2016 MEDICAL, DENTAL AND VISION PLAN OPEN ENROLLMENT

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1 TO: FROM: All OrthoSynetics Employees Human Resources Department DATE: November 10, 2015 RE: 2016 MEDICAL, DENTAL AND VISION PLAN OPEN ENROLLMENT The open enrollment period will begin on November 16 th and end on November 30 th. OrthoSynetics, Inc. will continue to offer comprehensive benefits solutions which provide an array of options including medical, dental and vision coverage. However, the insurance providers will be changing in Therefore, it is imperative that each person desiring to enroll in health insurance log in, make elections and ensure the accuracy of their elections prior to November 30. No insurance will roll over from 2015 to 2016, so you must log in to make your 2016 elections regardless of whether you participated in any insurance plans in Please take your time and read this information carefully, so that you may make the best decision for you and/or your family members. After a particularly costly and difficult 2015, our insurance rates have increased significantly. While OSI is shouldering much of the burden on behalf of its staff, paying approximately $550 for each employee s health insurance each month, the medical insurance rates have increased 8%. Below is the detailed breakdown of the total cost associated with each plan. In addition to medical and dental insurance options, the vision plan has become an elective option, so that each employee may make the decision to, or to not, enroll. Please note: this means enrollment in the vision plan is no longer automatic upon enrollment in medical insurance. Any employee wishing to elect or continue to receive vision benefits will need to make an election separate from medical insurance enrollment. Monthly contributions for the 2016 plan year (effective 1/1/16), are as follows: Monthly Cost Medical Medical Medical Plan Plan Plan Platinum Gold Silver Dental Plan Vision Plan Employee Only $72.29 $53.43 $29.33 $5.20 $2.14 Employee + Spouse $ $ $ $24.44 $4.28 Employee + Child(ren) $ $ $ $24.44 $4.58 Family $ $ $ $24.44 $7.32 Open Enrollment Memo OrthoSynetics

2 2016 BENEFIT CHANGES OrthoSynetics is proud to be introducing United Healthcare as our new medical insurance provider and Cigna as our new dental insurance provider. Our vision insurance will remain with VSP. WHAT ARE YOUR CHOICES? United Healthcare Medical Plan United Healthcare will be administering our medical plans in United s coverage will help you maintain your wellbeing through preventive care and access to an extensive network of providers, as well as affordable prescription medication. Please visit the United Healthcare website at to find a listing of providers in your area. You can also download the app from your app store by searching for Health4Me. Once on the United Healthcare website, simply click on Find a Physician, Laboratory or Facility link and you can perform a search by clicking on All United Healthcare Plans and then navigating to the Choice Plus link. Employees will continue to have a choice of three medical plan offerings. During this open enrollment period, you can decide between the following levels of coverage: 1. United Healthcare PLATINUM PPO Plan Coverage is provided in-network at 80% co-insurance and 50% co-insurance out-of-network. 2. United Healthcare GOLD PPO Plan Coverage is provided in-network at 80% coinsurance and 50% co-insurance out-of-network. 3. United Healthcare SILVER PPO Plan Coverage is provided in-network at 70% co-insurance and 50% co-insurance out-of-network Benefit summaries are available at under the section titled 2016 OrthoSynetics Insurance Open Enrollment. Please read each summary carefully to choose the medical plan offering which best meets the needs of you and your family. Prescription Drug Program Please note: because the prescription drug program administrator is changing to United Healthcare, you will need to submit new subscriptions for processing. **Additional details on the Prescription Drug Program can be found in trifold you received via mail or at under the section titled 2016 OrthoSynetics Insurance Open Enrollment. Prescription Drug Co-Pays Platinum Gold Silver Generic $10 Co-pay $10 Co-pay $10 Co-pay Formulary $25 Co-pay $35 Co-pay $35 Co-pay Non-Formulary $50 Co-pay $60 Co-pay $60 Co-pay $25/$62.50/$125 $25/$87.50/$150 $25/$87.50/$510 Mail Order Program Co-pay 3 mo. supply Co-pay 3 mo. supply Co-pay 3 mo. supply Open Enrollment Memo OrthoSynetics

3 Cigna Dental Insurance Plan Cigna will be administering our dental plans in Cigna s coverage will provide you and your family affordable options for overall health. Please visit the Cigna website at to find a listing of providers in your area. You can also download the app from your app store by searching for mycigna. Once on the Cigna website, simply click on Individual and Family Plans, Find a Doctor, and then ensure you have elected Find a Dentist. Our plan is a Dental PPO (DPPO) option, which you will need to specify when searching. Preventive Services will continue to be covered at 100% with no deductible. The deductible for an individual per calendar year will be $50, and will be $150 for a family. Additional information related to the dental plan can be found in the trifold you received via mail or by going to under the section titled 2016 OrthoSynetics Insurance Open Enrollment. If you need to contact Cigna, please call (800) and reference policy number VSP Vision Insurance Plan Our vision plan will continue to be administered by VSP. VSP offers a comprehensive vision benefit that will assist with the cost of eye exams and contact lenses/glasses. Please visit the VSP website at to find a listing of providers in your area. Once on the VSP website, you can easily search for a doctor by typing your zip code into the box under Find a VSP doctor. Life and Accidental Death & Dismemberment (AD&D) Coverage Regardless if you participate in the OrthoSynetics medical and/or dental plan, the company will continue to provide $20,000 of Life and AD&D insurance, at no cost to you. This benefit will be provided through Reliance Standard. Please verify the appropriate beneficiary is listed by logging onto My Payroll Page at Employee Assistance Program Personal issues can affect not only our health, but our everyday life including job performance. That s why OrthoSynetics provides all employees with access to an EAP through Reliance Standard. This is a voluntary program which allows employees to deal with personal concerns in a completely confidential manner. The EAP provides professional counseling and information on several topics including, but not limited to grief and loss, single parenting, substance abuse, financial planning, and child care. Additional information is available at under the section titled 2016 OrthoSynetics Insurance Open Enrollment. Click on the link titled Employee Assistance Program (EAP) to take advantage of the services available with this free benefit! Identification (ID) Cards Because OSI is changing our insurance providers, any person choosing benefits will receive a new medical insurance card in This care should arrive by early January. Human Resources will also have generic dental insurance cards available for anyone who would like one. If a medical need arises prior to the arrival of your insurance card, employees will have the ability to use the app on their cell phone to get a copy of their enrollment card, or contact United Healthcare at (866) using their social security number and providing policy number Open Enrollment Memo OrthoSynetics

4 WHAT DO YOU NEED TO DO? Open Enrollment During this annual open enrollment, you may add, drop or change coverage for yourself or your eligible dependents. Once elections are made during open enrollment they cannot be changed unless you experience a Life Event (e.g. marriage, divorce, birth, adoption, and loss or addition of other coverage). The duration of the special enrollment period for any Life Event is 30 days, and begins on the date of the marriage, birth, adoption, etc. Further details and required paperwork to enact a Life Event change can be obtained by contacting the Human Resources Department. As a reminder, your current coverage will terminate on 12/31/2015. In order to be enrolled in United Healthcare s medical insurance, you must make elections during open enrollment. IMPORTANT REMINDERS Coverage is provided for newborn dependents of a plan participant for the first 31 days after birth. A plan participant must make written application to the Human Resources Department within those 31 days after birth in order for coverage to continue on the 32 nd day forward for the newborn. If written application is not made to add the newborn within 31 days of birth, then the newborn will NOT be allowed on the medical plan until the next open enrollment. Participants with dependent children must remember that dependent children ages 19 through 26 are allowed to remain on OrthoSynetics medical, dental and vision plans only if they are not eligible for other coverage through their employer. Individuals may request enrollment for such children during open enrollment or within 30 days of a Life Event. If a dependent child is not eligible to remain on the plan, they may be eligible for coverage under the COBRA Act of Should your employment terminate for any reason, your coverage will be terminated on the last day of the month in which you terminate. You will then be eligible for COBRA continuation benefits. OrthoSynetics will not retroactively terminate coverage, except in limited situations, such as when the covered individual commits fraud against the plan or makes intentional misrepresentations. If rescission is permitted, plan will give proper notice at least 30 calendar days before coverage is rescinded. We realize that you may have questions or concerns regarding the change in benefits. Please contact Bonnie Buckley in the Human Resources Department at (888) or, via at bbuckley@orthosynetics.com and she will be happy to assist you. Open Enrollment Memo OrthoSynetics

5 Required Notices Important Notice from OrthoSynetics About Your Prescription Drug Coverage and Medicare under the United Healthcare Plan(s) Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with OrthoSynetics and about your options under Medicare s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. OrthoSynetics has determined that the prescription drug coverage offered by the United Healthcare plan(s) is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare during a seven-month initial enrollment period. That period begins three months prior to your 65th birthday, includes the month you turn 65, and continues for the ensuing three months. You may also enroll each year from October 15th through December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current OrthoSynetics coverage will not be affected. For most persons covered under the Plan, the Plan will pay prescription drug benefits first, and Medicare will determine its payments second. For more information about this issue of what program pays first and what program pays second, see the Plan s summary plan description or contact Medicare at the telephone number or web address listed herein. If you do decide to join a Medicare drug plan and drop your current OrthoSynetics coverage, be aware that you and your dependents will not be able to get this coverage back. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with OrthoSynetics and don t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information about This Notice or Your Current Prescription Drug Coverage Contact the person listed at the end of these notices for further information. NOTE: You ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through OrthoSynetics changes. You also may request a copy of this notice at any time. For More Information about Your Options under Medicare Prescription Drug Coverage More detailed information about Medicare plans that offer prescription drug coverage is in the Medicare & You handbook. You ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the Medicare & You handbook for their telephone number) for personalized help Call MEDICARE ( ). TTY users should call If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at or call them at (TTY ). Remember: Keep this Medicare Part D notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: January 1, 2016 Name of Entity/Sender: Contact Position/Office: OrthoSynetics Human Resources Address: 3850 N Causeway Blvd, Suite 800 Metairie, LA Phone Number:

6 Women s Health and Cancer Rights Act The Women s Health and Cancer Rights Act of 1998 was signed into law on October 21, The Act requires that all group health plans providing medical and surgical benefits with respect to a mastectomy must provide coverage for all of the following: Reconstruction of the breast on which a mastectomy has been performed Surgery and reconstruction of the other breast to produce a symmetrical appearance Prostheses Treatment of physical complications of all stages of mastectomy, including lymphedema This coverage will be provided in consultation with the attending physician and the patient, and will be subject to the same annual deductibles and coinsurance provisions which apply for the mastectomy. For deductibles and coinsurance information applicable to the plan in which you enroll, please refer to the summary plan description or contact Human Resources at HIPAA Privacy and Security The Health Insurance Portability and Accountability Act of 1996 deals with how an employer can enforce eligibility and enrollment for health care benefits, as well as ensuring that protected health information which identifies you is kept private. You have the right to inspect and copy protected health information that is maintained by and for the plan for enrollment, payment, claims and case management. If you feel that protected health information about you is incorrect or incomplete, you may ask your benefits administrator to amend the information. The Notice of Privacy Practices has been recently updated. For a full copy of the Notice of Privacy Practices, describing how protected health information about you may be used and disclosed and how you can get access to the information, contact Human Resources at

7 Premium Assistance Under Medicaid and the Children s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren t eligible for Medicaid or CHIP, you won t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit 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 KIDS NOW or 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 employersponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren t already enrolled. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at or call 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, Contact your State for more information on eligibility ALABAMA Medicaid WEBSITE PHONE ALASKA Medicaid WEBSITE PHONE (Outside of Anchorage): PHONE (Anchorage): COLORADO Medicaid WEBSITE PHONE Medicaid Customer Contact Center: FLORIDA Medicaid WEBSITE PHONE GEORGIA Medicaid WEBSITE - Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) PHONE INDIANA Medicaid WEBSITE PHONE IOWA Medicaid WEBSITE PHONE KANSAS Medicaid WEBSITE PHONE KENTUCKY Medicaid WEBSITE PHONE LOUISIANA Medicaid WEBSITE PHONE MAINE Medicaid WEBSITE PHONE TTY MASSACHUSETTS Medicaid and CHIP WEBSITE PHONE MINNESOTA Medicaid WEBSITE Click on Health Care, then Medical Assistance PHONE MISSOURI Medicaid WEBSITE PHONE MONTANA Medicaid WEBSITE PHONE NEBRASKA Medicaid WEBSITE PHONE NEVADA Medicaid WEBSITE PHONE NEW HAMPSHIRE Medicaid WEBSITE PHONE NEW JERSEY Medicaid and CHIP WEBSITE Medicaid: PHONE Medicaid: WEBSITE CHIP: PHONE CHIP: NEW YORK Medicaid WEBSITE PHONE of 2

8 NORTH CAROLINA Medicaid WEBSITE PHONE NORTH DAKOTA Medicaid WEBSITE PHONE OKLAHOMA Medicaid and CHIP WEBSITE PHONE OREGON Medicaid WEBSITE WEBSITE PHONE PENNSYLVANIA Medicaid WEBSITE PHONE RHODE ISLAND Medicaid WEBSITE PHONE SOUTH CAROLINA Medicaid WEBSITE PHONE SOUTH DAKOTA Medicaid WEBSITE PHONE TEXAS Medicaid WEBSITE PHONE UTAH Medicaid and CHIP WEBSITE Medicaid: WEBSITE CHIP: PHONE VERMONT Medicaid WEBSITE PHONE VIRGINIA Medicaid and CHIP WEBSITE Medicaid: PHONE Medicaid: WEBSITE CHIP: PHONE CHIP: WASHINGTON Medicaid WEBSITE index.aspx PHONE ext WEST VIRGINIA Medicaid WEBSITE PHONE , HMS Third Party Liability WISCONSIN Medicaid and CHIP WEBSITE PHONE WYOMING Medicaid WEBSITE PHONE To see if any other states have added a premium assistance program since July 31, 2015, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services , Menu Option 4, Ext OMB Control Number (expires 10/31/2016) 2 of 2

9 Asistencia con las primas bajo Medicaid y el Programa de Seguro de Salud para Menores (CHIP) Si usted o sus hijos son elegibles para Medicaid o CHIP y usted es elegible para cobertura médica de su empleador, su estado puede tener un programa de asistencia con las primas que puede ayudar a pagar por la cobertura, utilizando fondos de sus programas Medicaid o CHIP. Si usted o sus hijos no son elegibles para Medicaid o CHIP, usted no será elegible para estos programas de asistencia con las primas, pero es probable que pueda comprar cobertura de seguro inividual a través del mercado de seguros médicos. Para obtener más información, visite Si usted o sus dependientes ya están inscritos en Medicaid o CHIP y usted vive en uno de los estados enumerados a continuación, comuníquese con la oficina de Medicaid o CHIP de su estado para saber si hay asistencia con primas disponible. Si usted o sus dependientes NO están inscritos actualmente en Medicaid o CHIP, y usted cree que usted o cualquiera de sus dependientes puede ser elegible para cualquiera de estos programas, comuníquese con la oficina de Medicaid o CHIP de su estado, llame al KIDS NOW o visite para información sobre como presentar su solicitud. Si usted es elegible, pregunte a su estado si tiene un programa que pueda ayudarle a pagar las primas de un plan patrocinado por el empleador. Si usted o sus dependientes son elegibles para asistencia con primas bajo Medicaid o CHIP, y también son elegibles bajo el plan de su empleador, su empleador debe permitirle inscribirse en el plan de su empleador, si usted aún no está inscrito. Esto se llama oportunidad de inscripción especial, y usted debe solicitar la cobertura dentro de los 60 días de haberse determinado que usted es elegible para la asistencia con las primas. Si tiene preguntas sobre la inscripción en el plan de su empleador, comuníquese con el Departamento del Trabajo electrónicamente a través de o llame al servicio telefónico gratuito EBSA (3272). Si usted vive en uno de los siguientes estados, tal vez sea elegible para asistencia para pagar las primas del plan de salud de su empleador. La siguiente es una lista de estados actualizada al 31 de julio de Comuníquese con su estado para obtener más información sobre la elegibilidad - ALABAMA Medicaid SITIO WEB TELÉFONO ALASKA Medicaid SITIO WEB TELÉFONO (Fuera de Anchorage): TELÉFONO (Anchorage): COLORADO Medicaid SITIO WEB TELÉFONO Medicaid Phone (fuera de estado) FLORIDA Medicaid SITIO WEB TELÉFONO GEORGIA Medicaid SITIO WEB Haga clic en Programs, luego en Medicaid, luego en Health Insurance Premium Payment (HIPP) TELÉFONO INDIANA Medicaid SITIO WEB TELÉFONO IOWA Medicaid SITIO WEB TELÉFONO KANSAS Medicaid SITIO WEB TELÉFONO KENTUCKY Medicaid SITIO WEB TELÉFONO LOUISIANA Medicaid SITIO WEB TELÉFONO MAINE Medicaid SITIO WEB TELÉFONO TTY MASSACHUSETTS Medicaid y CHIP SITIO WEB TELÉFONO MINNESOTA Medicaid SITIO WEB Haga clic en Health Care y luego en Medical Assistance TELÉFONO MISSOURI Medicaid SITIO WEB TELÉFONO MONTANA Medicaid SITIO WEB TELÉFONO NEBRASKA Medicaid SITIO WEB TELÉFONO NEVADA Medicaid SITIO WEB TELÉFONO of 2

10 NUEVO HAMPSHIRE Medicaid SITIO WEB TELÉFONO NUEVA JERSEY Medicaid y CHIP SITIO WEB Medicaid: TELÉFONO Medicaid: SITIO WEB CHIP: TELÉFONO CHIP: NUEVA YORK Medicaid SITIO WEB TELÉFONO CAROLINA DEL NORTE Medicaid SITIO WEB TELÉFONO DAKOTA DEL NORTE Medicaid SITIO WEB TELÉFONO OKLAHOMA Medicaid y CHIP SITIO WEB TELÉFONO OREGON Medicaid y CHIP SITIO WEB SITIO WEB TELÉFONO PENSILVANIA Medicaid SITIO WEB TELÉFONO RHODE ISLAND Medicaid SITIO WEB TELÉFONO CAROLINA DEL SUR Medicaid SITIO WEB TELÉFONO VIRGINIA Medicaid y CHIP SITIO WEB Medicaid: TELÉFONO Medicaid: SITIO WEB CHIP: TELÉFONO CHIP: WASHINGTON Medicaid SITIO WEB TELÉFONO ext WEST VIRGINIA Medicaid SITIO WEB TELÉFONO , HMS Third Party Liability WISCONSIN Medicaid SITIO WEB TELÉFONO WYOMING Medicaid y CHIP SITIO WEB TELÉFONO Para saber si otros estados han agregado el programa de asistencia con primas desde el 31 de julio de 2015, o para obtener más información sobre derechos de inscripción especial, comuníquese con alguno de los siguientes: Departamento del Trabajo de EE.UU. Administración de Seguridad de Beneficios de los Empleados EBSA (3272) Departamento de Salud y Servicios Humanos de EE.UU. Centros para Servicios de Medicare y Medicaid , opción de menú 4, Ext Número de Control de OMB (vence al 31 de octubre de 2016) DAKOTA DEL SUR Medicaid SITIO WEB TELÉFONO TEXAS Medicaid SITIO WEB TELÉFONO UTAH Medicaid y CHIP SITIO WEB Medicaid: SITIO WEB CHIP: TELÉFONO VERMONT Medicaid SITIO WEB TELÉFONO of 2