 year of age or
older) $1000
Yes amounts left in your HSA can be rolled over year to year and are portable if your employment ends
9
FLEXIBLE SPENDING ACCOUNTS (FSA) ndash WEXDISCOVERY BENEFITS
If you are enrolling in the High Deductible Health Plan and contributing to a Health Savings Account you cannot open a Flexible Spending Account
Who is Eligible
All Full-Time Employees working at least 30 hours each week
Benefits You Receive
FSAs provide you with an important tax advantage that can help you pay health care and dependent care expenses on a pretax basis By anticipating your familyrsquos health care and dependent care costs for the next year you can actually lower your taxable income
Health Care Reimbursement FSA
This program lets employees pay for certain IRS-approved medical care expenses and prescriptions not covered by their insurance plan with pretax dollars The annual pretax maximum amount you may contribute to the Health Care Reimbursement FSA is $2750This limit will be indexed for cost-of-living adjustments You can rollover up to $550 into the following plan year Some examples of eligible expenses include
bull Hearing services including hearing aids and batteries
bull Vision services including contact lenses contact lens solution eye examinations and eyeglasses
bull Dental services and orthodontia
bull Chiropractic services
bull Acupuncture
bull Prescription contraceptives
Dependent Care FSA
The Dependent Care FSA lets employees use pretax dollars toward qualified dependent care such as caring for children under the age 13 or caring for elders The annual maximum amount you may contribute to the Dependent Care FSA is $5000 (or $2500 if married and filing separately) per calendar year Examples include
bull The cost of child or adult dependent care
bull The cost for an individual to provide care either in or out of your house
bull Nursery schools and preschools (excluding kindergarten)
The benefit plan information shown in this guide is illustrative only This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
10
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
DENTAL PLAN ndash DELTA DENTAL
One can of soda is the amount of sugar
recommended for three days for a child
Sugary Sodas are a major risk factor for
tooth decay
Source American Dental Association (ADA)
For this plan year dental coverage is offered through The Local Choice and administered by Delta Dental Refer to the carrier benefit summary for the exact benefit level associated with your plan
In Network Benefits Comprehensive
DentalPreventive Dental
Individual Annual Maximum
$1500 None
Annual Deductible$25 Individual
$50 Two People$75 Family
None
Preventive Services (exams cleaning x-rays
fluoride etc)100 100
Basic Services(fillings root canals periodontics simple
extractions etc)
80 afterdeductible
Not covered
Major Services(crowns dentures
bridges etc)
50 after deductible
Not covered
Orthodontic Services(Adult and Child)
50 to $1500 lifetime maximum
Not covered
Out of Network BenefitsOut of network benefits mirror in network benefits However out of
network providers may balance bill
11
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VISION PLAN ndash ANTHEM
Your eyes need a rest even while yoursquore awake Use the 20-20-20 rule to reduce eyestrain After
working for 20 minutes look away about 20 feet in front of you for
about 20 seconds
Source National Eye Institute httpsneinihgovhealthhealthyeyes
For this plan year vision coverage is offered through The Local Choice and administered by Anthem Blue View Vision Refer to the carrier benefit summary for the exact benefit level associated with your plan
In-NetworkOut of
Network
Key Advantage
$250
Key Advantage
$500HDHP $2800
Allowance for All Plans
Annual Exam
$35 copay $40 copay $15 copay$50
allowance
LensesSingleBifocalTrifocal
$20 copay $20 copay $20 copay
$50$75
$100
ContactLensesin lieu of glasses lenses
$100 allowance+ 15 off remaining
balance
$100 allowance + 15 off remaining
balance
$100 allowance+ 15 off remaining
balance
$80
Frames
$100 allowance+ 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$80
FrequencyExamLensesFrames
Once every 12 monthsOnce every 12 monthsOnce every 12 months
12
2021-2022 MEDICAL DENTAL AND VISION PER PAY DEDUCTIONS
Key Advantage $250 Plan
ComprehensiveDental amp Vision
Key Advantage $500 Plan
ComprehensiveDental amp Vision
HDHP $2800 ComprehensiveDental amp Vision
Employee Only $2500 $000 $000
Employee + One $21800 $19500 $16600
Employee Family $43600 $39000 $33250
Dual Enrollment Spouse
$5000 $000 $11150
Dual Enrollment Family
$31775 $29000 $22300
Key Advantage $250 Plan
Preventive Dentalamp Vision
Key Advantage $500 Plan
Preventive Dental amp Vision
HDHP $2800 Preventive Dental
amp Vision
Employee Only $2150 $000 $000
Employee + One $21150 $19000 $15800
Employee Family $42650 $38000 $31600
Dual Enrollment Spouse
$4300 $000 $10800
Dual Enrollment Family
$30900 $28000 $21600
Dual Enrollment = Both eligible employees work for New Kent County
Say hi to SydneyAnthemrsquos new app is s imple
smart mdash and al l about you
With Sydney you can find everything you need to know about your Anthem
benefits -- personalized and all in one place Sydney makes it easier to get
things done so you can spend more time focused on your health
Get started with Sydney
Download the app today
Ready for you to use quickly easily
seamlessly mdash with one-click access
to benefits info Member Services
wellness resources and more
Sydney acts like a personal health
guide answering your questions
and connecting you to the right
resources at the right time And
you can use the chatbot to get
answers quickly
Get alerts reminders and tips
directly from Sydney Get doctor
suggestions based on your needs
The more you use it the more
Sydney can help you stay healthy
and save money
With just one click you can
Find care and check costs
Check all benefits
See claims
Already using one of our apps
Itrsquos easy to make the switch Simply
download the Sydney app and log in
with your Anthem username and password
Get answers even faster with
our chatbot
View and use digital ID cards
AnthemBlueCrossandBlueShield is the trade name of InColorado RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc InConnecticut AnthemHealth Plans Inc InGeorgia BlueCross BlueShield Healthcare Planof Georgia Inc In IndianaAnthemInsurance Companies Inc InKentuckyAnthemHealth Plans of Kentucky Inc InMaine AnthemHealth Plans of Maine Inc InMissouri (excluding 30 counties in the Kansas City area) RightCHOICEregManaged Care Inc (RIT)Healthy Alliancereg Life Insurance Company(HALIC) andHMOMissouri Inc RITandcertain affiliates administer non-HMObenefits underwritten byHALICandHMObenefits underwritten byHMOMissouri Inc RITandcertain affiliates onlyprovide administrative services for self-funded plans anddonot underwrite benefits InNevada RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc dba HMONevada InNewHampshire AnthemHealth Plans of NewHampshire Inc HMOplans are administered byAnthemHealth Plans of NewHampshire Inc andunderwritten byMatthewThorntonHealthPlan Inc In Ohio Community Insurance Company In Virginia Anthem Health Plans of Virginia Inc trades as Anthem Blue Cross and Blue Shield6in V4irginia and its service area is all of Virginia except for the City of Fairfax the Town of Vienna and the area east
of State Route 123 In Wisconsin
Blue Cross Blue Shield of Wisconsin (BCBSWI) underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC) Compcare underwrites or administers HMO or POS policies WCIC underwrites or administers Well Priority HMO or POS policies Independent licensees of the Blue Cross and Blue Shield Association Anthem is a registered trademark of Anthem Insurance Companies Inc
115993MUMENABS 0619
13
14
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life
You may purchase 15 or 30 year coverage up to $100000
Guaranteed Issue for new hires $25000
Spouse LifeYou may purchase up to $50000 Guaranteed
Issue $10000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
VOLUNTARY TERM LIFE ndash AFLAC
Voluntary Life coverage provides an additional benefit to the beneficiaries It provides a benefit to your
designated beneficiary in the event of your death and you can choose the term of coverage To be eligible
for coverage you must qualify as an eligible member (working at least 30 hours per week) and be
considered actively at work If you are not currently enrolled and make a Voluntary Life election for 2021
you will be subject to underwriting and required to answer medical questions to enroll If you have questions
or would like to enroll in coverage contact Rebecca Smith at Aflacsmithagencyinccom or 804-422-3522
15
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life You may purchase up to $300000Guaranteed Issue for new hires
$40000
Spouse LifeYou may purchase up to $100000
Guaranteed Issue $5000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
If you are not currently enrolled and make a Voluntary Life election for 2021 you will be subject to underwriting and required to answer medical questions to enroll Employees must enroll in order to elect dependent coverage If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
VOLUNTARY WHOLE LIFE ndash AFLAC
16
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY SHORT TERM DISABILITY INSURANCE
Only 48 percent of American adults indicate they have enough savings to cover three months of living expenses in the event they become disabled
Source Council for Disability Awareness httpdisabilitycanhappenorgdisability-statistic
3 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income ReplacedUp to 60 of base monthly earnings
Guarantee Issue up to $3000 per month
Maximum Benefit $6000 per week
Duration of Benefits 3 months
6 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income Replaced Up to 60 of base monthly earnings
Maximum Benefit$6000 per month
Guaranteed Issue up to $3000 per month
Duration of Benefits 6 months
All benefit eligible employees can choose to enroll in one of two Voluntary Short Term Disability plans Should you have an accident or an illness your benefit will be paid for either 3 or 6 months If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
12 month pre-existing clause still applies
17
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY ACCIDENT ndash AFLAC
This is not a complete list of all covered accidents Please consult the plan summary for more details If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
24 Hour On or Off Job Accident
Annual Wellness Benefit
Year 1 $25 per insuredYear 2-4 $50 per insuredYear 5+ $75 per insured
Does not include children
Initial Treatment
Doctorrsquos office or other facility $75Doctorrsquos office or other facility
with x-ray $100ERUrgent Care $150
ERUrgent Care with X-ray $200
Hospital Admission$900
Additional $225 per dayAdditional $525 per day
AmbulanceGround $300
Air $900
Burns Lacerations Fractures Dislocations Concussion etc
$75-$15000
Accidental Death $50000
Accidental Dismemberment Up to $17500
18
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY CRITICAL ILLNESS ndash AFLAC
Voluntary Critical Illness
Wellness Benefit$50 per year ndash Employeeand Spouse (if applicable)
Coverage Amount Options
New Employee Guaranteed Issue up to $20000If a spousedependent is covered under the employees
plan they can elect 50 of the employees coverageChildren are automatically covered at 50 with no
charge
Included Illness at 100Cancer heart attack stroke major organ transplant
end stage renal failure paralysis coma and major third-degree burns ndash and more
Pre-existing Conditions
12 month exclusion for pre-existing cancerNo pre-existing exclusions on other health benefits as
long as diagnosis is made after the plan is in effect
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
7
TELEMEDICINE ndash LIVEHEALTH ONLINE
What is Telemedicine bull Telemedicine uses technology to facilitate communication
between a doctor and patient who are not in the same physical location for medical evaluation diagnosis and treatment
bull Speak to a real live doctor 247365
bull All doctors are US Board Certified licensed to practice medicine and write prescriptions in the state the caller is located in
bull 100 HIPAA Compliant
bull Designed for non-emergency care 71 of all medical visits today are non-emergency
Common issues treated via LiveHealth Onlinebull Allergies
bull CoughCold or Flu
bull Pinkeye
bull Sore throat
bull Sinus Infection
bull Stomachache
Enroll for free at wwwlivehealthonlinecom
8
HEALTH SAVINGS ACCOUNT (HSA) ndash WEXDISCOVERY BENEFITS
Option for theHigh Deductible Health Plan
Employees who enroll in the High Deductible Health Plan offered through New Kent County have the option of opening a Health Savings Account (HSA) This HSA eligible plan provides a way to save money that is available in future years for health care expensesbull For 2021 New Kent County will contribute
$1000 for individuals who enroll in the HDHP and $2000 for employees with any dependents enrolled You will receive half of the employer contribution in the July 15 2021 pay period and the other half in the January 15 2022 pay period
bull In 2021 individuals can contribute up to $3600 and families can contribute up to $7200 to their HSA
bull If you are 55 or older you can make a $1000 catch-up contribution
bull Contributions to an HSA can be made on a pre-tax or post-tax basis and funds within the HSA grow without incurring taxes Funds are withdrawn tax-free for healthcare related needs without having to file receipts although you should keep your receipts in case you are ever audited
bull Money deposited in the HSA by the employee AND employer immediately become the employeersquos asset and is portable
The benefit plan information shown in this guide is illustrative only This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
Pre-Tax PlanWhat is this account
and how does it work Maximum Contribution
AllowedCan money in accounts
be ldquorolled overrdquo
Health Savings Account (HSA)
A HSA can be funded with pre-tax dollars to
help pay for eligible medical expenses
Employee only coverage $3600
Family coverage $7200
Catch up contribution (55 year of age or
older) $1000
Yes amounts left in your HSA can be rolled over year to year and are portable if your employment ends
9
FLEXIBLE SPENDING ACCOUNTS (FSA) ndash WEXDISCOVERY BENEFITS
If you are enrolling in the High Deductible Health Plan and contributing to a Health Savings Account you cannot open a Flexible Spending Account
Who is Eligible
All Full-Time Employees working at least 30 hours each week
Benefits You Receive
FSAs provide you with an important tax advantage that can help you pay health care and dependent care expenses on a pretax basis By anticipating your familyrsquos health care and dependent care costs for the next year you can actually lower your taxable income
Health Care Reimbursement FSA
This program lets employees pay for certain IRS-approved medical care expenses and prescriptions not covered by their insurance plan with pretax dollars The annual pretax maximum amount you may contribute to the Health Care Reimbursement FSA is $2750This limit will be indexed for cost-of-living adjustments You can rollover up to $550 into the following plan year Some examples of eligible expenses include
bull Hearing services including hearing aids and batteries
bull Vision services including contact lenses contact lens solution eye examinations and eyeglasses
bull Dental services and orthodontia
bull Chiropractic services
bull Acupuncture
bull Prescription contraceptives
Dependent Care FSA
The Dependent Care FSA lets employees use pretax dollars toward qualified dependent care such as caring for children under the age 13 or caring for elders The annual maximum amount you may contribute to the Dependent Care FSA is $5000 (or $2500 if married and filing separately) per calendar year Examples include
bull The cost of child or adult dependent care
bull The cost for an individual to provide care either in or out of your house
bull Nursery schools and preschools (excluding kindergarten)
The benefit plan information shown in this guide is illustrative only This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
10
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
DENTAL PLAN ndash DELTA DENTAL
One can of soda is the amount of sugar
recommended for three days for a child
Sugary Sodas are a major risk factor for
tooth decay
Source American Dental Association (ADA)
For this plan year dental coverage is offered through The Local Choice and administered by Delta Dental Refer to the carrier benefit summary for the exact benefit level associated with your plan
In Network Benefits Comprehensive
DentalPreventive Dental
Individual Annual Maximum
$1500 None
Annual Deductible$25 Individual
$50 Two People$75 Family
None
Preventive Services (exams cleaning x-rays
fluoride etc)100 100
Basic Services(fillings root canals periodontics simple
extractions etc)
80 afterdeductible
Not covered
Major Services(crowns dentures
bridges etc)
50 after deductible
Not covered
Orthodontic Services(Adult and Child)
50 to $1500 lifetime maximum
Not covered
Out of Network BenefitsOut of network benefits mirror in network benefits However out of
network providers may balance bill
11
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VISION PLAN ndash ANTHEM
Your eyes need a rest even while yoursquore awake Use the 20-20-20 rule to reduce eyestrain After
working for 20 minutes look away about 20 feet in front of you for
about 20 seconds
Source National Eye Institute httpsneinihgovhealthhealthyeyes
For this plan year vision coverage is offered through The Local Choice and administered by Anthem Blue View Vision Refer to the carrier benefit summary for the exact benefit level associated with your plan
In-NetworkOut of
Network
Key Advantage
$250
Key Advantage
$500HDHP $2800
Allowance for All Plans
Annual Exam
$35 copay $40 copay $15 copay$50
allowance
LensesSingleBifocalTrifocal
$20 copay $20 copay $20 copay
$50$75
$100
ContactLensesin lieu of glasses lenses
$100 allowance+ 15 off remaining
balance
$100 allowance + 15 off remaining
balance
$100 allowance+ 15 off remaining
balance
$80
Frames
$100 allowance+ 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$80
FrequencyExamLensesFrames
Once every 12 monthsOnce every 12 monthsOnce every 12 months
12
2021-2022 MEDICAL DENTAL AND VISION PER PAY DEDUCTIONS
Key Advantage $250 Plan
ComprehensiveDental amp Vision
Key Advantage $500 Plan
ComprehensiveDental amp Vision
HDHP $2800 ComprehensiveDental amp Vision
Employee Only $2500 $000 $000
Employee + One $21800 $19500 $16600
Employee Family $43600 $39000 $33250
Dual Enrollment Spouse
$5000 $000 $11150
Dual Enrollment Family
$31775 $29000 $22300
Key Advantage $250 Plan
Preventive Dentalamp Vision
Key Advantage $500 Plan
Preventive Dental amp Vision
HDHP $2800 Preventive Dental
amp Vision
Employee Only $2150 $000 $000
Employee + One $21150 $19000 $15800
Employee Family $42650 $38000 $31600
Dual Enrollment Spouse
$4300 $000 $10800
Dual Enrollment Family
$30900 $28000 $21600
Dual Enrollment = Both eligible employees work for New Kent County
Say hi to SydneyAnthemrsquos new app is s imple
smart mdash and al l about you
With Sydney you can find everything you need to know about your Anthem
benefits -- personalized and all in one place Sydney makes it easier to get
things done so you can spend more time focused on your health
Get started with Sydney
Download the app today
Ready for you to use quickly easily
seamlessly mdash with one-click access
to benefits info Member Services
wellness resources and more
Sydney acts like a personal health
guide answering your questions
and connecting you to the right
resources at the right time And
you can use the chatbot to get
answers quickly
Get alerts reminders and tips
directly from Sydney Get doctor
suggestions based on your needs
The more you use it the more
Sydney can help you stay healthy
and save money
With just one click you can
Find care and check costs
Check all benefits
See claims
Already using one of our apps
Itrsquos easy to make the switch Simply
download the Sydney app and log in
with your Anthem username and password
Get answers even faster with
our chatbot
View and use digital ID cards
AnthemBlueCrossandBlueShield is the trade name of InColorado RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc InConnecticut AnthemHealth Plans Inc InGeorgia BlueCross BlueShield Healthcare Planof Georgia Inc In IndianaAnthemInsurance Companies Inc InKentuckyAnthemHealth Plans of Kentucky Inc InMaine AnthemHealth Plans of Maine Inc InMissouri (excluding 30 counties in the Kansas City area) RightCHOICEregManaged Care Inc (RIT)Healthy Alliancereg Life Insurance Company(HALIC) andHMOMissouri Inc RITandcertain affiliates administer non-HMObenefits underwritten byHALICandHMObenefits underwritten byHMOMissouri Inc RITandcertain affiliates onlyprovide administrative services for self-funded plans anddonot underwrite benefits InNevada RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc dba HMONevada InNewHampshire AnthemHealth Plans of NewHampshire Inc HMOplans are administered byAnthemHealth Plans of NewHampshire Inc andunderwritten byMatthewThorntonHealthPlan Inc In Ohio Community Insurance Company In Virginia Anthem Health Plans of Virginia Inc trades as Anthem Blue Cross and Blue Shield6in V4irginia and its service area is all of Virginia except for the City of Fairfax the Town of Vienna and the area east
of State Route 123 In Wisconsin
Blue Cross Blue Shield of Wisconsin (BCBSWI) underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC) Compcare underwrites or administers HMO or POS policies WCIC underwrites or administers Well Priority HMO or POS policies Independent licensees of the Blue Cross and Blue Shield Association Anthem is a registered trademark of Anthem Insurance Companies Inc
115993MUMENABS 0619
13
14
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life
You may purchase 15 or 30 year coverage up to $100000
Guaranteed Issue for new hires $25000
Spouse LifeYou may purchase up to $50000 Guaranteed
Issue $10000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
VOLUNTARY TERM LIFE ndash AFLAC
Voluntary Life coverage provides an additional benefit to the beneficiaries It provides a benefit to your
designated beneficiary in the event of your death and you can choose the term of coverage To be eligible
for coverage you must qualify as an eligible member (working at least 30 hours per week) and be
considered actively at work If you are not currently enrolled and make a Voluntary Life election for 2021
you will be subject to underwriting and required to answer medical questions to enroll If you have questions
or would like to enroll in coverage contact Rebecca Smith at Aflacsmithagencyinccom or 804-422-3522
15
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life You may purchase up to $300000Guaranteed Issue for new hires
$40000
Spouse LifeYou may purchase up to $100000
Guaranteed Issue $5000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
If you are not currently enrolled and make a Voluntary Life election for 2021 you will be subject to underwriting and required to answer medical questions to enroll Employees must enroll in order to elect dependent coverage If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
VOLUNTARY WHOLE LIFE ndash AFLAC
16
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY SHORT TERM DISABILITY INSURANCE
Only 48 percent of American adults indicate they have enough savings to cover three months of living expenses in the event they become disabled
Source Council for Disability Awareness httpdisabilitycanhappenorgdisability-statistic
3 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income ReplacedUp to 60 of base monthly earnings
Guarantee Issue up to $3000 per month
Maximum Benefit $6000 per week
Duration of Benefits 3 months
6 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income Replaced Up to 60 of base monthly earnings
Maximum Benefit$6000 per month
Guaranteed Issue up to $3000 per month
Duration of Benefits 6 months
All benefit eligible employees can choose to enroll in one of two Voluntary Short Term Disability plans Should you have an accident or an illness your benefit will be paid for either 3 or 6 months If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
12 month pre-existing clause still applies
17
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY ACCIDENT ndash AFLAC
This is not a complete list of all covered accidents Please consult the plan summary for more details If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
24 Hour On or Off Job Accident
Annual Wellness Benefit
Year 1 $25 per insuredYear 2-4 $50 per insuredYear 5+ $75 per insured
Does not include children
Initial Treatment
Doctorrsquos office or other facility $75Doctorrsquos office or other facility
with x-ray $100ERUrgent Care $150
ERUrgent Care with X-ray $200
Hospital Admission$900
Additional $225 per dayAdditional $525 per day
AmbulanceGround $300
Air $900
Burns Lacerations Fractures Dislocations Concussion etc
$75-$15000
Accidental Death $50000
Accidental Dismemberment Up to $17500
18
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY CRITICAL ILLNESS ndash AFLAC
Voluntary Critical Illness
Wellness Benefit$50 per year ndash Employeeand Spouse (if applicable)
Coverage Amount Options
New Employee Guaranteed Issue up to $20000If a spousedependent is covered under the employees
plan they can elect 50 of the employees coverageChildren are automatically covered at 50 with no
charge
Included Illness at 100Cancer heart attack stroke major organ transplant
end stage renal failure paralysis coma and major third-degree burns ndash and more
Pre-existing Conditions
12 month exclusion for pre-existing cancerNo pre-existing exclusions on other health benefits as
long as diagnosis is made after the plan is in effect
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
8
HEALTH SAVINGS ACCOUNT (HSA) ndash WEXDISCOVERY BENEFITS
Option for theHigh Deductible Health Plan
Employees who enroll in the High Deductible Health Plan offered through New Kent County have the option of opening a Health Savings Account (HSA) This HSA eligible plan provides a way to save money that is available in future years for health care expensesbull For 2021 New Kent County will contribute
$1000 for individuals who enroll in the HDHP and $2000 for employees with any dependents enrolled You will receive half of the employer contribution in the July 15 2021 pay period and the other half in the January 15 2022 pay period
bull In 2021 individuals can contribute up to $3600 and families can contribute up to $7200 to their HSA
bull If you are 55 or older you can make a $1000 catch-up contribution
bull Contributions to an HSA can be made on a pre-tax or post-tax basis and funds within the HSA grow without incurring taxes Funds are withdrawn tax-free for healthcare related needs without having to file receipts although you should keep your receipts in case you are ever audited
bull Money deposited in the HSA by the employee AND employer immediately become the employeersquos asset and is portable
The benefit plan information shown in this guide is illustrative only This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
Pre-Tax PlanWhat is this account
and how does it work Maximum Contribution
AllowedCan money in accounts
be ldquorolled overrdquo
Health Savings Account (HSA)
A HSA can be funded with pre-tax dollars to
help pay for eligible medical expenses
Employee only coverage $3600
Family coverage $7200
Catch up contribution (55 year of age or
older) $1000
Yes amounts left in your HSA can be rolled over year to year and are portable if your employment ends
9
FLEXIBLE SPENDING ACCOUNTS (FSA) ndash WEXDISCOVERY BENEFITS
If you are enrolling in the High Deductible Health Plan and contributing to a Health Savings Account you cannot open a Flexible Spending Account
Who is Eligible
All Full-Time Employees working at least 30 hours each week
Benefits You Receive
FSAs provide you with an important tax advantage that can help you pay health care and dependent care expenses on a pretax basis By anticipating your familyrsquos health care and dependent care costs for the next year you can actually lower your taxable income
Health Care Reimbursement FSA
This program lets employees pay for certain IRS-approved medical care expenses and prescriptions not covered by their insurance plan with pretax dollars The annual pretax maximum amount you may contribute to the Health Care Reimbursement FSA is $2750This limit will be indexed for cost-of-living adjustments You can rollover up to $550 into the following plan year Some examples of eligible expenses include
bull Hearing services including hearing aids and batteries
bull Vision services including contact lenses contact lens solution eye examinations and eyeglasses
bull Dental services and orthodontia
bull Chiropractic services
bull Acupuncture
bull Prescription contraceptives
Dependent Care FSA
The Dependent Care FSA lets employees use pretax dollars toward qualified dependent care such as caring for children under the age 13 or caring for elders The annual maximum amount you may contribute to the Dependent Care FSA is $5000 (or $2500 if married and filing separately) per calendar year Examples include
bull The cost of child or adult dependent care
bull The cost for an individual to provide care either in or out of your house
bull Nursery schools and preschools (excluding kindergarten)
The benefit plan information shown in this guide is illustrative only This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
10
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
DENTAL PLAN ndash DELTA DENTAL
One can of soda is the amount of sugar
recommended for three days for a child
Sugary Sodas are a major risk factor for
tooth decay
Source American Dental Association (ADA)
For this plan year dental coverage is offered through The Local Choice and administered by Delta Dental Refer to the carrier benefit summary for the exact benefit level associated with your plan
In Network Benefits Comprehensive
DentalPreventive Dental
Individual Annual Maximum
$1500 None
Annual Deductible$25 Individual
$50 Two People$75 Family
None
Preventive Services (exams cleaning x-rays
fluoride etc)100 100
Basic Services(fillings root canals periodontics simple
extractions etc)
80 afterdeductible
Not covered
Major Services(crowns dentures
bridges etc)
50 after deductible
Not covered
Orthodontic Services(Adult and Child)
50 to $1500 lifetime maximum
Not covered
Out of Network BenefitsOut of network benefits mirror in network benefits However out of
network providers may balance bill
11
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VISION PLAN ndash ANTHEM
Your eyes need a rest even while yoursquore awake Use the 20-20-20 rule to reduce eyestrain After
working for 20 minutes look away about 20 feet in front of you for
about 20 seconds
Source National Eye Institute httpsneinihgovhealthhealthyeyes
For this plan year vision coverage is offered through The Local Choice and administered by Anthem Blue View Vision Refer to the carrier benefit summary for the exact benefit level associated with your plan
In-NetworkOut of
Network
Key Advantage
$250
Key Advantage
$500HDHP $2800
Allowance for All Plans
Annual Exam
$35 copay $40 copay $15 copay$50
allowance
LensesSingleBifocalTrifocal
$20 copay $20 copay $20 copay
$50$75
$100
ContactLensesin lieu of glasses lenses
$100 allowance+ 15 off remaining
balance
$100 allowance + 15 off remaining
balance
$100 allowance+ 15 off remaining
balance
$80
Frames
$100 allowance+ 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$80
FrequencyExamLensesFrames
Once every 12 monthsOnce every 12 monthsOnce every 12 months
12
2021-2022 MEDICAL DENTAL AND VISION PER PAY DEDUCTIONS
Key Advantage $250 Plan
ComprehensiveDental amp Vision
Key Advantage $500 Plan
ComprehensiveDental amp Vision
HDHP $2800 ComprehensiveDental amp Vision
Employee Only $2500 $000 $000
Employee + One $21800 $19500 $16600
Employee Family $43600 $39000 $33250
Dual Enrollment Spouse
$5000 $000 $11150
Dual Enrollment Family
$31775 $29000 $22300
Key Advantage $250 Plan
Preventive Dentalamp Vision
Key Advantage $500 Plan
Preventive Dental amp Vision
HDHP $2800 Preventive Dental
amp Vision
Employee Only $2150 $000 $000
Employee + One $21150 $19000 $15800
Employee Family $42650 $38000 $31600
Dual Enrollment Spouse
$4300 $000 $10800
Dual Enrollment Family
$30900 $28000 $21600
Dual Enrollment = Both eligible employees work for New Kent County
Say hi to SydneyAnthemrsquos new app is s imple
smart mdash and al l about you
With Sydney you can find everything you need to know about your Anthem
benefits -- personalized and all in one place Sydney makes it easier to get
things done so you can spend more time focused on your health
Get started with Sydney
Download the app today
Ready for you to use quickly easily
seamlessly mdash with one-click access
to benefits info Member Services
wellness resources and more
Sydney acts like a personal health
guide answering your questions
and connecting you to the right
resources at the right time And
you can use the chatbot to get
answers quickly
Get alerts reminders and tips
directly from Sydney Get doctor
suggestions based on your needs
The more you use it the more
Sydney can help you stay healthy
and save money
With just one click you can
Find care and check costs
Check all benefits
See claims
Already using one of our apps
Itrsquos easy to make the switch Simply
download the Sydney app and log in
with your Anthem username and password
Get answers even faster with
our chatbot
View and use digital ID cards
AnthemBlueCrossandBlueShield is the trade name of InColorado RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc InConnecticut AnthemHealth Plans Inc InGeorgia BlueCross BlueShield Healthcare Planof Georgia Inc In IndianaAnthemInsurance Companies Inc InKentuckyAnthemHealth Plans of Kentucky Inc InMaine AnthemHealth Plans of Maine Inc InMissouri (excluding 30 counties in the Kansas City area) RightCHOICEregManaged Care Inc (RIT)Healthy Alliancereg Life Insurance Company(HALIC) andHMOMissouri Inc RITandcertain affiliates administer non-HMObenefits underwritten byHALICandHMObenefits underwritten byHMOMissouri Inc RITandcertain affiliates onlyprovide administrative services for self-funded plans anddonot underwrite benefits InNevada RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc dba HMONevada InNewHampshire AnthemHealth Plans of NewHampshire Inc HMOplans are administered byAnthemHealth Plans of NewHampshire Inc andunderwritten byMatthewThorntonHealthPlan Inc In Ohio Community Insurance Company In Virginia Anthem Health Plans of Virginia Inc trades as Anthem Blue Cross and Blue Shield6in V4irginia and its service area is all of Virginia except for the City of Fairfax the Town of Vienna and the area east
of State Route 123 In Wisconsin
Blue Cross Blue Shield of Wisconsin (BCBSWI) underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC) Compcare underwrites or administers HMO or POS policies WCIC underwrites or administers Well Priority HMO or POS policies Independent licensees of the Blue Cross and Blue Shield Association Anthem is a registered trademark of Anthem Insurance Companies Inc
115993MUMENABS 0619
13
14
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life
You may purchase 15 or 30 year coverage up to $100000
Guaranteed Issue for new hires $25000
Spouse LifeYou may purchase up to $50000 Guaranteed
Issue $10000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
VOLUNTARY TERM LIFE ndash AFLAC
Voluntary Life coverage provides an additional benefit to the beneficiaries It provides a benefit to your
designated beneficiary in the event of your death and you can choose the term of coverage To be eligible
for coverage you must qualify as an eligible member (working at least 30 hours per week) and be
considered actively at work If you are not currently enrolled and make a Voluntary Life election for 2021
you will be subject to underwriting and required to answer medical questions to enroll If you have questions
or would like to enroll in coverage contact Rebecca Smith at Aflacsmithagencyinccom or 804-422-3522
15
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life You may purchase up to $300000Guaranteed Issue for new hires
$40000
Spouse LifeYou may purchase up to $100000
Guaranteed Issue $5000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
If you are not currently enrolled and make a Voluntary Life election for 2021 you will be subject to underwriting and required to answer medical questions to enroll Employees must enroll in order to elect dependent coverage If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
VOLUNTARY WHOLE LIFE ndash AFLAC
16
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY SHORT TERM DISABILITY INSURANCE
Only 48 percent of American adults indicate they have enough savings to cover three months of living expenses in the event they become disabled
Source Council for Disability Awareness httpdisabilitycanhappenorgdisability-statistic
3 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income ReplacedUp to 60 of base monthly earnings
Guarantee Issue up to $3000 per month
Maximum Benefit $6000 per week
Duration of Benefits 3 months
6 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income Replaced Up to 60 of base monthly earnings
Maximum Benefit$6000 per month
Guaranteed Issue up to $3000 per month
Duration of Benefits 6 months
All benefit eligible employees can choose to enroll in one of two Voluntary Short Term Disability plans Should you have an accident or an illness your benefit will be paid for either 3 or 6 months If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
12 month pre-existing clause still applies
17
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY ACCIDENT ndash AFLAC
This is not a complete list of all covered accidents Please consult the plan summary for more details If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
24 Hour On or Off Job Accident
Annual Wellness Benefit
Year 1 $25 per insuredYear 2-4 $50 per insuredYear 5+ $75 per insured
Does not include children
Initial Treatment
Doctorrsquos office or other facility $75Doctorrsquos office or other facility
with x-ray $100ERUrgent Care $150
ERUrgent Care with X-ray $200
Hospital Admission$900
Additional $225 per dayAdditional $525 per day
AmbulanceGround $300
Air $900
Burns Lacerations Fractures Dislocations Concussion etc
$75-$15000
Accidental Death $50000
Accidental Dismemberment Up to $17500
18
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY CRITICAL ILLNESS ndash AFLAC
Voluntary Critical Illness
Wellness Benefit$50 per year ndash Employeeand Spouse (if applicable)
Coverage Amount Options
New Employee Guaranteed Issue up to $20000If a spousedependent is covered under the employees
plan they can elect 50 of the employees coverageChildren are automatically covered at 50 with no
charge
Included Illness at 100Cancer heart attack stroke major organ transplant
end stage renal failure paralysis coma and major third-degree burns ndash and more
Pre-existing Conditions
12 month exclusion for pre-existing cancerNo pre-existing exclusions on other health benefits as
long as diagnosis is made after the plan is in effect
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
9
FLEXIBLE SPENDING ACCOUNTS (FSA) ndash WEXDISCOVERY BENEFITS
If you are enrolling in the High Deductible Health Plan and contributing to a Health Savings Account you cannot open a Flexible Spending Account
Who is Eligible
All Full-Time Employees working at least 30 hours each week
Benefits You Receive
FSAs provide you with an important tax advantage that can help you pay health care and dependent care expenses on a pretax basis By anticipating your familyrsquos health care and dependent care costs for the next year you can actually lower your taxable income
Health Care Reimbursement FSA
This program lets employees pay for certain IRS-approved medical care expenses and prescriptions not covered by their insurance plan with pretax dollars The annual pretax maximum amount you may contribute to the Health Care Reimbursement FSA is $2750This limit will be indexed for cost-of-living adjustments You can rollover up to $550 into the following plan year Some examples of eligible expenses include
bull Hearing services including hearing aids and batteries
bull Vision services including contact lenses contact lens solution eye examinations and eyeglasses
bull Dental services and orthodontia
bull Chiropractic services
bull Acupuncture
bull Prescription contraceptives
Dependent Care FSA
The Dependent Care FSA lets employees use pretax dollars toward qualified dependent care such as caring for children under the age 13 or caring for elders The annual maximum amount you may contribute to the Dependent Care FSA is $5000 (or $2500 if married and filing separately) per calendar year Examples include
bull The cost of child or adult dependent care
bull The cost for an individual to provide care either in or out of your house
bull Nursery schools and preschools (excluding kindergarten)
The benefit plan information shown in this guide is illustrative only This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
10
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
DENTAL PLAN ndash DELTA DENTAL
One can of soda is the amount of sugar
recommended for three days for a child
Sugary Sodas are a major risk factor for
tooth decay
Source American Dental Association (ADA)
For this plan year dental coverage is offered through The Local Choice and administered by Delta Dental Refer to the carrier benefit summary for the exact benefit level associated with your plan
In Network Benefits Comprehensive
DentalPreventive Dental
Individual Annual Maximum
$1500 None
Annual Deductible$25 Individual
$50 Two People$75 Family
None
Preventive Services (exams cleaning x-rays
fluoride etc)100 100
Basic Services(fillings root canals periodontics simple
extractions etc)
80 afterdeductible
Not covered
Major Services(crowns dentures
bridges etc)
50 after deductible
Not covered
Orthodontic Services(Adult and Child)
50 to $1500 lifetime maximum
Not covered
Out of Network BenefitsOut of network benefits mirror in network benefits However out of
network providers may balance bill
11
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VISION PLAN ndash ANTHEM
Your eyes need a rest even while yoursquore awake Use the 20-20-20 rule to reduce eyestrain After
working for 20 minutes look away about 20 feet in front of you for
about 20 seconds
Source National Eye Institute httpsneinihgovhealthhealthyeyes
For this plan year vision coverage is offered through The Local Choice and administered by Anthem Blue View Vision Refer to the carrier benefit summary for the exact benefit level associated with your plan
In-NetworkOut of
Network
Key Advantage
$250
Key Advantage
$500HDHP $2800
Allowance for All Plans
Annual Exam
$35 copay $40 copay $15 copay$50
allowance
LensesSingleBifocalTrifocal
$20 copay $20 copay $20 copay
$50$75
$100
ContactLensesin lieu of glasses lenses
$100 allowance+ 15 off remaining
balance
$100 allowance + 15 off remaining
balance
$100 allowance+ 15 off remaining
balance
$80
Frames
$100 allowance+ 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$80
FrequencyExamLensesFrames
Once every 12 monthsOnce every 12 monthsOnce every 12 months
12
2021-2022 MEDICAL DENTAL AND VISION PER PAY DEDUCTIONS
Key Advantage $250 Plan
ComprehensiveDental amp Vision
Key Advantage $500 Plan
ComprehensiveDental amp Vision
HDHP $2800 ComprehensiveDental amp Vision
Employee Only $2500 $000 $000
Employee + One $21800 $19500 $16600
Employee Family $43600 $39000 $33250
Dual Enrollment Spouse
$5000 $000 $11150
Dual Enrollment Family
$31775 $29000 $22300
Key Advantage $250 Plan
Preventive Dentalamp Vision
Key Advantage $500 Plan
Preventive Dental amp Vision
HDHP $2800 Preventive Dental
amp Vision
Employee Only $2150 $000 $000
Employee + One $21150 $19000 $15800
Employee Family $42650 $38000 $31600
Dual Enrollment Spouse
$4300 $000 $10800
Dual Enrollment Family
$30900 $28000 $21600
Dual Enrollment = Both eligible employees work for New Kent County
Say hi to SydneyAnthemrsquos new app is s imple
smart mdash and al l about you
With Sydney you can find everything you need to know about your Anthem
benefits -- personalized and all in one place Sydney makes it easier to get
things done so you can spend more time focused on your health
Get started with Sydney
Download the app today
Ready for you to use quickly easily
seamlessly mdash with one-click access
to benefits info Member Services
wellness resources and more
Sydney acts like a personal health
guide answering your questions
and connecting you to the right
resources at the right time And
you can use the chatbot to get
answers quickly
Get alerts reminders and tips
directly from Sydney Get doctor
suggestions based on your needs
The more you use it the more
Sydney can help you stay healthy
and save money
With just one click you can
Find care and check costs
Check all benefits
See claims
Already using one of our apps
Itrsquos easy to make the switch Simply
download the Sydney app and log in
with your Anthem username and password
Get answers even faster with
our chatbot
View and use digital ID cards
AnthemBlueCrossandBlueShield is the trade name of InColorado RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc InConnecticut AnthemHealth Plans Inc InGeorgia BlueCross BlueShield Healthcare Planof Georgia Inc In IndianaAnthemInsurance Companies Inc InKentuckyAnthemHealth Plans of Kentucky Inc InMaine AnthemHealth Plans of Maine Inc InMissouri (excluding 30 counties in the Kansas City area) RightCHOICEregManaged Care Inc (RIT)Healthy Alliancereg Life Insurance Company(HALIC) andHMOMissouri Inc RITandcertain affiliates administer non-HMObenefits underwritten byHALICandHMObenefits underwritten byHMOMissouri Inc RITandcertain affiliates onlyprovide administrative services for self-funded plans anddonot underwrite benefits InNevada RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc dba HMONevada InNewHampshire AnthemHealth Plans of NewHampshire Inc HMOplans are administered byAnthemHealth Plans of NewHampshire Inc andunderwritten byMatthewThorntonHealthPlan Inc In Ohio Community Insurance Company In Virginia Anthem Health Plans of Virginia Inc trades as Anthem Blue Cross and Blue Shield6in V4irginia and its service area is all of Virginia except for the City of Fairfax the Town of Vienna and the area east
of State Route 123 In Wisconsin
Blue Cross Blue Shield of Wisconsin (BCBSWI) underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC) Compcare underwrites or administers HMO or POS policies WCIC underwrites or administers Well Priority HMO or POS policies Independent licensees of the Blue Cross and Blue Shield Association Anthem is a registered trademark of Anthem Insurance Companies Inc
115993MUMENABS 0619
13
14
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life
You may purchase 15 or 30 year coverage up to $100000
Guaranteed Issue for new hires $25000
Spouse LifeYou may purchase up to $50000 Guaranteed
Issue $10000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
VOLUNTARY TERM LIFE ndash AFLAC
Voluntary Life coverage provides an additional benefit to the beneficiaries It provides a benefit to your
designated beneficiary in the event of your death and you can choose the term of coverage To be eligible
for coverage you must qualify as an eligible member (working at least 30 hours per week) and be
considered actively at work If you are not currently enrolled and make a Voluntary Life election for 2021
you will be subject to underwriting and required to answer medical questions to enroll If you have questions
or would like to enroll in coverage contact Rebecca Smith at Aflacsmithagencyinccom or 804-422-3522
15
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life You may purchase up to $300000Guaranteed Issue for new hires
$40000
Spouse LifeYou may purchase up to $100000
Guaranteed Issue $5000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
If you are not currently enrolled and make a Voluntary Life election for 2021 you will be subject to underwriting and required to answer medical questions to enroll Employees must enroll in order to elect dependent coverage If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
VOLUNTARY WHOLE LIFE ndash AFLAC
16
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY SHORT TERM DISABILITY INSURANCE
Only 48 percent of American adults indicate they have enough savings to cover three months of living expenses in the event they become disabled
Source Council for Disability Awareness httpdisabilitycanhappenorgdisability-statistic
3 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income ReplacedUp to 60 of base monthly earnings
Guarantee Issue up to $3000 per month
Maximum Benefit $6000 per week
Duration of Benefits 3 months
6 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income Replaced Up to 60 of base monthly earnings
Maximum Benefit$6000 per month
Guaranteed Issue up to $3000 per month
Duration of Benefits 6 months
All benefit eligible employees can choose to enroll in one of two Voluntary Short Term Disability plans Should you have an accident or an illness your benefit will be paid for either 3 or 6 months If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
12 month pre-existing clause still applies
17
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY ACCIDENT ndash AFLAC
This is not a complete list of all covered accidents Please consult the plan summary for more details If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
24 Hour On or Off Job Accident
Annual Wellness Benefit
Year 1 $25 per insuredYear 2-4 $50 per insuredYear 5+ $75 per insured
Does not include children
Initial Treatment
Doctorrsquos office or other facility $75Doctorrsquos office or other facility
with x-ray $100ERUrgent Care $150
ERUrgent Care with X-ray $200
Hospital Admission$900
Additional $225 per dayAdditional $525 per day
AmbulanceGround $300
Air $900
Burns Lacerations Fractures Dislocations Concussion etc
$75-$15000
Accidental Death $50000
Accidental Dismemberment Up to $17500
18
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY CRITICAL ILLNESS ndash AFLAC
Voluntary Critical Illness
Wellness Benefit$50 per year ndash Employeeand Spouse (if applicable)
Coverage Amount Options
New Employee Guaranteed Issue up to $20000If a spousedependent is covered under the employees
plan they can elect 50 of the employees coverageChildren are automatically covered at 50 with no
charge
Included Illness at 100Cancer heart attack stroke major organ transplant
end stage renal failure paralysis coma and major third-degree burns ndash and more
Pre-existing Conditions
12 month exclusion for pre-existing cancerNo pre-existing exclusions on other health benefits as
long as diagnosis is made after the plan is in effect
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
10
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
DENTAL PLAN ndash DELTA DENTAL
One can of soda is the amount of sugar
recommended for three days for a child
Sugary Sodas are a major risk factor for
tooth decay
Source American Dental Association (ADA)
For this plan year dental coverage is offered through The Local Choice and administered by Delta Dental Refer to the carrier benefit summary for the exact benefit level associated with your plan
In Network Benefits Comprehensive
DentalPreventive Dental
Individual Annual Maximum
$1500 None
Annual Deductible$25 Individual
$50 Two People$75 Family
None
Preventive Services (exams cleaning x-rays
fluoride etc)100 100
Basic Services(fillings root canals periodontics simple
extractions etc)
80 afterdeductible
Not covered
Major Services(crowns dentures
bridges etc)
50 after deductible
Not covered
Orthodontic Services(Adult and Child)
50 to $1500 lifetime maximum
Not covered
Out of Network BenefitsOut of network benefits mirror in network benefits However out of
network providers may balance bill
11
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VISION PLAN ndash ANTHEM
Your eyes need a rest even while yoursquore awake Use the 20-20-20 rule to reduce eyestrain After
working for 20 minutes look away about 20 feet in front of you for
about 20 seconds
Source National Eye Institute httpsneinihgovhealthhealthyeyes
For this plan year vision coverage is offered through The Local Choice and administered by Anthem Blue View Vision Refer to the carrier benefit summary for the exact benefit level associated with your plan
In-NetworkOut of
Network
Key Advantage
$250
Key Advantage
$500HDHP $2800
Allowance for All Plans
Annual Exam
$35 copay $40 copay $15 copay$50
allowance
LensesSingleBifocalTrifocal
$20 copay $20 copay $20 copay
$50$75
$100
ContactLensesin lieu of glasses lenses
$100 allowance+ 15 off remaining
balance
$100 allowance + 15 off remaining
balance
$100 allowance+ 15 off remaining
balance
$80
Frames
$100 allowance+ 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$80
FrequencyExamLensesFrames
Once every 12 monthsOnce every 12 monthsOnce every 12 months
12
2021-2022 MEDICAL DENTAL AND VISION PER PAY DEDUCTIONS
Key Advantage $250 Plan
ComprehensiveDental amp Vision
Key Advantage $500 Plan
ComprehensiveDental amp Vision
HDHP $2800 ComprehensiveDental amp Vision
Employee Only $2500 $000 $000
Employee + One $21800 $19500 $16600
Employee Family $43600 $39000 $33250
Dual Enrollment Spouse
$5000 $000 $11150
Dual Enrollment Family
$31775 $29000 $22300
Key Advantage $250 Plan
Preventive Dentalamp Vision
Key Advantage $500 Plan
Preventive Dental amp Vision
HDHP $2800 Preventive Dental
amp Vision
Employee Only $2150 $000 $000
Employee + One $21150 $19000 $15800
Employee Family $42650 $38000 $31600
Dual Enrollment Spouse
$4300 $000 $10800
Dual Enrollment Family
$30900 $28000 $21600
Dual Enrollment = Both eligible employees work for New Kent County
Say hi to SydneyAnthemrsquos new app is s imple
smart mdash and al l about you
With Sydney you can find everything you need to know about your Anthem
benefits -- personalized and all in one place Sydney makes it easier to get
things done so you can spend more time focused on your health
Get started with Sydney
Download the app today
Ready for you to use quickly easily
seamlessly mdash with one-click access
to benefits info Member Services
wellness resources and more
Sydney acts like a personal health
guide answering your questions
and connecting you to the right
resources at the right time And
you can use the chatbot to get
answers quickly
Get alerts reminders and tips
directly from Sydney Get doctor
suggestions based on your needs
The more you use it the more
Sydney can help you stay healthy
and save money
With just one click you can
Find care and check costs
Check all benefits
See claims
Already using one of our apps
Itrsquos easy to make the switch Simply
download the Sydney app and log in
with your Anthem username and password
Get answers even faster with
our chatbot
View and use digital ID cards
AnthemBlueCrossandBlueShield is the trade name of InColorado RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc InConnecticut AnthemHealth Plans Inc InGeorgia BlueCross BlueShield Healthcare Planof Georgia Inc In IndianaAnthemInsurance Companies Inc InKentuckyAnthemHealth Plans of Kentucky Inc InMaine AnthemHealth Plans of Maine Inc InMissouri (excluding 30 counties in the Kansas City area) RightCHOICEregManaged Care Inc (RIT)Healthy Alliancereg Life Insurance Company(HALIC) andHMOMissouri Inc RITandcertain affiliates administer non-HMObenefits underwritten byHALICandHMObenefits underwritten byHMOMissouri Inc RITandcertain affiliates onlyprovide administrative services for self-funded plans anddonot underwrite benefits InNevada RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc dba HMONevada InNewHampshire AnthemHealth Plans of NewHampshire Inc HMOplans are administered byAnthemHealth Plans of NewHampshire Inc andunderwritten byMatthewThorntonHealthPlan Inc In Ohio Community Insurance Company In Virginia Anthem Health Plans of Virginia Inc trades as Anthem Blue Cross and Blue Shield6in V4irginia and its service area is all of Virginia except for the City of Fairfax the Town of Vienna and the area east
of State Route 123 In Wisconsin
Blue Cross Blue Shield of Wisconsin (BCBSWI) underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC) Compcare underwrites or administers HMO or POS policies WCIC underwrites or administers Well Priority HMO or POS policies Independent licensees of the Blue Cross and Blue Shield Association Anthem is a registered trademark of Anthem Insurance Companies Inc
115993MUMENABS 0619
13
14
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life
You may purchase 15 or 30 year coverage up to $100000
Guaranteed Issue for new hires $25000
Spouse LifeYou may purchase up to $50000 Guaranteed
Issue $10000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
VOLUNTARY TERM LIFE ndash AFLAC
Voluntary Life coverage provides an additional benefit to the beneficiaries It provides a benefit to your
designated beneficiary in the event of your death and you can choose the term of coverage To be eligible
for coverage you must qualify as an eligible member (working at least 30 hours per week) and be
considered actively at work If you are not currently enrolled and make a Voluntary Life election for 2021
you will be subject to underwriting and required to answer medical questions to enroll If you have questions
or would like to enroll in coverage contact Rebecca Smith at Aflacsmithagencyinccom or 804-422-3522
15
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life You may purchase up to $300000Guaranteed Issue for new hires
$40000
Spouse LifeYou may purchase up to $100000
Guaranteed Issue $5000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
If you are not currently enrolled and make a Voluntary Life election for 2021 you will be subject to underwriting and required to answer medical questions to enroll Employees must enroll in order to elect dependent coverage If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
VOLUNTARY WHOLE LIFE ndash AFLAC
16
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY SHORT TERM DISABILITY INSURANCE
Only 48 percent of American adults indicate they have enough savings to cover three months of living expenses in the event they become disabled
Source Council for Disability Awareness httpdisabilitycanhappenorgdisability-statistic
3 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income ReplacedUp to 60 of base monthly earnings
Guarantee Issue up to $3000 per month
Maximum Benefit $6000 per week
Duration of Benefits 3 months
6 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income Replaced Up to 60 of base monthly earnings
Maximum Benefit$6000 per month
Guaranteed Issue up to $3000 per month
Duration of Benefits 6 months
All benefit eligible employees can choose to enroll in one of two Voluntary Short Term Disability plans Should you have an accident or an illness your benefit will be paid for either 3 or 6 months If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
12 month pre-existing clause still applies
17
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY ACCIDENT ndash AFLAC
This is not a complete list of all covered accidents Please consult the plan summary for more details If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
24 Hour On or Off Job Accident
Annual Wellness Benefit
Year 1 $25 per insuredYear 2-4 $50 per insuredYear 5+ $75 per insured
Does not include children
Initial Treatment
Doctorrsquos office or other facility $75Doctorrsquos office or other facility
with x-ray $100ERUrgent Care $150
ERUrgent Care with X-ray $200
Hospital Admission$900
Additional $225 per dayAdditional $525 per day
AmbulanceGround $300
Air $900
Burns Lacerations Fractures Dislocations Concussion etc
$75-$15000
Accidental Death $50000
Accidental Dismemberment Up to $17500
18
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY CRITICAL ILLNESS ndash AFLAC
Voluntary Critical Illness
Wellness Benefit$50 per year ndash Employeeand Spouse (if applicable)
Coverage Amount Options
New Employee Guaranteed Issue up to $20000If a spousedependent is covered under the employees
plan they can elect 50 of the employees coverageChildren are automatically covered at 50 with no
charge
Included Illness at 100Cancer heart attack stroke major organ transplant
end stage renal failure paralysis coma and major third-degree burns ndash and more
Pre-existing Conditions
12 month exclusion for pre-existing cancerNo pre-existing exclusions on other health benefits as
long as diagnosis is made after the plan is in effect
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
11
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VISION PLAN ndash ANTHEM
Your eyes need a rest even while yoursquore awake Use the 20-20-20 rule to reduce eyestrain After
working for 20 minutes look away about 20 feet in front of you for
about 20 seconds
Source National Eye Institute httpsneinihgovhealthhealthyeyes
For this plan year vision coverage is offered through The Local Choice and administered by Anthem Blue View Vision Refer to the carrier benefit summary for the exact benefit level associated with your plan
In-NetworkOut of
Network
Key Advantage
$250
Key Advantage
$500HDHP $2800
Allowance for All Plans
Annual Exam
$35 copay $40 copay $15 copay$50
allowance
LensesSingleBifocalTrifocal
$20 copay $20 copay $20 copay
$50$75
$100
ContactLensesin lieu of glasses lenses
$100 allowance+ 15 off remaining
balance
$100 allowance + 15 off remaining
balance
$100 allowance+ 15 off remaining
balance
$80
Frames
$100 allowance+ 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$100 allowance + 20 off remaining
balance
$80
FrequencyExamLensesFrames
Once every 12 monthsOnce every 12 monthsOnce every 12 months
12
2021-2022 MEDICAL DENTAL AND VISION PER PAY DEDUCTIONS
Key Advantage $250 Plan
ComprehensiveDental amp Vision
Key Advantage $500 Plan
ComprehensiveDental amp Vision
HDHP $2800 ComprehensiveDental amp Vision
Employee Only $2500 $000 $000
Employee + One $21800 $19500 $16600
Employee Family $43600 $39000 $33250
Dual Enrollment Spouse
$5000 $000 $11150
Dual Enrollment Family
$31775 $29000 $22300
Key Advantage $250 Plan
Preventive Dentalamp Vision
Key Advantage $500 Plan
Preventive Dental amp Vision
HDHP $2800 Preventive Dental
amp Vision
Employee Only $2150 $000 $000
Employee + One $21150 $19000 $15800
Employee Family $42650 $38000 $31600
Dual Enrollment Spouse
$4300 $000 $10800
Dual Enrollment Family
$30900 $28000 $21600
Dual Enrollment = Both eligible employees work for New Kent County
Say hi to SydneyAnthemrsquos new app is s imple
smart mdash and al l about you
With Sydney you can find everything you need to know about your Anthem
benefits -- personalized and all in one place Sydney makes it easier to get
things done so you can spend more time focused on your health
Get started with Sydney
Download the app today
Ready for you to use quickly easily
seamlessly mdash with one-click access
to benefits info Member Services
wellness resources and more
Sydney acts like a personal health
guide answering your questions
and connecting you to the right
resources at the right time And
you can use the chatbot to get
answers quickly
Get alerts reminders and tips
directly from Sydney Get doctor
suggestions based on your needs
The more you use it the more
Sydney can help you stay healthy
and save money
With just one click you can
Find care and check costs
Check all benefits
See claims
Already using one of our apps
Itrsquos easy to make the switch Simply
download the Sydney app and log in
with your Anthem username and password
Get answers even faster with
our chatbot
View and use digital ID cards
AnthemBlueCrossandBlueShield is the trade name of InColorado RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc InConnecticut AnthemHealth Plans Inc InGeorgia BlueCross BlueShield Healthcare Planof Georgia Inc In IndianaAnthemInsurance Companies Inc InKentuckyAnthemHealth Plans of Kentucky Inc InMaine AnthemHealth Plans of Maine Inc InMissouri (excluding 30 counties in the Kansas City area) RightCHOICEregManaged Care Inc (RIT)Healthy Alliancereg Life Insurance Company(HALIC) andHMOMissouri Inc RITandcertain affiliates administer non-HMObenefits underwritten byHALICandHMObenefits underwritten byHMOMissouri Inc RITandcertain affiliates onlyprovide administrative services for self-funded plans anddonot underwrite benefits InNevada RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc dba HMONevada InNewHampshire AnthemHealth Plans of NewHampshire Inc HMOplans are administered byAnthemHealth Plans of NewHampshire Inc andunderwritten byMatthewThorntonHealthPlan Inc In Ohio Community Insurance Company In Virginia Anthem Health Plans of Virginia Inc trades as Anthem Blue Cross and Blue Shield6in V4irginia and its service area is all of Virginia except for the City of Fairfax the Town of Vienna and the area east
of State Route 123 In Wisconsin
Blue Cross Blue Shield of Wisconsin (BCBSWI) underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC) Compcare underwrites or administers HMO or POS policies WCIC underwrites or administers Well Priority HMO or POS policies Independent licensees of the Blue Cross and Blue Shield Association Anthem is a registered trademark of Anthem Insurance Companies Inc
115993MUMENABS 0619
13
14
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life
You may purchase 15 or 30 year coverage up to $100000
Guaranteed Issue for new hires $25000
Spouse LifeYou may purchase up to $50000 Guaranteed
Issue $10000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
VOLUNTARY TERM LIFE ndash AFLAC
Voluntary Life coverage provides an additional benefit to the beneficiaries It provides a benefit to your
designated beneficiary in the event of your death and you can choose the term of coverage To be eligible
for coverage you must qualify as an eligible member (working at least 30 hours per week) and be
considered actively at work If you are not currently enrolled and make a Voluntary Life election for 2021
you will be subject to underwriting and required to answer medical questions to enroll If you have questions
or would like to enroll in coverage contact Rebecca Smith at Aflacsmithagencyinccom or 804-422-3522
15
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life You may purchase up to $300000Guaranteed Issue for new hires
$40000
Spouse LifeYou may purchase up to $100000
Guaranteed Issue $5000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
If you are not currently enrolled and make a Voluntary Life election for 2021 you will be subject to underwriting and required to answer medical questions to enroll Employees must enroll in order to elect dependent coverage If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
VOLUNTARY WHOLE LIFE ndash AFLAC
16
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY SHORT TERM DISABILITY INSURANCE
Only 48 percent of American adults indicate they have enough savings to cover three months of living expenses in the event they become disabled
Source Council for Disability Awareness httpdisabilitycanhappenorgdisability-statistic
3 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income ReplacedUp to 60 of base monthly earnings
Guarantee Issue up to $3000 per month
Maximum Benefit $6000 per week
Duration of Benefits 3 months
6 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income Replaced Up to 60 of base monthly earnings
Maximum Benefit$6000 per month
Guaranteed Issue up to $3000 per month
Duration of Benefits 6 months
All benefit eligible employees can choose to enroll in one of two Voluntary Short Term Disability plans Should you have an accident or an illness your benefit will be paid for either 3 or 6 months If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
12 month pre-existing clause still applies
17
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY ACCIDENT ndash AFLAC
This is not a complete list of all covered accidents Please consult the plan summary for more details If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
24 Hour On or Off Job Accident
Annual Wellness Benefit
Year 1 $25 per insuredYear 2-4 $50 per insuredYear 5+ $75 per insured
Does not include children
Initial Treatment
Doctorrsquos office or other facility $75Doctorrsquos office or other facility
with x-ray $100ERUrgent Care $150
ERUrgent Care with X-ray $200
Hospital Admission$900
Additional $225 per dayAdditional $525 per day
AmbulanceGround $300
Air $900
Burns Lacerations Fractures Dislocations Concussion etc
$75-$15000
Accidental Death $50000
Accidental Dismemberment Up to $17500
18
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY CRITICAL ILLNESS ndash AFLAC
Voluntary Critical Illness
Wellness Benefit$50 per year ndash Employeeand Spouse (if applicable)
Coverage Amount Options
New Employee Guaranteed Issue up to $20000If a spousedependent is covered under the employees
plan they can elect 50 of the employees coverageChildren are automatically covered at 50 with no
charge
Included Illness at 100Cancer heart attack stroke major organ transplant
end stage renal failure paralysis coma and major third-degree burns ndash and more
Pre-existing Conditions
12 month exclusion for pre-existing cancerNo pre-existing exclusions on other health benefits as
long as diagnosis is made after the plan is in effect
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
12
2021-2022 MEDICAL DENTAL AND VISION PER PAY DEDUCTIONS
Key Advantage $250 Plan
ComprehensiveDental amp Vision
Key Advantage $500 Plan
ComprehensiveDental amp Vision
HDHP $2800 ComprehensiveDental amp Vision
Employee Only $2500 $000 $000
Employee + One $21800 $19500 $16600
Employee Family $43600 $39000 $33250
Dual Enrollment Spouse
$5000 $000 $11150
Dual Enrollment Family
$31775 $29000 $22300
Key Advantage $250 Plan
Preventive Dentalamp Vision
Key Advantage $500 Plan
Preventive Dental amp Vision
HDHP $2800 Preventive Dental
amp Vision
Employee Only $2150 $000 $000
Employee + One $21150 $19000 $15800
Employee Family $42650 $38000 $31600
Dual Enrollment Spouse
$4300 $000 $10800
Dual Enrollment Family
$30900 $28000 $21600
Dual Enrollment = Both eligible employees work for New Kent County
Say hi to SydneyAnthemrsquos new app is s imple
smart mdash and al l about you
With Sydney you can find everything you need to know about your Anthem
benefits -- personalized and all in one place Sydney makes it easier to get
things done so you can spend more time focused on your health
Get started with Sydney
Download the app today
Ready for you to use quickly easily
seamlessly mdash with one-click access
to benefits info Member Services
wellness resources and more
Sydney acts like a personal health
guide answering your questions
and connecting you to the right
resources at the right time And
you can use the chatbot to get
answers quickly
Get alerts reminders and tips
directly from Sydney Get doctor
suggestions based on your needs
The more you use it the more
Sydney can help you stay healthy
and save money
With just one click you can
Find care and check costs
Check all benefits
See claims
Already using one of our apps
Itrsquos easy to make the switch Simply
download the Sydney app and log in
with your Anthem username and password
Get answers even faster with
our chatbot
View and use digital ID cards
AnthemBlueCrossandBlueShield is the trade name of InColorado RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc InConnecticut AnthemHealth Plans Inc InGeorgia BlueCross BlueShield Healthcare Planof Georgia Inc In IndianaAnthemInsurance Companies Inc InKentuckyAnthemHealth Plans of Kentucky Inc InMaine AnthemHealth Plans of Maine Inc InMissouri (excluding 30 counties in the Kansas City area) RightCHOICEregManaged Care Inc (RIT)Healthy Alliancereg Life Insurance Company(HALIC) andHMOMissouri Inc RITandcertain affiliates administer non-HMObenefits underwritten byHALICandHMObenefits underwritten byHMOMissouri Inc RITandcertain affiliates onlyprovide administrative services for self-funded plans anddonot underwrite benefits InNevada RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc dba HMONevada InNewHampshire AnthemHealth Plans of NewHampshire Inc HMOplans are administered byAnthemHealth Plans of NewHampshire Inc andunderwritten byMatthewThorntonHealthPlan Inc In Ohio Community Insurance Company In Virginia Anthem Health Plans of Virginia Inc trades as Anthem Blue Cross and Blue Shield6in V4irginia and its service area is all of Virginia except for the City of Fairfax the Town of Vienna and the area east
of State Route 123 In Wisconsin
Blue Cross Blue Shield of Wisconsin (BCBSWI) underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC) Compcare underwrites or administers HMO or POS policies WCIC underwrites or administers Well Priority HMO or POS policies Independent licensees of the Blue Cross and Blue Shield Association Anthem is a registered trademark of Anthem Insurance Companies Inc
115993MUMENABS 0619
13
14
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life
You may purchase 15 or 30 year coverage up to $100000
Guaranteed Issue for new hires $25000
Spouse LifeYou may purchase up to $50000 Guaranteed
Issue $10000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
VOLUNTARY TERM LIFE ndash AFLAC
Voluntary Life coverage provides an additional benefit to the beneficiaries It provides a benefit to your
designated beneficiary in the event of your death and you can choose the term of coverage To be eligible
for coverage you must qualify as an eligible member (working at least 30 hours per week) and be
considered actively at work If you are not currently enrolled and make a Voluntary Life election for 2021
you will be subject to underwriting and required to answer medical questions to enroll If you have questions
or would like to enroll in coverage contact Rebecca Smith at Aflacsmithagencyinccom or 804-422-3522
15
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life You may purchase up to $300000Guaranteed Issue for new hires
$40000
Spouse LifeYou may purchase up to $100000
Guaranteed Issue $5000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
If you are not currently enrolled and make a Voluntary Life election for 2021 you will be subject to underwriting and required to answer medical questions to enroll Employees must enroll in order to elect dependent coverage If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
VOLUNTARY WHOLE LIFE ndash AFLAC
16
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY SHORT TERM DISABILITY INSURANCE
Only 48 percent of American adults indicate they have enough savings to cover three months of living expenses in the event they become disabled
Source Council for Disability Awareness httpdisabilitycanhappenorgdisability-statistic
3 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income ReplacedUp to 60 of base monthly earnings
Guarantee Issue up to $3000 per month
Maximum Benefit $6000 per week
Duration of Benefits 3 months
6 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income Replaced Up to 60 of base monthly earnings
Maximum Benefit$6000 per month
Guaranteed Issue up to $3000 per month
Duration of Benefits 6 months
All benefit eligible employees can choose to enroll in one of two Voluntary Short Term Disability plans Should you have an accident or an illness your benefit will be paid for either 3 or 6 months If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
12 month pre-existing clause still applies
17
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY ACCIDENT ndash AFLAC
This is not a complete list of all covered accidents Please consult the plan summary for more details If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
24 Hour On or Off Job Accident
Annual Wellness Benefit
Year 1 $25 per insuredYear 2-4 $50 per insuredYear 5+ $75 per insured
Does not include children
Initial Treatment
Doctorrsquos office or other facility $75Doctorrsquos office or other facility
with x-ray $100ERUrgent Care $150
ERUrgent Care with X-ray $200
Hospital Admission$900
Additional $225 per dayAdditional $525 per day
AmbulanceGround $300
Air $900
Burns Lacerations Fractures Dislocations Concussion etc
$75-$15000
Accidental Death $50000
Accidental Dismemberment Up to $17500
18
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY CRITICAL ILLNESS ndash AFLAC
Voluntary Critical Illness
Wellness Benefit$50 per year ndash Employeeand Spouse (if applicable)
Coverage Amount Options
New Employee Guaranteed Issue up to $20000If a spousedependent is covered under the employees
plan they can elect 50 of the employees coverageChildren are automatically covered at 50 with no
charge
Included Illness at 100Cancer heart attack stroke major organ transplant
end stage renal failure paralysis coma and major third-degree burns ndash and more
Pre-existing Conditions
12 month exclusion for pre-existing cancerNo pre-existing exclusions on other health benefits as
long as diagnosis is made after the plan is in effect
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
Say hi to SydneyAnthemrsquos new app is s imple
smart mdash and al l about you
With Sydney you can find everything you need to know about your Anthem
benefits -- personalized and all in one place Sydney makes it easier to get
things done so you can spend more time focused on your health
Get started with Sydney
Download the app today
Ready for you to use quickly easily
seamlessly mdash with one-click access
to benefits info Member Services
wellness resources and more
Sydney acts like a personal health
guide answering your questions
and connecting you to the right
resources at the right time And
you can use the chatbot to get
answers quickly
Get alerts reminders and tips
directly from Sydney Get doctor
suggestions based on your needs
The more you use it the more
Sydney can help you stay healthy
and save money
With just one click you can
Find care and check costs
Check all benefits
See claims
Already using one of our apps
Itrsquos easy to make the switch Simply
download the Sydney app and log in
with your Anthem username and password
Get answers even faster with
our chatbot
View and use digital ID cards
AnthemBlueCrossandBlueShield is the trade name of InColorado RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc InConnecticut AnthemHealth Plans Inc InGeorgia BlueCross BlueShield Healthcare Planof Georgia Inc In IndianaAnthemInsurance Companies Inc InKentuckyAnthemHealth Plans of Kentucky Inc InMaine AnthemHealth Plans of Maine Inc InMissouri (excluding 30 counties in the Kansas City area) RightCHOICEregManaged Care Inc (RIT)Healthy Alliancereg Life Insurance Company(HALIC) andHMOMissouri Inc RITandcertain affiliates administer non-HMObenefits underwritten byHALICandHMObenefits underwritten byHMOMissouri Inc RITandcertain affiliates onlyprovide administrative services for self-funded plans anddonot underwrite benefits InNevada RockyMountain Hospital andMedical Service Inc HMOproducts underwritten byHMOColorado Inc dba HMONevada InNewHampshire AnthemHealth Plans of NewHampshire Inc HMOplans are administered byAnthemHealth Plans of NewHampshire Inc andunderwritten byMatthewThorntonHealthPlan Inc In Ohio Community Insurance Company In Virginia Anthem Health Plans of Virginia Inc trades as Anthem Blue Cross and Blue Shield6in V4irginia and its service area is all of Virginia except for the City of Fairfax the Town of Vienna and the area east
of State Route 123 In Wisconsin
Blue Cross Blue Shield of Wisconsin (BCBSWI) underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC) Compcare underwrites or administers HMO or POS policies WCIC underwrites or administers Well Priority HMO or POS policies Independent licensees of the Blue Cross and Blue Shield Association Anthem is a registered trademark of Anthem Insurance Companies Inc
115993MUMENABS 0619
13
14
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life
You may purchase 15 or 30 year coverage up to $100000
Guaranteed Issue for new hires $25000
Spouse LifeYou may purchase up to $50000 Guaranteed
Issue $10000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
VOLUNTARY TERM LIFE ndash AFLAC
Voluntary Life coverage provides an additional benefit to the beneficiaries It provides a benefit to your
designated beneficiary in the event of your death and you can choose the term of coverage To be eligible
for coverage you must qualify as an eligible member (working at least 30 hours per week) and be
considered actively at work If you are not currently enrolled and make a Voluntary Life election for 2021
you will be subject to underwriting and required to answer medical questions to enroll If you have questions
or would like to enroll in coverage contact Rebecca Smith at Aflacsmithagencyinccom or 804-422-3522
15
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life You may purchase up to $300000Guaranteed Issue for new hires
$40000
Spouse LifeYou may purchase up to $100000
Guaranteed Issue $5000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
If you are not currently enrolled and make a Voluntary Life election for 2021 you will be subject to underwriting and required to answer medical questions to enroll Employees must enroll in order to elect dependent coverage If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
VOLUNTARY WHOLE LIFE ndash AFLAC
16
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY SHORT TERM DISABILITY INSURANCE
Only 48 percent of American adults indicate they have enough savings to cover three months of living expenses in the event they become disabled
Source Council for Disability Awareness httpdisabilitycanhappenorgdisability-statistic
3 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income ReplacedUp to 60 of base monthly earnings
Guarantee Issue up to $3000 per month
Maximum Benefit $6000 per week
Duration of Benefits 3 months
6 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income Replaced Up to 60 of base monthly earnings
Maximum Benefit$6000 per month
Guaranteed Issue up to $3000 per month
Duration of Benefits 6 months
All benefit eligible employees can choose to enroll in one of two Voluntary Short Term Disability plans Should you have an accident or an illness your benefit will be paid for either 3 or 6 months If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
12 month pre-existing clause still applies
17
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY ACCIDENT ndash AFLAC
This is not a complete list of all covered accidents Please consult the plan summary for more details If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
24 Hour On or Off Job Accident
Annual Wellness Benefit
Year 1 $25 per insuredYear 2-4 $50 per insuredYear 5+ $75 per insured
Does not include children
Initial Treatment
Doctorrsquos office or other facility $75Doctorrsquos office or other facility
with x-ray $100ERUrgent Care $150
ERUrgent Care with X-ray $200
Hospital Admission$900
Additional $225 per dayAdditional $525 per day
AmbulanceGround $300
Air $900
Burns Lacerations Fractures Dislocations Concussion etc
$75-$15000
Accidental Death $50000
Accidental Dismemberment Up to $17500
18
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY CRITICAL ILLNESS ndash AFLAC
Voluntary Critical Illness
Wellness Benefit$50 per year ndash Employeeand Spouse (if applicable)
Coverage Amount Options
New Employee Guaranteed Issue up to $20000If a spousedependent is covered under the employees
plan they can elect 50 of the employees coverageChildren are automatically covered at 50 with no
charge
Included Illness at 100Cancer heart attack stroke major organ transplant
end stage renal failure paralysis coma and major third-degree burns ndash and more
Pre-existing Conditions
12 month exclusion for pre-existing cancerNo pre-existing exclusions on other health benefits as
long as diagnosis is made after the plan is in effect
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
14
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life
You may purchase 15 or 30 year coverage up to $100000
Guaranteed Issue for new hires $25000
Spouse LifeYou may purchase up to $50000 Guaranteed
Issue $10000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
VOLUNTARY TERM LIFE ndash AFLAC
Voluntary Life coverage provides an additional benefit to the beneficiaries It provides a benefit to your
designated beneficiary in the event of your death and you can choose the term of coverage To be eligible
for coverage you must qualify as an eligible member (working at least 30 hours per week) and be
considered actively at work If you are not currently enrolled and make a Voluntary Life election for 2021
you will be subject to underwriting and required to answer medical questions to enroll If you have questions
or would like to enroll in coverage contact Rebecca Smith at Aflacsmithagencyinccom or 804-422-3522
15
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life You may purchase up to $300000Guaranteed Issue for new hires
$40000
Spouse LifeYou may purchase up to $100000
Guaranteed Issue $5000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
If you are not currently enrolled and make a Voluntary Life election for 2021 you will be subject to underwriting and required to answer medical questions to enroll Employees must enroll in order to elect dependent coverage If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
VOLUNTARY WHOLE LIFE ndash AFLAC
16
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY SHORT TERM DISABILITY INSURANCE
Only 48 percent of American adults indicate they have enough savings to cover three months of living expenses in the event they become disabled
Source Council for Disability Awareness httpdisabilitycanhappenorgdisability-statistic
3 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income ReplacedUp to 60 of base monthly earnings
Guarantee Issue up to $3000 per month
Maximum Benefit $6000 per week
Duration of Benefits 3 months
6 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income Replaced Up to 60 of base monthly earnings
Maximum Benefit$6000 per month
Guaranteed Issue up to $3000 per month
Duration of Benefits 6 months
All benefit eligible employees can choose to enroll in one of two Voluntary Short Term Disability plans Should you have an accident or an illness your benefit will be paid for either 3 or 6 months If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
12 month pre-existing clause still applies
17
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY ACCIDENT ndash AFLAC
This is not a complete list of all covered accidents Please consult the plan summary for more details If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
24 Hour On or Off Job Accident
Annual Wellness Benefit
Year 1 $25 per insuredYear 2-4 $50 per insuredYear 5+ $75 per insured
Does not include children
Initial Treatment
Doctorrsquos office or other facility $75Doctorrsquos office or other facility
with x-ray $100ERUrgent Care $150
ERUrgent Care with X-ray $200
Hospital Admission$900
Additional $225 per dayAdditional $525 per day
AmbulanceGround $300
Air $900
Burns Lacerations Fractures Dislocations Concussion etc
$75-$15000
Accidental Death $50000
Accidental Dismemberment Up to $17500
18
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY CRITICAL ILLNESS ndash AFLAC
Voluntary Critical Illness
Wellness Benefit$50 per year ndash Employeeand Spouse (if applicable)
Coverage Amount Options
New Employee Guaranteed Issue up to $20000If a spousedependent is covered under the employees
plan they can elect 50 of the employees coverageChildren are automatically covered at 50 with no
charge
Included Illness at 100Cancer heart attack stroke major organ transplant
end stage renal failure paralysis coma and major third-degree burns ndash and more
Pre-existing Conditions
12 month exclusion for pre-existing cancerNo pre-existing exclusions on other health benefits as
long as diagnosis is made after the plan is in effect
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
15
The benefit plan information shown in this guide is illustrative only To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide
the underlying insurance documents will govern in all cases
Eligible Employees All full-time employees
Employee Life You may purchase up to $300000Guaranteed Issue for new hires
$40000
Spouse LifeYou may purchase up to $100000
Guaranteed Issue $5000
Child(ren) LifeYou may purchase up to $25000
Guaranteed Issue $10000
If you are not currently enrolled and make a Voluntary Life election for 2021 you will be subject to underwriting and required to answer medical questions to enroll Employees must enroll in order to elect dependent coverage If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
VOLUNTARY WHOLE LIFE ndash AFLAC
16
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY SHORT TERM DISABILITY INSURANCE
Only 48 percent of American adults indicate they have enough savings to cover three months of living expenses in the event they become disabled
Source Council for Disability Awareness httpdisabilitycanhappenorgdisability-statistic
3 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income ReplacedUp to 60 of base monthly earnings
Guarantee Issue up to $3000 per month
Maximum Benefit $6000 per week
Duration of Benefits 3 months
6 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income Replaced Up to 60 of base monthly earnings
Maximum Benefit$6000 per month
Guaranteed Issue up to $3000 per month
Duration of Benefits 6 months
All benefit eligible employees can choose to enroll in one of two Voluntary Short Term Disability plans Should you have an accident or an illness your benefit will be paid for either 3 or 6 months If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
12 month pre-existing clause still applies
17
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY ACCIDENT ndash AFLAC
This is not a complete list of all covered accidents Please consult the plan summary for more details If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
24 Hour On or Off Job Accident
Annual Wellness Benefit
Year 1 $25 per insuredYear 2-4 $50 per insuredYear 5+ $75 per insured
Does not include children
Initial Treatment
Doctorrsquos office or other facility $75Doctorrsquos office or other facility
with x-ray $100ERUrgent Care $150
ERUrgent Care with X-ray $200
Hospital Admission$900
Additional $225 per dayAdditional $525 per day
AmbulanceGround $300
Air $900
Burns Lacerations Fractures Dislocations Concussion etc
$75-$15000
Accidental Death $50000
Accidental Dismemberment Up to $17500
18
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY CRITICAL ILLNESS ndash AFLAC
Voluntary Critical Illness
Wellness Benefit$50 per year ndash Employeeand Spouse (if applicable)
Coverage Amount Options
New Employee Guaranteed Issue up to $20000If a spousedependent is covered under the employees
plan they can elect 50 of the employees coverageChildren are automatically covered at 50 with no
charge
Included Illness at 100Cancer heart attack stroke major organ transplant
end stage renal failure paralysis coma and major third-degree burns ndash and more
Pre-existing Conditions
12 month exclusion for pre-existing cancerNo pre-existing exclusions on other health benefits as
long as diagnosis is made after the plan is in effect
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
16
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY SHORT TERM DISABILITY INSURANCE
Only 48 percent of American adults indicate they have enough savings to cover three months of living expenses in the event they become disabled
Source Council for Disability Awareness httpdisabilitycanhappenorgdisability-statistic
3 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income ReplacedUp to 60 of base monthly earnings
Guarantee Issue up to $3000 per month
Maximum Benefit $6000 per week
Duration of Benefits 3 months
6 Month Short Term Disability
Benefit Begins1st day of an accident 8th day of a sickness
Percentage of Income Replaced Up to 60 of base monthly earnings
Maximum Benefit$6000 per month
Guaranteed Issue up to $3000 per month
Duration of Benefits 6 months
All benefit eligible employees can choose to enroll in one of two Voluntary Short Term Disability plans Should you have an accident or an illness your benefit will be paid for either 3 or 6 months If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
12 month pre-existing clause still applies
17
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY ACCIDENT ndash AFLAC
This is not a complete list of all covered accidents Please consult the plan summary for more details If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
24 Hour On or Off Job Accident
Annual Wellness Benefit
Year 1 $25 per insuredYear 2-4 $50 per insuredYear 5+ $75 per insured
Does not include children
Initial Treatment
Doctorrsquos office or other facility $75Doctorrsquos office or other facility
with x-ray $100ERUrgent Care $150
ERUrgent Care with X-ray $200
Hospital Admission$900
Additional $225 per dayAdditional $525 per day
AmbulanceGround $300
Air $900
Burns Lacerations Fractures Dislocations Concussion etc
$75-$15000
Accidental Death $50000
Accidental Dismemberment Up to $17500
18
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY CRITICAL ILLNESS ndash AFLAC
Voluntary Critical Illness
Wellness Benefit$50 per year ndash Employeeand Spouse (if applicable)
Coverage Amount Options
New Employee Guaranteed Issue up to $20000If a spousedependent is covered under the employees
plan they can elect 50 of the employees coverageChildren are automatically covered at 50 with no
charge
Included Illness at 100Cancer heart attack stroke major organ transplant
end stage renal failure paralysis coma and major third-degree burns ndash and more
Pre-existing Conditions
12 month exclusion for pre-existing cancerNo pre-existing exclusions on other health benefits as
long as diagnosis is made after the plan is in effect
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
17
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY ACCIDENT ndash AFLAC
This is not a complete list of all covered accidents Please consult the plan summary for more details If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
24 Hour On or Off Job Accident
Annual Wellness Benefit
Year 1 $25 per insuredYear 2-4 $50 per insuredYear 5+ $75 per insured
Does not include children
Initial Treatment
Doctorrsquos office or other facility $75Doctorrsquos office or other facility
with x-ray $100ERUrgent Care $150
ERUrgent Care with X-ray $200
Hospital Admission$900
Additional $225 per dayAdditional $525 per day
AmbulanceGround $300
Air $900
Burns Lacerations Fractures Dislocations Concussion etc
$75-$15000
Accidental Death $50000
Accidental Dismemberment Up to $17500
18
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY CRITICAL ILLNESS ndash AFLAC
Voluntary Critical Illness
Wellness Benefit$50 per year ndash Employeeand Spouse (if applicable)
Coverage Amount Options
New Employee Guaranteed Issue up to $20000If a spousedependent is covered under the employees
plan they can elect 50 of the employees coverageChildren are automatically covered at 50 with no
charge
Included Illness at 100Cancer heart attack stroke major organ transplant
end stage renal failure paralysis coma and major third-degree burns ndash and more
Pre-existing Conditions
12 month exclusion for pre-existing cancerNo pre-existing exclusions on other health benefits as
long as diagnosis is made after the plan is in effect
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
18
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY CRITICAL ILLNESS ndash AFLAC
Voluntary Critical Illness
Wellness Benefit$50 per year ndash Employeeand Spouse (if applicable)
Coverage Amount Options
New Employee Guaranteed Issue up to $20000If a spousedependent is covered under the employees
plan they can elect 50 of the employees coverageChildren are automatically covered at 50 with no
charge
Included Illness at 100Cancer heart attack stroke major organ transplant
end stage renal failure paralysis coma and major third-degree burns ndash and more
Pre-existing Conditions
12 month exclusion for pre-existing cancerNo pre-existing exclusions on other health benefits as
long as diagnosis is made after the plan is in effect
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
19
The rates and benefit plan information shown in this guide are illustrative only To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this
guide the underlying insurance documents will govern in all cases
VOLUNTARY HOSPITAL PLAN ndash AFLAC
Voluntary Hospital Plan
Wellness Benefit $50 per person per year
HOSPITAL ADMISSION $1000
DAILY HOSPITAL CONFINEMENT (Up to 31 days)
$150day
DAILY ICU CONFINEMENT (Up to 10 days)
$250day
If you have any questions or would like to enroll in coverage contact Rebecca Smith at aflacsmithagencyinccom or (804) 422-3522
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
20
This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice
THE LOCAL CHOICE EMPLOYEE ASSISTANCE PROGRAM - ANTHEM
New Kent County provides these services at no cost to all employees and dependents enrolled in The Local Choice No referrals are needed to speak with an EAP counselor and you never have to worry about finding a provider who is in your network
The call center is open 24 hours a day 7 days a week You can talk to a licensed counselor at any time In some instances the employee can visit in person with a counselor
This program helps people work through common issues such as those listed below and many more
bull Dependent Carebull Working Smarterbull Educationbull Legal concerns
bull Lifestyle and Fitness Managementbull Substance Abusebull Griefbull Financial issues
Visit wwwanthemcomTLCCall 1-855-223-9277
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
21
VOLUNTARY PET INSURANCE - NATIONWIDE
New Kent County is pleased offer a voluntary pet insurance option through Nationwide the
countryrsquos largest pet insurer Rates vary by pet needs Go to PetsNationwidecom for pricing and
additional information Sign up multiple pets with individual plans and receive a discount for even
more savings
Plan 1 Medical with wellness
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
bull Wellness exams
bull Spay or neuter
bull Flea and tick
bull Teeth cleaning
bull Shots
bull And more
$7500 annual maximum
Plan 2 Medical
bull Up to 90 reimbursement on vet bills
bull $250 annual deductible
bull Accidents amp illness
bull Hereditary amp congenital
bull Cancer
bull Dental diseases
bull Behavioral treatments
bull Rx therapeutic diets amp supplements
bull Use any vet
$7500 annual maximum
Call 1-877-738-7874 and let them know you are a New Kent County employee or visit
httpsbenefitspetinsurancecomnew-kent to enroll with our preferred pricing
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
22
Womenrsquos Health andCancer Rights ActIn October 1998 Congress enacted the Womenrsquos Health and Cancer Rights Act of 1998 This notice explains some important provisions of the Act Please review this information carefully As specified in the Womenrsquos Health and Cancer Rights Act a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits 1 All stages of reconstruction of the breast on which the mastectomy has been performed 2 Surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 Prostheses and treatment of physical complications of the mastectomy including lymphedemas Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan
Newborn and MothersrsquoHealth Protection ActGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours)
REQUIRED NOTICES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
Premium Assistance Under Medicaid and the
Childrenrsquos Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and yoursquore 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 arenrsquot eligible for Medicaid or CHIP
you wonrsquot 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
wwwhealthcaregov
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 wwwinsurekidsnowgov 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 arenrsquot
already enrolled This is called a ldquospecial enrollmentrdquo 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 wwwaskebsadolgov or call 1-866-444-EBSA
(3272)
If you live in one of the following states you may be eligible for assistance paying your employer
health plan premiums The following list of states is current as of July 31 2020 Contact your
State for more information on eligibility ndash
ALABAMA ndash MedicaidCOLORADO ndash Health First Colorado (Coloradorsquos Medicaid
Program) amp Child Health Plan Plus (CHP+)
Website httpmyalhippcom
Phone 1-855-692-5447
Health First Colorado Website
httpswwwhealthfirstcoloradocom
Health First Colorado Member Contact Center
1-800-221-3943 State Relay 711
CHP+ httpswwwcoloradogovpacifichcpfchild-health-
plan-plus
CHP+ Customer Service 1-800-359-1991 State Relay 711
Health Insurance Buy-In Program
(HIBI) httpswwwcoloradogovpacifichcpfhealth-
insurance-buy-program
HIBI Customer Service 1-855-692-6442
ALASKA ndash Medicaid FLORIDA ndash Medicaid
The AK Health Insurance Premium Payment Program
Website httpmyakhippcom
Phone 1-866-251-4861
Email CustomerServiceMyAKHIPPcom
Medicaid Eligibility
httpdhssalaskagovdpaPagesmedicaiddefaultaspx
Website
httpswwwflmedicaidtplrecoverycomflmedicaidtplrecoveryc
omhippindexhtml
Phone 1-877-357-3268
ARKANSAS ndash Medicaid GEORGIA ndash Medicaid
Website httpmyarhippcom
Phone 1-855-MyARHIPP (855-692-7447)
Website httpsmedicaidgeorgiagovhealth-insurance-
premium-payment-program-hipp
Phone 678-564-1162 ext 2131
CALIFORNIA ndash Medicaid INDIANA ndash Medicaid
Website httpswwwdhcscagovservicesPagesTPLRD_CAU_contaspx
Phone 916-440-5676
Healthy Indiana Plan for low-income adults 19-64
Website httpwwwingovfssahip
Phone 1-877-438-4479
All other Medicaid Website httpswwwingovmedicaid
Phone 1-800-457-4584
REQUIRED NOTICES
23
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
IOWA ndash Medicaid and CHIP (Hawki) MONTANA ndash Medicaid
Medicaid Website
httpsdhsiowagovimemembers
Medicaid Phone 1-800-338-8366
Hawki Website httpdhsiowagovHawki
Hawki Phone 1-800-257-8563
Website
httpdphhsmtgovMontanaHealthcareProgramsHIPP
Phone 1-800-694-3084
KANSAS ndash Medicaid NEBRASKA ndash Medicaid
Website httpwwwkdheksgovhcfdefaulthtm
Phone 1-800-792-4884
Website httpwwwACCESSNebraskanegov
Phone 1-855-632-7633 Lincoln 402-473-7000
Omaha 402-595-1178
KENTUCKY ndash Medicaid NEVADA ndash Medicaid
Kentucky Integrated Health Insurance Premium Payment
Program (KI-HIPP) Website
httpschfskygovagenciesdmsmemberPageskihippasp
x
Phone 1-855-459-6328
Email KIHIPPPROGRAMkygov
KCHIP Website httpskidshealthkygovPagesindexaspx
Phone 1-877-524-4718
Kentucky Medicaid Website httpschfskygov
Medicaid Website httpdhcfpnvgov
Medicaid Phone 1-800-992-0900
LOUISIANA ndash Medicaid NEW HAMPSHIRE ndash Medicaid
Website wwwmedicaidlagov or wwwldhlagovlahipp
Phone 1-888-342-6207 (Medicaid hotline) or 1-855-618-
5488 (LaHIPP)
Website httpswwwdhhsnhgovoiihipphtm
Phone 603-271-5218
Toll free number for the HIPP program 1-800-852-3345
ext 5218
MAINE ndash Medicaid NEW JERSEY ndash Medicaid and CHIP
Website httpwwwmainegovdhhsofipublic-
assistanceindexhtml
Phone 1-800-442-6003
TTY Maine relay 711
Medicaid Website
httpwwwstatenjushumanservicesdmahsclientsmedica
id
Medicaid Phone 609-631-2392
CHIP Website httpwwwnjfamilycareorgindexhtml
CHIP Phone 1-800-701-0710
MASSACHUSETTS ndash Medicaid and CHIP NEW YORK ndash Medicaid
Website
httpwwwmassgoveohhsgovdepartmentsmasshealth
Phone 1-800-862-4840
Website httpswwwhealthnygovhealth_caremedicaid
Phone 1-800-541-2831
MINNESOTA ndash Medicaid NORTH CAROLINA ndash Medicaid
Website
httpsmngovdhspeople-we-servechildren-and-
familieshealth-carehealth-care-programsprograms-and-
servicesmedical-assistancejsp [Under ELIGIBILITY tab
see ldquowhat if I have other health insurancerdquo]
Phone 1-800-657-3739
Website httpsmedicaidncdhhsgov
Phone 919-855-4100
MISSOURI ndash Medicaid NORTH DAKOTA ndash Medicaid
Website
httpwwwdssmogovmhdparticipantspageshipphtm
Phone 573-751-2005
Website
httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-844-854-4825
REQUIRED NOTICES
24
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
25
OKLAHOMA ndash Medicaid and CHIP UTAH ndash Medicaid and CHIP
Website httpwwwinsureoklahomaorg
Phone 1-888-365-3742
Medicaid Website httpsmedicaidutahgov
CHIP Website httphealthutahgovchip
Phone 1-877-543-7669
OREGON ndash Medicaid VERMONTndash Medicaid
Website httphealthcareoregongovPagesindexaspx
httpwwworegonhealthcaregovindex-eshtml
Phone 1-800-699-9075
Website httpwwwgreenmountaincareorg
Phone 1-800-250-8427
PENNSYLVANIA ndash Medicaid VIRGINIA ndash Medicaid and CHIP
Website
httpswwwdhspagovprovidersProvidersPagesMedical
HIPP-Programaspx
Phone 1-800-692-7462
Website httpswwwcovervaorghipp
Medicaid Phone 1-800-432-5924
CHIP Phone 1-855-242-8282
RHODE ISLAND ndash Medicaid and CHIP WASHINGTON ndash Medicaid
Website httpwwweohhsrigov
Phone 1-855-697-4347 or 401-462-0311 (Direct RIte
Share Line)
Website httpswwwhcawagov
Phone 1-800-562-3022
SOUTH CAROLINA ndash Medicaid WEST VIRGINIA ndash Medicaid
Website httpswwwscdhhsgov
Phone 1-888-549-0820
Website httpmywvhippcom
Toll-free phone 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN ndash Medicaid and CHIP
Website httpdsssdgov
Phone 1-888-828-0059
Website
httpswwwdhswisconsingovbadgercareplusp-
10095htm
Phone 1-800-362-3002
TEXAS ndash Medicaid WYOMING ndash Medicaid
Website httpgethipptexascom
Phone 1-800-440-0493
Website httpswyequalitycareacs-inccom
Phone 307-777-7531
To see if any other states have added a premium assistance program since July 31 2020
or for more information on special enrollment rights contact either
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub L 104-13) (PRA) no persons are
required to respond to a collection of information unless such collection displays a valid Office of
Management and Budget (OMB) control number The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB under the
PRA and displays a currently valid OMB control number and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number
See 44 USC 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 USC 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 US Department of Labor Employee
Benefits Security Administration Office of Policy and Research Attention PRA Clearance
Officer 200 Constitution Avenue NW Room N-5718 Washington DC 20210 or email
ebsaoprdolgov and reference the OMB Control Number 1210-0137OMB Control Number 1210-0137 (expires 12312019)
US Department of Health and Human
Services
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
US Department of Labor
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
REQUIRED NOTICES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
26
HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected personal health information (PHI) to enrolled participants All employers must distribute HIPAA Privacy Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI If the employer maintains a benefits website the HIPAA Privacy Notice must be included on the website
The HIPAA Privacy Notice must be written in plain language and must describe three things (1) the use and disclosures of PHI that may be made by the group health plan (2) plan participantsrsquo privacy rights and (3) the group health planrsquos legal responsibilities with respect to the PHI
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices for health plans to choose from booklet version layered version and full-page version
More information can be found at httpswwwhhsgovhipaafor-professionalsprivacyguidanceprivacy-practices-for-protected-health-informationindexhtml
Link to OneDigitalrsquos privacy policy httpswwwonedigitalcomprivacy-policy
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) However you must request enrollment within the appropriate time period that applies under the plan after you or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents However you must request enrollment within the appropriate time period that applies under the plan after the marriage birth adoption or placement for adoption To request special enrollment or obtain more information contact the appropriate plan representative
For additional information on your employerrsquos privacy policy please contact your HR department
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
27
CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer sensitive questions about your medical history physical condition and personal health habits as required by our insurance carrier partners
We collect nonpublic personal information from the following sources
bull Information from you including data provided on applications or other forms such as name address telephone number date of birth and Social Security number
bull Information from your transactions with us andor our partners such as policy coverage premium claim and payment history
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients and we pledge to protect the confidential nature of your personal information We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with an environment of complete trust
In the course of business we may disclose all or part of your customer information without your permission to the following persons or entities for the following reasons
bull To an insurance carrier agent or credit reporting agency to detect prevent or prosecute actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a medical care institution or medical professional to verify coverage or benefits to inform you of a medical problem of which you may or may not be aware or to conduct an audit that would enable us to verify treatment
bull To an insurance regulatory authority law enforcement or other governmental authority to protect our interests in detecting preventing or prosecuting actual or potential criminal activity fraud misrepresentation unauthorized transactions claims or other liabilities in connection with an insurance transaction
bull To a third party for any other disclosures required or permitted by law We may disclose all of the information that we collect about you as described above
Our practices regarding information confidentiality and security We restrict access to your customer information only to those individuals who need it to provide you with products or services or to otherwise service your account In addition we have security measures in place to protect against the loss misuse andor unauthorized alteration of the customer information under our control including physical electronic and procedural safeguards that meet or exceed applicable federal and state standards
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
28
CARRIER CONTACT INFORMATION
Program Vendor Contact Information
MedicalPharmacyVision
Virtual Visits
TLC Anthem
LiveHealth Online
1-800-552-2682
wwwAnthemcomTLC
wwwTheLocalChoicevirginiagov
wwwLiveHealthOnlinecom
Health Savings Account and
Flexible Spending Account WexDiscovery
Benefits
1-866-451-3399
wwwwexinccom
Dental Delta Dental1-855-648-1411
wwwDeltaDentalcom
Term and Whole Life
Insurance
Short Term Disability
Accident Critical Illness
Hospital Plans
AflacOffice (804) 422-3522Fax (804) 422-3524aflacsmithagencyinccom
Employee Assistance
ProgramTLC Anthem EAP
1-855-223-9277wwwanthemcomTLC
Pet Insurance Nationwide
1-877-738-7874
httpsbenefitsperinsurancecom
new-kent
Advanced Resolution Team OneDigital ARTonedigitalcom
1 866-802-6311
35
CARRIERS VENDORS amp CONTACTSNOTES
35
CARRIERS VENDORS amp CONTACTSNOTES
