BENEFITS GUIDE January 1, 2020 – December 31,2020

Inside the Guide WELCOME 3

2020 BENEFIT PLAN HIGHLIGHTS 4

WHEN CAN I ENROLL IN BENEFITS? 6

ENROLL WITH EASE 7

MEDICAL 8

HEALTH SAVINGS ACCOUNT (HSA) 10

HUGH CHATHAM MEMORIAL HOSPITAL’S WELLNESS INITIATIVES 13

DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT 14

TELEMEDICINE 15

DENTAL 16

VISION – MATERIALS ONLY 17

BASIC LIFE, AD&D, AND SUPPLEMENTAL LIFE 18

SHORT & LONG-TERM DISABILITY INSURANCE 19

VOLUNTARY PLANS 20

EAP 21

401(k) 22

EQUI-VEST 403(b) TSA 24

IMPORTANT CONTACTS 27

REQUIRED NOTIFICATIONS 30

MISSION STATEMENT:

To consistently deliver

exceptional health

care by demonstrating

the values of service,

teamwork,

accountability, respect

and self-care.

VISION STATEMENT:

To be the best

community hospital in

the nation, with

service as our guiding

principle.

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WELCOMEDear Hugh Chatham Memorial Hospital Employee: At Hugh Chatham Memorial Hospital we recognize our ultimate success depends on our talented and dedicated workforce. We understand the contribution each employee makes to our accomplishments and so our goal is to provide a comprehensive program of competitive benefits to attract and retain the best employees available. Through our benefits programs we strive to support the needs of our employees and their dependents by providing a benefit package that is easy to understand, easy to access and affordable for all our employees. The enrollment period for benefits coverage effective January 1, 2020, is scheduled for October 28 -November 11, 2019. You may enroll anytime during that period using the online website http://www.mybensite.com/hughchatham.

As healthcare costs continue to rise due to inflation and increased government regulation, the cost to provide healthcare coverage has also increased. Additionally, Hugh Chatham Memorial Hospital has seen an increase in the occurrence as well as the severity of claims of healthcare costs. This has been a common scenario across the market as costs increase in an effort to keep pace with healthcare trends. Hugh Chatham Memorial Hospital is committed to providing a comprehensive benefits package to its employees.

Below are important dates to put on your calendar: Q&A Sessions: October 22 – MSCR 7:00 am, 10:00 am, 12:00 pm, 3:00 pm, 8:00 pm and 9:30 pm October 23 – MSCR 7:00 am, 10:00 am, 12:00 pm and 3:00 pm PowerPoint slides with voiceover narration will be on Quick Click, covering the benefit information on all plans for 2020, should you not be able to attend the meetings. Annual Enrollment: October 28, 2019 - November 11, 2019 (All benefit eligible employees must elect or waive coverage for 2020.) Benefits Fair: October 29th - Cardiac & Lung Rehab Area 7:30am – 4:00pm Human Resources staff will be available in the Computer Classroom at the following times should you need assistance with your enrollment. October 28: 9:00 am - 10:30 am November 1: 9:00 am - 10:30 am November 4: 7:30 am - 9:30 am November 4: 3:30 pm - 5:00 pm November 6: 7:30 am - 9:30 am November 8: 11:30 am -12:30 pm November 8: 2:30 pm - 3:30 pm November 11: 7:30 am - 3:30 pm Please note enrollment deadlines so that you may select and use the benefits that are right for you. Thank you for your continued dedication to providing exceptional care and service to our patients, their loved ones, and for your efforts to improve the overall quality of life for our entire community. Sincerely,

Hugh Chatham Executive Team

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2020 BENEFIT PLAN HIGHLIGHTS Medical and Pharmacy/Rx Coverage • The coinsurance level for most covered services

provided by a HCMH will be covered at 100% after meeting the deductible.

• There is a now a new tier of coverage for covered serviced provided at Wake Forest Baptist Health.

• HSA Seed funds will be $750 for Employee Only Coverage and $1,500 for Dependent Coverage.

Telemedicine HCMH continues to offer the benefit of accessing a doctor 24/7/365 via mobile app, web browser or phone call. Please see page 15 for more details.

Wellness Program • New Wellness Program available to all employees

and covered spouses • By engaging in the wellness program employees

and their spouses may each earn up to an additional $250 in HSA Seed Funds.

Working Spouse Provision & Tobacco Attestation • As a reminder, Hugh Chatham Memorial Hospital

does not allow working spouses with access to other health coverage to be enrolled in the medical plan. Spouses that do not have access to other coverage may enroll.

• You will need to complete an Affidavit concerning spousal coverage. You will complete this process via the online enrollment system.

• The tobacco surcharge for employee and spouse will remain the same for the 2020 plan year. You may attest to your current tobacco status via the online enrollment site.

Remember that you are required to notify HR if you have a dependent that is no longer eligible within 30 days or you waive your rights to COBRA.

Dental & Vision Coverage There are no plan design changes or contribution changes for 2020.

Life/AD&D, Disability Life/AD&D and STD/LTD disability benefits continue to be available through Cigna, for eligible employees. Voluntary Offerings Universal Whole Life will remain with Unum. You may enroll with a counselor via the enrollment line. Please

see page 20 for more details. Specified Disease (Critical Illness), Hospital Indemnity and Accident products will be available through Voya. You may enroll or make changes to these benefits via the online enrollment system without the need to meet with an enroller.

New Hires: New hires are effective the 1st of the month after 30 days of benefit eligible employment. However, dependent care FSA is effective immediately. Please review your beneficiary information. Beneficiary information recorded in the benefit enrollment system is for life insurance provided by HCMH and supplemental life at your choice. If you need to make 401K beneficiary changes, log into www.netbenefits.com and select “Profile” on the top right hand side of the home page. You will then click on beneficiaries and follow the prompts to make changes. Employee Eligibility Due to the Health Care Reform Act, Hugh Chatham has elected to allow employees who regularly work an average of 24 hours or more a week to be eligible for benefits. HCMH Human Resources will monitor and will notify employees who meet that criteria. Eligibility will be checked every six months (May and November) for the six-month lookback. Dependent Eligibility Your spouse, as defined by the State of North Carolina; unless you are divorced or are legally separated with documentation. Your dependent child(ren) up to the end of the month of which they turn 26 (regardless of marital status, financial dependence, residency, student status, employment status or access to employer sponsored health insurance) under the medical, dental, vision and child life. Children may include natural, adopted, stepchildren and children obtained through court-appointed legal guardship. Required Documents For Spouse: • A copy of your marriage certificate • Affidavit of Spousal Health Care Coverage must be

completed during the enrollment process • And one of the following: • A copy of the front page of your most recent

federal tax return confirming this dependent is your spouse.

• A document dated within the last 60 days showing current relationship status such as a recurring monthly household bill or statement of account. The document must list your spouse’s name, the date and your mailing address.

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For Children up to age 26: • A copy of the child’s birth certificate or adoption

certificate naming you or your spouse as the child’s parent OR

• A copy of the court document naming you or your spouse as the child’s legal guardian

• Note for a stepchild: If you are covering a stepchild you must also provide documentation of your current relationship to your spouse as requested above

For disabled Children age 26 or older: • Documentation indicating that your child is legally

disabled • A copy of the child’s birth certificate or adoption

certificate naming you or your spouse as the child’s parent OR

• A copy of the court order naming you or your spouse as the child’s legal guardian AND

• A copy of the front page of your most recent federal tax return claiming this child as your dependent

• Note for a stepchild: If you are covering a stepchild you must also provide documentation of your current relationship to your spouse as requested above

Keep in mind employees will be required to provide the following information by November 11th when adding/ enrolling new dependents on the medical plan (Spouse and/or Children). For new hires, and newly added dependents (through qualifying life event) employees must submit their documentation within their 30-day enrollment deadline.

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WHEN CAN I ENROLL IN BENEFITS? New Hires You must enroll within 30 days of your benefit eligibility date. If you fail to enroll within your 30 day window, you will be required to wait until open enrollment to enroll or make changes. Please complete your online enrollment prior to your effective date.

Open Enrollment You may enroll and make changes online during the open enrollment season. Once open enrollment is closed, you may not make any changes to your benefit elections unless you experience a qualifying event.

Qualifying Events If you experience a “Qualifying Event,” during the plan year, you must request the appropriate changes in the Online Enrollment system within 30 days of the event and supply HR with appropriate document within 30 days. If you fail to do so, you will be required to wait until open enrollment to enroll or make changes.

Qualifying Events Include: • Any change in your legal marital status which

includes divorce, marriage or annulment. • Any change in the number of dependents in

your health insurance plan including birth, death or adoption.

• Any change in your employment status or your spouse or any change in the employment status of dependents will also trigger a qualifying event. The change includes termination or commencement of a job. Change or return from an unpaid leave of absence. Change in place of work or situation (hourly or weekly salary changes). All this is also applicable to your spouse’s employment or dependents employment conditions.

• Any dependent which does not satisfy eligibility requirements due to attainment of age, student status or similar qualifying events.

• Significant changes in cost of coverage. FMLA (Family Medical Leave Act) Leave.

• Judgments, orders and decree’s trigger a qualifying event for health insurance changes. • Any changes in the coverage of your spouse or dependent from another employer plan. • HIPAA (Health Insurance Portability and Accountability Act) special qualifying events for dependents and due to

loss of coverage in insurance. We will discuss this in detail down below under qualifying events under HIPPA. • Qualifying events for health insurance under COBRA. Qualification under • Medicaid or Medicare. • Loss of coverage under a group health plan of the federal government like state sponsored health insurance

programs, CHIP (Children Health Insurance Program), state health risk pools etc.

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ENROLL WITH EASE Welcome to your employee benefits website! As you know, benefits are an important part of your overall compensation. We are proud to offer our simple, convenient online benefits enrollment system that will make enrollment faster and easier than ever before!

Please visit your employee benefits website: www.mybensite.com/hughchatham Inside the website you will find important information such as benefit summaries, forms, summary plan descriptions, provider search directories, frequently asked questions, health and wellness resources and much more. Please review this information thoroughly before entering the enrollment section of the website. It is important that you understand your benefit options BEFORE starting the enrollment process.

If at any point during this process you have questions or require technical support, please call Tiffany Sparks at (336) 527-7069.

HOW TO LOG IN - First time User Step 1 Visit www.mybensite.com/hughchatham Step 2 You will be asked to register as a user on the system by clicking “create a new user account”. When creating a new user account, you must enter your last name, date of birth (mm/dd/yyyy), and last 4 digits of the employee’s SSN.

Step 3 You will also be asked to enter an email address (this becomes your User Name), along with your password. Once that has been completed, you will be logged into the website with access to the enrollment system. Step 4 Once logged in, select the “Enroll Now” tab. You will be guided through a series of screens, each taking only a few moments to complete. All of your benefit elections will be displayed on a cost “per paycheck” (Bi-Weekly) basis, based on your specific benefit options ENROLLMENT HAS NEVER BEEN EASIER Once inside the site, you will go through a series of screens, each screen takes only a few moments to complete.

Personal Information Please verify that all the information is accurate. If you see any blank fields or need to make changes, please update the information on this screen.

Dependent Information If you have a spouse or children that you wish to cover, please enter their information in this section. Remember that you will need correct names, dates of birth and social security numbers for all covered individuals. You are now able to upload dependent information directly onto the enrollment site. Below is a screen shot of where on the enrollment you will be directed to upload the required documentation for dependents.

Benefit Selections The next few screens will present benefit selections by product (medical, dental, vision, life insurance, etc.). Each page will show you the benefits you are eligible for along with a cost “per paycheck” (Bi-Weekly). If at any point in time you would like to see more information, simply click on one of the menu items to the right to see expanded benefit summaries, forms, provider links and more. After you’ve made your selection, click “continue” to go to the next benefit.

Review and Submit Benefits This is the final step. Please review your benefit choices and costs. If you wish to make changes to your selections, click on the “edit” button to update your information. Once you have completed your review, agree to the terms and hit “Continue”.

Beneficiary Information It is important that you select a beneficiary for your life insurance benefits. You may select a beneficiary from the dependents section, or you can designate any other person, organization or estate trust. We recommend updating this information on an annual basis or after any major life event. You must complete enrollment in one session.

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MEDICAL All employees working on average 24 or more hours per week are eligible for this coverage, under ACA guidelines. HCMH Human Resources will monitor and will notify employees who meet that criteria. For the 2020 plan year Allegiance will continue as our medical plan administrator while providing access to the same Cigna network of providers that we’ve always utilized. New for 2020 the HCMH health plan is increasing the tier 1 coinsurance to 100% after deductible and adding a new tier for enhanced benefits at Wake Forest Baptist Health. HCMH WFBH Cigna Out-of-Network

Tier 1 Tier 2 Tier 3 Tier 4

Annual Deductible

Individual $1,500 $2,000 $3,000 $5,000

Family $3,000 $4,000 $6,000 $15,000

Coinsurance 100% 80% 70% 40%

Maximum Out-of-Pocket

Individual $6,000 $6,000 $6,450 $10,000

Family $12,000 $12,000 $12,800 $20,000

Physician Office Visit

Primary Care 100% after deductible 80% after deductible 70% after deductible 40% after deductible

Specialty Care 100% after deductible 80% after deductible 70% after deductible 40% after deductible

Preventive Care

Adult Periodic Exams 100% 100% 100% 40% after deductible

Well-Child Care 100% 100% 100% 40% after deductible

Diagnostic Services

X-ray and Lab Tests 100% after deductible 80% after deductible 70% after deductible 40% after deductible

Complex Radiology 100% after deductible 80% after deductible 70% after deductible 40% after deductible

Urgent Care Facility 100% after deductible 80% after deductible 70% after deductible 40% after deductible

Emergency Room Facility

Charges 70% after deductible 70% after deductible 70% after deductible 70% after deductible

Inpatient/Outpatient 100% after deductible 80% after deductible 70% after deductible 40% after deductible

Mental Health

Inpatient/Outpatient 100% after deductible 80% after deductible 70% after deductible 40% after deductible

Substance Abuse

Inpatient/Outpatient 100% after deductible 80% after deductible 70% after deductible 40% after deductible

Retail Pharmacy (30 Day Supply)

Generic (Tier 1)

Preventative 85%, no deductible.

All other prescriptions are 80%, after the HCHM In-Network deductible.

No Coverage

Preferred (Tier 2)

Non-Preferred (Tier 3)

Preferred Specialty (Tier 4)

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MEDICAL Employee Contributions (Biweekly)

Non-Tobacco Tobacco Tobacco (if spouse is also a tobacco user)

Employee Only $42.31 $82.31 N/A

Employee & Child(ren) $87.57 $127.57 N/A

Employee & Spouse $123.88 $163.88 $203.88

Employee & Family $153.85 $173.85 $213.85

Hugh Chatham Memorial Hospital offers employees an additional discount on outpatient services for Imaging Services and Laboratory, processed and completed at Hugh Chatham Memorial Hospital. This discount will be only for outpatient services for Imaging Services and Labs performed at Hugh Chatham Memorial Hospital. The discount will be applied to the member responsibility. Employees will need to contact Hugh Chatham’s business office within 30 days of the claims processing date to request the additional 50% discount on outpatient Imaging Services and an additional 75% discount on outpatient Lab services performed at HCMH. The discount will now be applied before the deductible is met. Example: If you have an imaging procedure at Hugh Chatham and the amount billed to Allegiance is $1,500, then Allegiance will discount the bill based on their allowable amount making your responsibility $900 (this is the amount applied to your deductible), then you get 50% off the $900, so your total cost is $450. This can be paid by using your HSA account, payroll deduct, PTO or your own personal funds. HCMH Tier is defined as Hugh Chatham owned and associated providers. Below is a list of facilities with associated tax ID number. that would fall under the new Tier 2 benefits. Should you seek services from providers not on this list but with the Cigna those services would be covered as Tier 3.

° North Carolina Baptist Hospital – 56-0552787

° Lexington Medical Center – 56-0543238

° High Point Regional Health – 56-0532309

° Wake Forest University Health Science (Professional Services) – 22-3849199

° Cornerstone Healthcare (Professional Services) – 56-1935767

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HEALTH SAVINGS ACCOUNT (HSA)

What is a Health Savings Account (HSA)? An HSA is a tax-sheltered bank account that you own to pay for eligible health care expenses for you and/or your eligible dependents for current or future healthcare expenses. The Health Savings Account (HSA) is yours to keep, even if you change jobs or medical plans. There is no “use it or lose it” rule; your balance carries over year to year. Plus, you get extra tax advantages with an HSA because:

¢ Money you deposit into an HSA is exempt from federal income taxes.

¢ Interest in your account grows tax free.

¢ You don’t pay income taxes on withdrawals used to pay for eligible health expenses. (If you withdraw funds for non-eligible expenses, taxes and penalties apply).

¢ You also have a choice of investment options which earn competitive interest rates, so your unused funds grow over time.

Are you eligible to open a Health Savings Account (HSA)?

If you do not meet these requirements, you cannot open an HSA.

¢ You must be enrolled in a Qualified High Deductible Health Plan (QHDHP). Which the HCMH Health plan qualifies as.

¢ You must not be covered by another non-QHDHP health plan, such as a spouse’s PPO plan.

¢ You are not enrolled in Medicare or Medicaid

¢ You are not in the TRICARE or TRICARE for Life military benefits program.

¢ You have not received Veterans Administration (VA) benefits within the past three months.

¢ You are not claimed as a dependent on another person’s tax return.

¢ You are not covered by a traditional health care flexible spending account (FSA). This includes your spouse’s FSA. (Enrollment in a limited purpose health care FSA is allowed).

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2020 HSA CONTRIBUTIONS For new HSA holders, your account will be automatically opened by HCMH. You may be contacted to validate your

identification to complete setting up this account. Funds will not be placed in to the HSA if it has not been validated. It

is your responsibility to contact Healthcare Bank to close that account, if you are not eligible for an HSA.

For existing HCMH HSA holders, your Healthcare account will remain open for the 2020 plan year, and you will continue

to use the same HSA Debit card (please do not throw away your debit cards).

Hugh Chatham Memorial Hospital-HSA Funding Schedule:

Benefit Effective Date January 1

January 1, 2020 April 1, 2020 July 1, 2020 October 1, 2020 Total Annual HCMH

Contribution

Employee Only $187.50 $187.50 $187.50 $187.50 $750.00

Employee + Dependent(s) $375.00 $375.00 $375.00 $375.00 $1,500.00

For new hires the HCMH HSA contribution will be pro-rated based on Benefit Effective Date. Examples are illustrated below:

Benefit Effective Date January 1, 2020 April 1, 2020 July 1, 2020 October 1, 2020

Total Annual

HCMH

Contribution

April 1, 2020

Employee Only N/A $187.50 $187.50 $187.50 $565.20

Employee + Dependent(s) N/A $375.00 $375.00 $375.00 $1,125.00

May 1, 2020

Employee Only N/A N/A $187.50 $187.50 $375.00

Employee + Dependent(s) N/A N/A $375.00 $375.00 $750.00

New Hires whose benefits are effective after October 1st or later will not receive an HCMH contribution into their HSA.

The chart below illustrates the maximum contribution you may make into your HSA as an employee after HCMH provides their standard contribution as well as the wellness contribution.

Maximum Allowable HSA Contribution IRS

Maximum Allowed after HCMH Contribution

Employee Only $3,550 $2,550

Employee + Children $7,100 $5,350

Employee + Spouse $7,100 $5,100

Employee + Family $7,100 $5,100

The HCMH contribution will be deposited within the first 15 days of the month that the quarter begins.

• Employees age 55 or older are eligible to make an additional catch-up contribution up to $1,000 for the calendar year.

• Employee is responsible to calculate and determine the maximum IRS HSA limits for their election. • You may make HSA contribution changes quarterly.

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How do I get reimbursed for my eligible expenses? The easiest way to use your HSA dollars is by using your HSA Debit Card at the time you incur an eligible expense. You can make online reimbursements to your personal account if needed. You must enter in your personal account information. Keep your receipts! You must be able to prove that you were reimbursing yourself for an eligible expense if you are audited. If you use your HSA funds for non-eligible expenses, you will be charged a 20% penalty tax (if under age 65) as well as federal income taxes. You can manage your HSA through www.askallegiance.com 24 hours a day, seven days a week. When you login, you will go to the Reimbursement Page to manage your HSA account. Allegiance Benefit Plan Management, Inc. provides helpful information about your HSA, including online calculators to help you add up your tax savings and see your HSA's possible future growth. For additional guidelines, please go online or call Health Care Bank 1-866-442-2472.

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HUGH CHATHAM WAY TO WELLNESS

Whether your goal is to have more energy, lose weight, manage stress, or improve your diet, Hugh Chatham Way to Wellness program can help you. We consider Wellness to be a vital part of our overall benefits program. As healthcare costs continue to rise, we strive to offer competitive health benefits to take care of you and your family. A successful wellness program is a win-win — it means our employees are improving their lives, and we are one step closer to managing rising health insurance costs.

Program Incentives By engaging and remaining compliant in the program you will have the opportunity to earn up to an additional $250 annually into your Health Savings Account for each employee and enrolled spouse. The incentive will be paid out in two installments, $125 in June and $125 in December, as long as you complete the following requirements:

1. Complete the Health Risk Assessment 2. Obtain required biometric screening 3. Meet with the Hugh Chatham Wellness Coach 4. Follow the care plan as defined by the Hugh

Chatham Wellness Coach

You must comply with items above by May 31, 2020 in order to receive the first incentive installment and by November 30, 2020 to receive the second installment. If items 1 and 2 are completed prior to May 31, 2020, you will not be required to complete them again to receive the second installment.

Disease Management Program Benefits • The Hugh Chatham Wellness Coach can assist

you in the effective management of your condition{s} • Coordination between your physician and Hugh

Chatham Wellness Coach • Educational programs and materials targeted

towards your needs, as well as your full range of general health education resources

• Better control over your medical condition • Fewer health complications • Reduced medical bills

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DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT Hugh Chatham’s Dependent Care Flexible Benefit Plan allows payroll contribution to a “flexible spending account (FSA) to pay eligible dependent care expenses with tax-free benefit dollars incurred during 2020.

Who is eligible to participate in the Dependent Care Spending Account? • Active Full Time / Part Time ( with a FTE of .5 or higher) employees who have a dependent: • Child or children under the age of 13 who attend(s) a child care facility so you and your spouse can maintain gainful employment; or • Child under the age of 13 for whom, due to a court order, you are responsible for child care services; or • Child, parent or spouse who is physically or mentally incapable of caring for him/herself and requires day care services so you can maintain gainful employment.

Dependent Care Spending Accounts For the Dependent Care Spending Account, you can submit expenses related to the care of your dependent child or children (up to age 13) toward those pre-tax dollars. An eligible provider of Dependent Care expense is one that can provide you with a Tax-ID number or a Social Security number for claim filing purposes. Also, both you and your spouse must be gainfully employed, or your spouse must be actively looking for employment. The annual limit you can put into your dependent care FSA is $5,000. If you are married and filing separately, the annual limit would be $2,500.

When are Dependent Care expenses reimbursed? Dependent care expenses are payable after your account balance can cover the actual expense. Any FSA funds not used for the 2020 plan year will not rollover and will be forfeited. Dependent Care FSA If your spouse works or if you are a single parent, how much do you pay for dependent care or babysitting service for children under age 13? (Expenses must be incurred as a result of employment and may not be paid to a dependent.)

Total Dependent Care Expense

$ Maximum $416.67/month ($5,000/year/household) Qualified Dependent Care Expenses

• Day Camp

• Nursery Schools

• Day Care Centers

• After-School Programs

Additional questions can be answered by Hugh Chatham’s benefit administrator or the plan service provider, Flores and Associates 1-800-532-3327.

Please visit www.flores247.com for a complete listing

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An easy & convenient way to see a doctor, fast.

Hugh Chatham Memorial Hospital offers all employees (even those not on the health plan) and dependents who are enrolled in the Hugh Chatham health plan, the unique benefit of accessing a doctor 24/7/365 via mobile app, web browser or phone call. This service is provided to save you time, money, and to get you feeling better faster in an easy and convenient way. The average wait time to see a doctor is fewer than 10 minutes.

When to Use RelyMD • When your primary care physician is closed • When you require care now & can't wait for an appointment • When considering an ER or Urgent Care visit for a non-emergency

What RelyMD Doctors Treat How Much Does It Cost?

• Sinus Infection • Sore Throat • Cold and Flu • Pink Eye • Fever • UTI • Vomiting and diarrhea • and more…

For all employees & any dependents enrolled in the Hugh Chatham health plan, visits are free.

• Ear Infections

Discounted visit rates

provided by

How to Use RelyMD • Visit RelyMD.com/hughchatham to register • When registering, enter Group ID "CHATHAM" to receive your

discounted rate

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DENTAL Hugh Chatham Memorial Hospital will continue to offer a dental program through Delta Dental for eligible employees who are .5 FTE or higher. Please visit the Delta Dental website at www.deltadentalnc.com to search for in-network dental providers, to obtain cost estimates for services and to review your dental claim information.

Benefit Coverage

Delta PPO Dentist Delta Premier Dentist Out-of-Network Benefits

Larger Dental Provider Network

Lower Provider Discounts

No Dental Provider Network

Claims are Reimbursed at 90th

UCR

Lifetime Deductible

Per Enrolled Member $100 $100 $100

Annual Maximum

Per Person/Family $1,300 $1,300 $1,300

Preventive 100% 100% 100%

Basic 100% 100% 80%

Major 50% 50% 50%

Orthodontia

Benefit Percentage 50% 50% 50%

Dependent Children Covered to age 26 Covered to age 26 Covered to age 26

Lifetime Maximum $1,200 $1,200 $1,200

Employee Contributions (Biweekly)

Dental PPO

Employee $16.87

Employee & Spouse $33.75

Employee & Child(ren) $40.50

Employee & Family $50.62

Procedure Benefit Frequency

Bitewings X-Rays One (1) every 12 months

Full X-Rays One (1) every 60 months

Fluoride One (1) every year under19

Smaller Provider Network

Higher Provider Discounts

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VISION – MATERIALS ONLY Your 2020 Vision Plan: Materials only Superior Vision will remain our vision provider for 2020. Superior offers cost savings to employees as well as deeper discounts. They have a network of providers that you can check at www.superiorvision.com. Superior’s customer service number is 1-800-507-3800.

Eligibility Employees with an FTE of .5 or higher are eligible for this coverage.

Copays Materials $10

Contact Lens Fitting (Standard & Specialty) $10

Maximum Member Out-of-Pocket (Single Vision) Scratch coat $13 Ultraviolet coat $15 Tints, solid or gradients $25 Anti-reflective coat $50 Polycarbonate $40 High Index 1.6 $55 Photochromics $80

Benefits In-Network Out-of-Network Frames $100 retail allowance Up to $50 retail Contact Lens Fitting (standard) Covered in full Not covered Contact Lens Fitting (specialty) $50 retail allowance Not covered Single Vision Lenses (standard) per pair Covered in full Up to $34 retail Bifocal Lenses (standard) per pair Covered in full Up to $48 retail Trifocal Lenses (standard) per pair Covered in full Up to $64 retail Progressive Lens Upgrade See description Up to $64 retail Contact Lenses (Contact lenses are in lieu of eyeglass lenses and frames benefit) $130 retail allowance Up to $100 retail

Frames 12 months Contact Lens Fitting 12 months Lenses 12 months Contact Lenses 12 months

Per Pay Period Rates Employee Only $2.89 Employee/Spouse $4.84 Employee/Child(ren) $6.48 Employee/Family $7.85

Discount Features Look for providers in the Provider Directory who accept discounts, as some do not; please verify their services and discounts (range from 10%-40%) prior to service as they vary. You may also find providers on the Superior Vision website.

Discounts on Covered Materials

• Frames: 20% off amount over allowance

• Lens options: 20% off retail

• Progressives: 20% off amount over retail lined trifocal lens, including lens options

• The following options have out-of-pocket maximums on standard (not premium, brand, or progressive) lenses.

Discounts on Non-Covered Exam and Materials

• Exams, frames, and prescription lenses: 30% off

retail

• Lens options, contacts, other prescription

materials: 20% off retail

• Disposable contact lenses: 10% off retail

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BASIC LIFE, AD&D AND SUPPLEMENTAL LIFE Group Term Life Benefits Hugh Chatham Memorial Hospital provides Basic Life and AD&D (Accidental Death and Dismemberment) benefits to eligible employees. The Life insurance benefit will be paid to your designated beneficiary in the event of death while covered under the plan. The AD&D benefit will be paid in the event of a loss of life or limb while covered under the plan.

As an employee you are automatically enrolled in the group basic term life and AD&D plan. To enroll in Supplemental Life coverage for you and your dependents you must complete the online benefits enrollment and complete any necessary Evidence of Insurability forms that may be required. Employees who currently have Supplemental Life can increase their coverage by an additional level of $10,000 up to the guaranteed issue amount without having to submit an EOI (Evidence of Insurability). If you elect coverage that requires an EOI please follow instructions on Web Benefits Design.

Newly eligible employees can elect up to the guaranteed issue without an EOI. Spouse must be at least 18 years old on the date of enrollment. If you and your spouse are employees only one of you may elect Supplemental Life coverage for your children. Coverage for dependent children ends at age 26. The Supplemental Life rate is based on your age at time of initial enrollment. Any future rate changes will be effective on your employer’s plan anniversary date (each January 1st) following the date you enter a new age bracket. The online enrollment system will provide you with the cost of coverage for your age and amount. If you would like a copy of the certificate of insurance for these coverages, a copy is available on Quick Click.

Group Term Life and AD&D Coverage You must be a Full-Time Employee to be eligible

Benefit Amount 1 times your base salary rounded to the next

higher $1,000

Benefit Maximum $250,000

Guaranteed Issue $250,000

Age Reduction

By 35% at age 65

By 60% at age 75

By 75% at age 80

Guaranteed Issue N/A

Supplemental Life Coverage To be eligible you must be a .5 FTE or higher

Employee

Benefit Amount Increments of $10,000

Benefit Maximum The lesser of $500,000 or 5 times your basic

annual earnings

Guaranteed Issue $100,000

Age Reduction

By 35% at age 65

By 60% at age 75

By 75% at age 80

Guaranteed Issue $100,000

Spouse

Benefit Amount Increments of $10,000

Benefit Maximum The lesser of $250,000 (cannot exceed 100% of

employee supplemental life election)

Guaranteed Issue $30,000

Child

Benefit Amount Increments of $2,500

Benefit Maximum The lesser of $10,000 (cannot exceed 100% of

the employee supplemental amount)

Guaranteed Issue All child benefit amounts are GI

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SHORT & LONG-TERM DISABILITY INSURANCE As part of your benefits package, HCMH provides full time employees with Long Term Disability at no cost to the employee. You may also purchase additional coverage by enrolling in Short Term Disability. These policies are administered by Cigna. Short Term Disability is a weekly income benefit to assists you with financial support when an injury or illness will prevent you from working for a shorter period of time. Long Term Disability is a monthly income benefit and assists you with financial support when an injury or illness occurs and prevents you from working for an extended period.

You are eligible for Short and Long Term Disability on the first day of the month on 30 days of continuous benefit eligible service. You may enroll during your initial eligibility enrollment period without having to provide an EOI. If you enroll after this initial eligibility period you will be required to complete the EOI forms to determine your eligibility. The cost for the STD plan is $.645 per $10 of benefit. The online enrollment system will assist you with the cost of the STD for your income level.

If you would like a copy of the certificate of insurance for these coverages, a copy is available on Quick Click.

Value Added Benefits Cigna Offers You Several Benefits At No Cost To You: ° Will Preparation: Cigna’s Will Center is available to you and your covered spouse seven days a week, 365 days a year. Once

registered on the site, you will have direct access to a Personal Estate Planning web page where you can create and maintain your personalized legal documents. You can follow an intuitive, interactive question and answer process to create state-specific legal documents tailored to your situation.

° Life Assistance Program: You and your family can use Cigna’s Life Assistance Program for answers, information and support for many of the questions and issues you face in your day-to-day life. With just one phone call or click of a mouse-you can start to gain perspective, peace of mind, and a renewed sense of possibility and purpose. Call 1-800-538-3543 or log onto www.cignabehavioral.com/cgi. There is unlimited access to online resources, 24 hour/365 day live phone access, and referrals for up to 3 free, face-to-face counseling visits for behavioral issues.

° Healthy rewards: You and your dependents can receive discounts on health programs and services that promote wellness such as fitness club memberships, weight management, alternative medicine, vitamins, health and wellness products. To access Healthy Rewards, go to cigna.com/rewards (password: savings) or call 1-800-258-3312.

Short Term Disability Coverage – Employee Paid (Employees with an FTE of .5 of higher)

Benefit Percentage 60%

Weekly Benefit Maximum Up to $1,000 per week

Maximum Period of

Payment

26 weeks (including the 2-week

elimination period)

Elimination Period

Sickness 14 Days

Accident 14 Days

Long Term Disability Coverage – Employer Paid (Full Time Employees Only)

Benefit Percentage 60%

Monthly Benefit Maximum Up to $7,000 per month

Maximum Period of

Payment

To age 65 of SSNRA (Social Security

Normal Retirement Age)

Elimination Period 180 Days

Minimum Benefit $100

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VOLUNTARY PLANS Voya will continue to be our provider for our Specified Disease (Critical Illness), accident and Hospital Indemnity Plans. Your coverage is guaranteed when you enroll.

Voya Compass Specified Disease Insurance

Voya Compass Specified Disease Insurance pays a lump-sum benefit if you are diagnosed with a covered disease or condition1. You can use this money however, you like, for example: to help pay for expenses not covered by your medical plan, lost wages, child care, travel, home health care costs or any of your regular household expenses. Voya Compass Specified Disease Insurance is a limited benefit policy. This is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act. During this open enrollment period, you may elect up to $20,000 for yourself and $10,000 for your spouse and children without having to answer any medical questions. If you enroll in Voya Compass Specified Disease Insurance coverage, you and your covered dependents will have access to the Wellness Benefit. The Wellness Benefit provides an annual benefit if you complete a health screening test, whether or not there were any out-of-pocket costs. This benefit is designed to encourage you to maintain a healthy lifestyle as the tests can help screen for a wide range of potential illnesses and diseases. Rates for Specified Disease are based on age and amount of coverage selected. This information is included within the benefit enrollment system.

Voya Compass Accident Insurance Accident insurance pays you benefits for specific injuries and events resulting from a covered accident.. You can use this money however you like, for example: deductibles, child care, housecleaning, groceries or utilities. Compass Accident Insurance is a limited benefit policy. This is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.

Rates per pay period: Employee $6.15

Employee & Spouse $9.99 Employee & Children $11.81

Family $15.65

Voya Compass Hospital Confinement Indemnity Insurance Hospital Confinement Indemnity Insurance pays a daily benefit if you have a covered stay in a hospital, critical care unit or rehabilitation facility1. You can use this money for any purpose you like, for example: to help pay for expenses not covered by your medical plan, lost wages, child care, travel, home health care costs or any of your regular household expenses. Compass Hospital Confinement Indemnity Insurance is a limited benefit policy. This is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act. There are no pre-existing condition restrictions.

Rates per pay period Employee $8.35

Employee + Spouse $16.97

Employee + Children $12.80

Family $21.42 1 See the product brochure, certificate of coverage and any applicable riders for the

definition of covered facilities, along with complete provisions, exclusions and limitations.

Insurance products issued by ReliaStar Life Insurance Company, a member of the Voya® family of

companies. Home and Administrative Office: 20 Washington Avenue South, Minneapolis, MN 55401.

Policy provisions and product availability may vary by state.

UNUM WHOLE LIFE

Why individual Whole Life Insurance coverage?

Whole Life Insurance is designed to provide a base of life insurance coverage for your lifetime. It offers you life insurance protection, tax-deferred cash accumulation (based on current tax laws), and cash value loan privileges – all in one policy.

The premium you pay is based on the death benefit you select and the optional riders you choose as well as your age and tobacco status. The insurance coverage, premium amounts, and cash value are guaranteed as long as you meet the required premium payments.

The chart below illustrates the difference between Term Life

and Whole Life Insurance

Term Life Insurance Whole Life Insurance

Only covered during the life of the policy Coverage for entire life

Less expensive than whole life for

comparable death benefit

Acquire cash value

You can only enroll in the Whole Life during open enrollment.

You may elect by calling the enrollment line at (877) 275-0016

21

EMPLOYEE ASSISTANCE PROGRAM (EAP) REACH EAP & Workplace Solutions (REACH) is proud to partner with your employer to provide integrated employee assistance program (EAP), Work- life, and Wellness services to help you and your family with interests and concerns ranging from significant life problems to everyday challenges. These services are prepaid by your employer at no cost to you and are very confidential. To help you gain and maintain balance in your home and work life, prevent further problems, and enhance your quality of life, we can help.

REACH OFFERS: • 24-hour access to services • Professional consultation in person or by phone • Work-life Services • Connections and referrals to additional supports and services as needed

REACH SERVICES ADDRESS: • job stress • family and parenting issues • depression • alcohol and drug abuse • financial worries • legal stressors • stress and anxiety • marital and relationship problems • grief and loss • other life stressors To schedule an EAP appointment or to get more information about your EAP benefits: Call toll-free 24/7: 800-950-3434 Email: info@reach-eap.com Visit our website: www.reach-eap.com

WEB-BASED SERVICES To help you make the time for what matters most, your Work-life service provides online access to a wide range of resources available by self- search for work and life topics of interest to you and your family including childcare, eldercare, and healthful living tips for all ages. Also available are monthly online seminars and a comprehensive library of health and wellness articles and self-assessments. Just log on with your company’s username and password, and navigate through articles, links, interactive content, financial calculators, and more.

To access, go to: http://reachworklife.powerflexweb.com

Username: reach-hcmh Password: reacheap

ROTH 401k Roth deferrals are deducted on an after tax basis, any growth of value is tax deferred, but distributions can be income tax free upon retirement. It should be noted that employees can elect both pretax and Roth contributions if they choose and are not limited to one or the other. Changes to deferral amounts or types can be made online at Netbenefits. com or by calling Fidelity directly.

22

401(k) This Plan is intended to be a participant-directed Plan as described in Section 404(c) of the Employee Retirement Income Security Act of 1974 (ERISA), which means that fiduciaries of the Plan are ordinarily relieved of liability for any losses under ERISA that are the direct and necessary result of investment instructions given by a participant or beneficiary. What follows is an introduction to the investment options you can choose for your plan account. You can spread your investments among several options to take advantage of what each has to offer and help balance different types of risk. Reviewing this information can help you understand and compare your options.

Stock values fluctuate in response to the activities of individual companies and general market and economic conditions. In general, bond prices rise when interest rates fall and vice versa. This effect is usually more pronounced for longer-term securities LLC or an affiliate.

This spectrum, with the exception of the Domestic Equity category, is based on Fidelity’s analysis of the general investment categories and not on the actual investment options and their holdings., which can change frequently. Investment options in the Domestic Equity category are based on the options’ Morningstar categories as of the most recent calendar quarter. Morningstar categories are based on a fund’s style as measured by its underlying portfolio holdings over the past three years and may change at any time. These style calculations do not represent the investment options’ objectives and do not predict the investment options’ future styles. Investment options are listed in alphabetical order within each investment category. Risk associated with the investment options may vary significantly within each category, and the relative risk of categories may change under certain conditions. For a complete discussion of risk associated with the mutual fund options, please read the prospectuses before making your investment choices. The spectrum does not represent actual or implied performance.

The 401(k) Plan provides our employees with a simple, cost effective way to save for retirement. The Plan provides the convenience of automatic payroll deduction and the power of tax deferred savings. All contributions and earnings are tax-deferred until withdrawn from the Plan. The Hospital provides even more incentive for you to save for your retirement by making a matching contribution on a portion of your contributions.

Eligibility All employees meet the following criteria: One (1) month of service and age 21.

Entry Dates Monthly after fulfilling one month of eligibility.

Auto-Enrollment Feature Eligible employees automatically enrolled at 4% when eligible.

Contribution Amount Changes Allowed Monthly

Employee Contributions May range from 1 to 90% of Compensation (please refer to full plan information for maximum allowable contributions). Your contribution will to be eligible for the Company Matching. Once you become eligible, you will not need to satisfy the 1,000 every year.

Catch-up Contributions and Contributions Limits Employees that are 50 or will be 50 by the end of the current calendar year will be automatically enrolled in the “catch-up contribution that allows an additional $6,000 each calendar year. (please refer to full plan information for maximum allowable contributions). The maximum contribution is $19,000 a year, unless your income is $270,000 or greater. Once your income has reached $275,000, contributions will need to cease.

Company Matching Contribution $.50 on $1.00 up to 4% of Contribution. Employees must be employed 1 year and have worked 1000 hours within a year (on their anniversary date) to be eligible for the Company Matching. Once you become eligible, you will not need to satisfy the 1,000 every year.

23

Employer Matching & Profit-Sharing Vesting Schedule

100%

75%

50%

25%

0% 0%

< 2 years Year 2 Year 3 Year 4 Year 5 Rollovers Permitted from Other Plans Employees are eligible to rollover balances from previous retirement plans. Please refer to full plan information for rules regarding permitted rollovers. Loan Provision: Plan permits you to take a loan from your account, which you repay through payroll deductions.

Distributions from the Plan: In-Service withdrawals available for Hardship reasons, and at age 59 1/2. At termination of employment or retirement, balances can be rolled to an IRA or another employer’s retirement plan. You will receive more detailed Plan information when you become eligible to enroll in the Plan. For a Summary Plan Description for the Plan, please contact the Human Resources Department.

Contact Information Fidelity website: www.netbenefits.com Fidelity Retirement Benefits Line: 1.800.294.4015 Financial Advisor Contact Information: Scott Graham, Susan Eisenman AXA Advisors, LLC 4000 Piedmont Parkway, Suite 205 High Point, NC 27265 336-405-8270

How do I access my account? You can access your account virtually at any time through NetBenefits. Log in to netbenefits.com and you will have access to your account information and retirement planning tools. You also can call the Retirement Benefits Line at 1.800.294.4015 between 8:30 a.m. and 8:30 p.m. ET on any business day* for more information on your account.

How do I change my investment options? You may request investment changes (exchanges) or redirect future contributions among investment options available to you any business day* online through Fidelity at netbenefits.com or by calling the Retirements Benefits Line at 1.800.294.4015.

*Available on days when the NYSE is open. It is important that you elect your Beneficiary when you enroll in the 401(k) program. If you are currently enrolled, and have not elected a beneficiary, you need to log into NetBenefits.com and provide that information.

The Fidelity Advisor Freedom Funds are represented on a separate investment spectrum because each fund (except the Fidelity Advisor Freedom Income fund) will gradually adjust its asset allocation to be more conservative as the fund approaches its target retirement date. Approximately ten to fifteen years after the target date, the asset allocation of each Freedom fund will match the allocation of the Freedom Income fund. The spectrum illustrates the relative risk and return of each fund as compared with the other funds in the Freedom family. This spectrum does not represent actual or implied performance.

The Advisor Freedom Funds are subject to the risks of their underlying funds, including the volatility of the financial markets in the U.S. and abroad, as well as the additional risks associated with investing in high yield, small-cap, and foreign securities. Principal invested is not guaranteed at any time, including at or after each fund’s target date.

Strategic Advisers, Inc., a subsidiary of FMR LLC., manages the Fidelity Advisor Freedom Funds.

Important Information: This document provides only a summary of the main features of Hugh Chatham Memorial Hospital, Inc. 401(k) Plan, and the Plan document will govern in the event of any discrepancy. This document is not a Summary Plan Description.

Unless otherwise noted, transaction requests confirmed after the close of the market, normally 4 p.m. Eastern time, or on weekends or holidays, will receive the next available closing prices.

The investment options available through the Plan reserve the right to modify or withdraw the exchange privilege.

This Plan is intended to be a participant-directed Plan as described in Section 404(c) of the Employee Retirement Income Security Act of 1974 (ERISA), which means that fiduciaries of the Plan are ordinarily relieved of liability for any losses under ERISA that are the direct and necessary result of investment instructions given by a participant or beneficiary.

The Fidelity Advisor Freedom Funds offer a blend of stocks, bonds and short- term investments within a single fund. The funds are designed for investors expecting to retire around the year indicated in each fund’s name. Consider an appropriate Fidelity Advisor Freedom Fund that matches your needs.

Non-Fidelity mutual funds are managed by non-Fidelity entities. Please consult the prospectus for more information. Class of shares may vary. Please consult your Summary Plan Description for the specific class of shares available through your Plan.

Fidelity Management & Research Company manages Fidelity Advisor mutual funds. All trademarks and service marks appearing herein are the property of FMR LLC or an affiliate. Not NCUA or NCUSIF insured. May lose value. No credit union guarantee.

Keep in mind that investing involves risk. The value of your investment will fluctuate over time, and you may gain or lose money.

An investment in a money market fund is not insured or guaranteed by the Federal Deposit Insurance Corporation or any other government agency. Although the fund seeks to preserve the value of your investment at $1.00 per share, it is possible to lose money by investing in the fund. Interest rate increases can cause the price of money market securities to decrease.

Before investing, consider the funds’ investment objectives, risks, charges, and expenses. Contact your investment professional for a prospectus or visit netbenefits.com for a Fidelity Advisor fund prospectus containing this information. Read it carefully before you make your investment choices.

NOT FDIC INSURED • MAY LOSE VALUE • NO BANK GUARANTEE

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EQUI-VEST 403(b) TSA A 403(b) Tax-Sheltered Annuity (TSA) is a tax-deferred retirement plan. EQUI-VEST®, a variable deferred annuity, offers you a way to help build and enhance your retirement savings. It also offers death benefit protection and a number of payout options. Your 403(b) TSA plan and EQUI-VEST® can be a lifelong resource as you save for retirement.

Market & Issue Ages Eligible employees of public schools, colleges and universities, hospitals and 501(c)(3) nonprofit organizations:

Ages 18 – 79

Investment Amounts Initial Minimum: $20

Contribution Limits1

• Maximum: $19,500 in 2020 or 100% of compensation, whichever is less. There is a salary cap of 265,000.

• Catch-Up: $6,000 in 2020 if you are at least age 50; this is in addition to the maximum amount shown above.

Investment Options An EQUI-VEST® account provides a wide variety of equity and guaranteed investment options, including options that offer one-step investing. Based on your retirement planning needs, you can select:

Asset Allocation Portfolios2

Invest according to your risk tolerance, with choices ranging from conservative to aggressive.

Target Date Allocation Portfolios2

Select a portfolio closest to your retirement date. These portfolios offer a one-step

Guaranteed Interest Option (GIO)3,4

Offers a guaranteed rate of interest and a guarantee of principal. The value of variable investment options within annuities will fluctuate and is subject to market risk, including the possible loss of principal. Contribution limits are indexed to inflation.

You may incur higher costs with these portfolios than if you were to invest directly in the underlying portfolios. Guarantees are based on the claims-paying ability of AXA Equitable Life Insurance Company. The GIO is part of AXA Equitable’s general account. AXA Equitable reserves the right to limit allocations to the GIO. No more than 25% of any transfer request and contribution can be allocated to the Guaranteed Interest Option (GIO). Therefore, we will not process any transfer requests and contribution that would result in more than 25% of your account value in the GIO. These transfer restrictions are currently waived in all states. We will notify you 45 days in advance if the transfer restrictions are reimposed.

Features are subject to availability and your employer’s plan.

Important Considerations Variable annuities are long-term financial products designed for retirement purposes. In essence, an annuity is a contractual agreement in which payment(s) are made to an insurance company, which agrees to pay out an income or a lump sum amount at a later date. There are fees and charges associated with variable annuities, which include, but are not limited to, mortality and expense risk charges, sales and surrender charges, administrative fees, and charges for optional benefits. For costs and complete details of coverage, speak to your financial professional. The variable investment portfolios offered in this contract will fluctuate in value and are subject to market risk, including loss of principal.

All guarantees described herein are subject to the claims paying ability of AXA Equitable Life Insurance Company. Guarantees do not apply to variable investment portfolios.

Because this EQUI-VEST® annuity contract would be used to fund a 403(b) TSA plan, you should be aware that such annuities do not provide tax-deferral benefits beyond those already provided by the Internal Revenue Code. Before purchasing, you should consider whether its features and benefits beyond tax deferral meet your needs and goals. You may also want to consider the relative features, benefits and costs of this annuity with any other investment that you may use in connection with your retirement plan or arrangement.

Certain types of contracts, features and benefits may not be available in all jurisdictions. This fact card does not cover all material provisions of the EQUI-VEST® contract. This fact card must be preceded or accompanied by a current applicable EQUI-VEST® prospectus and any applicable supplements, which contain detailed information about the EQUI-VEST® contract, including risks, charges, expenses, investment objectives, limitations and restrictions. You should carefully read the prospectus, and any prospectus supplements included in this kit, before purchasing a contract.

Features5 at No Additional Charge: (See prospectus for details)

• Special Dollar Cost Averaging • Loans

• Investment Simplifier • Systematic Withdrawal Option (SWO)

• Asset Rebalancing • Standard Death Benefitinvestment strategy that adjusts with you as you move through the phases of your life.

Your Own Asset Mix Choose from among all of our investment

options.

• Transfers among Investment Options (may be subject to restrictions)

• Beneficiary Continuation Option

1. Contribution limits are indexed to inflation. 2. You may incur higher costs with these portfolios than if you were to invest directly in the underlying portfolios. 3. Guarantees are based on the claims-paying ability of AXA Equitable Life Insurance Company. The GIO is part of AXA Equitable’s general account. AXA Equitable reserves the right to limit allocations to the GIO. 4. No more than 25% of any transfer request and contribution can be allocated to the Guaranteed Interest Option (GIO). Therefore, we will not process any transfer requests and contribution that would result in more than 25% of your account value in the GIO. These transfer restrictions are currently waived in all states. We will notify you 45 days in advance if the transfer restrictions are reimposed. 5. Features are subject to availability and your employer’s Please be advised that this document is not intended as legal or tax advice.

Accordingly, any tax information provided in this document is not intended or written to be used, and cannot be used, by any taxpayer for the purpose of avoiding penalties that may be imposed on the taxpayer. The tax information was written to support the promotion or marketing of the transaction(s) or matter(s) addressed, and you should seek advice based on your particular circumstances from an independent tax advisor. AXA Equitable Life Insurance Company and AXA Advisors, LLC do not provide tax or legal advice. Guarantees described herein are subject to the claims-paying ability of AXA Equitable Life Insurance Company. EQUI-VEST® is a registered service mark of AXA Equitable Life Insurance Company (AXA Equitable), New York, NY 10104. EQUI-VEST® is issued by AXA Equitable and distributed by an affiliate, AXA Advisors, LLC, New York, NY 10104. Contract form #s: 2006BASE-A, 2006BASE-B, 2006BASE-1A, 2006BASE-1B and any state variations ©2009 AXA Equitable Life Insurance Company. All rights reserved. 1290 Avenue of the Americas, New York, NY 10104, (212) 554-1234 Visit our Web site at www.axa.com

25

Summary of Employee Discount Programs

Program Discount/Benefit How to Obtain Cell Phone Discounts

AT&T Save up to 22% off on qualifying AT&T services. Reference: FAN 2000931

Visit your local AT&T store and bring proof of eligibility (employee badge or paystub).

Carolina West Wireless

Save up to 15% off on qualifying Carolina West Wireless access lines (excludes data buckets)

Visit your local CWW store and bring proof of eligibility (employee badge or paystub).

Sprint Save up to 22% discount off select regularly priced Sprint monthly data plans. Corporate ID: HCHPG_HCM-ZZZ

Use this code to claim your discount:

Call: 1-866-639-8354 Visit: www.sprint.com/storelocator

Verizon Wireless

Receive an employee discount up to 20% off. Discount applies to most voice and data plans with a monthly access fee of $34.99 or higher. Plus additional benefits.

Visit www.verizonwireless.com/discounts Call: 1-800-922-0204 Monday – Sunday, 6am-11pm Reference Profile Number: 661493

Entertainment Discounts

Biltmore House Discount on daytime admission tickets. Visit www.biltmore.com/hugh and enter promo

code: hugh.

Carowinds & Other Theme Parks

Discounted regular tickets for Carowinds & Other Theme Parks as well as discounts on other tickets & services.

How to Register: 1. Go to www.ticketsatwork.com/carowinds 2. Click on “Become a Member” 3. You will then be prompted to create an

account with your email address and company code “CAHUGH”

How To Purchase Tickets:

1. Visit www.ticketsatwork.com/carowinds then login using your email and password.

2. Place your order over the phone by calling customer service at 1.800.331.6483

Orders are taken over the phone Daily from 8:30am-12:00am

Dollywood Ticket discounts are available online. Visit: HCMH QuickClick for the ordering link. Wet’n Wild Emerald Pointe

Ticket discounts are available online. Visit: www.emeraldpointe.com Enter PROMO Code: HUGHCHATHAM19

Starmount Cinema V

$6.00 tickets for any movie at any time. Limited exceptions may apply.

Tickets may be purchased from the Hospital Cashier’s Office

Two Rivers Cinema

$6.00 tickets for any movie at any time. Limited exceptions may apply.

Tickets may be purchased from the Hospital Cashier’s Office

Ticket Monster Perks

Entertainment benefits platform that offers you exclusive discounts on hotels, sports, concerts, move and theme park tickets nationwide. Contact Customer Service: 1-866-217-4777 or email: service@ticketmonster.com

1. Go to www.ticketmonsterperks.com 2. Sign up & save $5 on your first order &

earn cash back with each purchase. 3. If prompted, enter your company ID:

Hugh Chatham. Wellness Discounts

Discount Pharmacy & Supplies at Hugh Chatham Memorial Hospital

Certain prescriptions for employee & dependents covered under the HCMH health plan. Filled at hospital cost plus a dispensing fee by Hugh Chatham Memorial Hospital Pharmacy. There are some supplies available for the employees to buy but it would be best if you contact Materials Management to see if the item you wish to purchase is an item available to sale.

Review Pharmacy Privileges – Policy 6.04 for complete details. Review Employee Purchases through Materials Management – Policy 8.28 for complete details.

Employee Fitness Program

Swimming, cardio equipment, strength training, fitness classes and personal training is available at our Aquatic & Wellness Center. Gym membership for employees and volunteers is free. Discounted fees are associated with personal training, fitness classes, and aquatics classes.

Located in the outpatient rehab department at 700 Chatham Medical Park Please contact Josh Vogler, Wellness Program Leader at ext 7468 for more information or to schedule an orientation

26

FTE

Accrued Hours Per Pay Period

Total Days

Total Hours

0.5 3.24 10.53 84.24

0.6 3.88 12.86 100.88

0.7 4.53 14.72 117.78

0.8 5.17 16.8 134.42

0.9 6.47 21 168

1.0 & 0.6 WE 6.47 21 168

Program Discount/Benefit How to Obtain Banking Discounts

BB&T Open a BB&T@Work checking account and receive an exclusive bundle of premium discounts and savings on BB&T products and services.

Enroll at a local BB&T financial center or online at BBT.com/atwork.

Members Credit Union Christmas Club

Christmas Club and Credit Union Convenient way to save for Christmas Shopping You elect the deduction amount that comes from your paycheck. The money goes directly to you Christmas Club account. Funds are distributed the first full week of November.

Visit the local Members Credit Union Branch at 827 N. Bridge to enroll. Employee deductions carry over automatically from year to year.

First National Bank

Eligibility for First National Bank- a valuable package of accounts, services, and special benefits.

Contact your local First National Bank

Wells Fargo Eligibility for Wells Fargo at Work program- a valuable package of accounts, services, and special benefits.

Contact any Wells Fargo. 336) 526-8233 or (336) 526-8216 Reference: WFAW ID- 024021

Childcare Discounts Rainbow Child Care Center

Preferred Partner discount up to 10% off your weekly tuition.

For more information visit: http://www.rainbowccc.com/hughchatham

Shopping Discounts

Collective Goods Twice a Year

Payroll deduction.

Uniform Sales Quarterly sales event. Shop and Go on the spot.

Payroll deduction. On-site at Hospital and Nursing Center.

Employee Discount Purchase Program for Computer Products

Special pricing for hardware and software. Option 1: If you have a Hugh Chatham email address -Create your personal account at www.zones.com/epp. Option 2: If you do not have a Hugh Chatham email address- Visit: http://www.zones.com/HughChathamEPP Contact Vaughn Adams at (800) 258-0882 Ext. 3887 with any questions.

HPG Membership Online Shopping

Shopping discounts on products and gift cards Visit http://values.corpshoppingco.com/screens.mvc?iaction=front and use the code: HPG

Sam’s Club Seasonal discount promotions with Sam’s club will be communicated when offers are available.

Watch HC QuickClick for membership drive and promotional information

Costco Seasonal discounts and promotions with Costco are available through membership drives throughout the year.

Watch HC QuickClick for membership drive and promotional information

Relocation/Moving & Storage Discounts Moving and Storage Discounts

HCMH hospital offers discounts with several companies that can assist you with moving and storage. HPG/CPG Contract/Vendor Agreement No.: HPG -3682 CPG - 2683

Contact David Church in Materials Mgmt @ 1- 336-527-7221 or Rachel Mascarenas with L& J Transportation Companies @ 1-919-423-3538

Please note all discount programs are subject to change at any time. The most current programs are listed on HC QuickClick under the employee portal, employee benefits page, under additional benefits

PAID TIME OFF (PTO) Paid Time Off (PTO) is to be used for: Vacation Time, Sick Time, and Personal Time. Hours earned are based on your FTE and years of benefit eligible service. Refer to PTO policy 6.03 for more details. Total Number of Hours Accrued Per Year

Years of Experience

168 hrs 0-4 yrs

208 hrs 5-9 yrs

240 hrs 10-14 yrs

248 hrs 15+ yrs

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IMPORTANT CONTACTSANT CONTACTSHave Questions? Need Help? Hugh Chatham Memorial Hospital is excited to offer

access to the USI Benefit Resource Center (BRC), which

is designed to provide you with a responsive, consistent,

hands-on approach to benefit inquiries. Benefit

Specialists are available to research and solve elevated

claims, unresolved eligibility problems, and any other

benefit issues with which you might need assistance. The

Benefit Specialists are experienced professionals and

their primary responsibility is to assist you.

The Specialists in the Benefit Resource Center are

available Monday through Friday 8:00am to 5:00pm

Eastern & Central Standard Time at 855-874-0835 or via

e-mail at BRCSouth@usi.com. If you need assistance

outside of regular business hours, please leave a

message and one of the Benefit Specialists will promptly

return your call or e-mail message by the end of the

following business day.

Coverage CARRIER PHONE NUMBER WEBSITE

Human Resources Hugh Chatham Memorial Hospital (336) 527-7660

Medical Allegiance Benefit Plan

Management, Inc. (800) 877-1122 www.askallegiance.com

Pharmacy Benefit RX Benefits/Express Scripts 1-800-334-8134 www.express-scripts.com

Dental Delta Dental of North Carolina (800) 662-8856 www.DeltaDentalNC.com

Vision Superior Vision (800) 507-3800 www.superiorvision.com

Group Term Life/AD&D

Supplemental Life

Short Term Disability (STD)

Long Term Disability (LTD)

Voluntary Life

Cigna Health and Life Insurance

Company (866) 562-8421 www.cigna.com

Dependent Care FSA Flores & Associates (800) 532-3327

www.flores247.com

Health Savings Account (HSA) New Healthcare Bank (866) 442-2472 www.askallegiance.com

Telemedicine RelyMD (855) 384-6688 www.relymd.com/hughchatham

Accident

Voluntary Critical Illness

Specified Diseases

Hospital Indemnity

Voya Financial (877) 236-7564 www.voya.com

401(k) & 401(k) Roth Fidelity (800) 294-4015 www.netbenefits.com

403(b) & 457b Equi-Vest (336) 812-8001 www.axa.com

BRC (Benefit Resource Center) USI (855) 874-0835 BRCSouth@usi.com

This brochure summarizes the benefit plans that are available to Hugh Chatham Memorial Hospital eligible employees and their dependents. Official plan documents, policies and certificates of insurance contain the details, conditions, maximum benefit levels and restrictions on benefits. These documents govern your benefits program. If there is any conflict, the official documents prevail. These documents are available upon request through the Human Resources Department. Information provided in this brochure is not a guarantee of benefits.

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IMPORTANT LEGAL NOTICES AFFECTING YOUR HEALTH PLAN COVERAGE If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

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

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. Please see your Plan Document for deductibles and coinsurance applicable to these benefits. If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. Further, if you decline enrollment for yourself or eligible dependents (including your spouse) while Medicaid coverage or coverage under a State CHIP program is in effect, you may be able to enroll yourself and your dependents in this plan if:

° coverage is lost under Medicaid or a State CHIP program; or ° you or your dependents become eligible for a premium assistance subsidy from the State.

In either case, you must request enrollment 60 Days from the loss of coverage or the date you become eligible for premium assistance. To request special enrollment or obtain more information, contact person listed at the end of this summary.

NOTICE OF SPECIAL ENROLLMENT RIGHTS

THE WOMEN’S HEALTH CANCER RIGHTS ACT OF 1998 (WHCRA)

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Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact us at 336-527-7661 and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status. CONTACT INFORMATION Questions regarding any of this information can be directed to: Kathy Poteate 180 Parkwood Drive Elkin, North Carolina 28621 336-527-7661 kpoteate@hughchatham.org

CONTACT INFORMATION

WELLNESS PROGRAM DISCLOSURE

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Your Information. Your Rights. Our Responsibilities. Recipients of the notice are encouraged to read the entire notice. Contact information for questions or complaints is

available at the end of the notice. Your Rights You have the right to:

• Get a copy of your health and claims records • Correct your health and claims records • Request confidential communication • Ask us to limit the information we share • Get a list of those with whom we’ve shared your

information • Get a copy of this privacy notice • Choose someone to act for you • File a complaint if you believe your privacy rights

have been violated Your Choices You have some choices in the way that we use and share information as we:

• Answer coverage questions from your family and friends

• Provide disaster relief • Market our services and sell your information

Our Uses and Disclosures We may use and share your information as we:

• Help manage the health care treatment you receive

• Run our organization • Pay for your health services • Administer your health plan • Help with public health and safety issues • Do research • Comply with the law • Respond to organ and tissue donation requests

and work with a medical examiner or funeral director

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

• Respond to lawsuits and legal actions Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get a copy of health and claims records

• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct health and claims records

• You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing, usually within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations.

• We are not required to agree to your request. Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for up to six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

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File a complaint if you feel your rights are violated • You can complain if you feel we have violated

your rights by contacting us using the information at the end of this notice.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in payment for your care

• Share information in a disaster relief situation If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. • In these cases we never share your information

unless you give us written permission: Marketing purposes Sale of your information Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Help manage the health care treatment you receive We can use your health information and share it with professionals who are treating you. Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services. Pay for your health services We can use and disclose your health information as we pay for your health services. Example: We share information about you with your dental plan to coordinate payment for your dental work. Administer your plan We may disclose your health information to your health plan sponsor for plan administration.

Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge. Run our organization

• We can use and disclose your information to run our organization and contact you when necessary.

• We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.

Example: We use health information about you to develop better services for you. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues We can share health information about you for certain situations such as:

• Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic

violence • Preventing or reducing a serious threat to

anyone’s health or safety Do research We can use or share your information for health research. Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Respond to organ and tissue donation requests and work with a medical examiner or funeral director

• We can share health information about you with organ procurement organizations.

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you:

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

enforcement official

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• With health oversight agencies for activities authorized by law

• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site (if applicable), and we will mail a copy to you.

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Important Notice from Hugh Chatham Memorial Hospital About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Hugh 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. Hugh Chatham Memorial Hospital has determined that the prescription drug coverage offered by the Hugh

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

When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Hugh Chatham Memorial Hospital coverage will not be affected. If you do decide to join a Medicare drug plan and drop your current Hugh Chatham Memorial Hospital coverage, be aware that you and your dependents will 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 Hugh Chatham Memorial Hospital and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Hugh Chatham Memorial Hospital changes. You also may request a copy of this notice at any time.

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

• Visit www.medicare.gov • Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare &

You” handbook for their telephone number) for personalized help • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

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

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: October, 2019 Name of Entity/Sender: Hugh Chatham Memorial Hospital Contact--Position/Office: Kathy Poteate, Human Resources Manager Address: 180 Parkwood Drive, Elkin, NC 28621 Phone Number: 336-527-7661

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Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2019. Contact your State for more information on eligibility –

ALABAMA – Medicaid FLORIDA – Medicaid

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

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

ALASKA – Medicaid GEORGIA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: Medicaid www.medicaid.georgia.gov - Click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507

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

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

IOWA – Medicaid KANSAS – Medicaid Website: http://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp Phone: 1-888-346-9562

Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512

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KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid

Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 Hotline: NH Medicaid Service Center at 1-888-901-4999

LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

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

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

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

MASSACHUSETTS – Medicaid and CHIP NORTH CAROLINA – Medicaid Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-462-1120

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

MINNESOTA – Medicaid NORTH DAKOTA – Medicaid Website: http://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/medical-assistance.jsp Phone: 1-800-657-3739

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

MISSOURI – Medicaid OKLAHOMA – Medicaid and CHIP Website: https://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

MONTANA – Medicaid OREGON – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

NEBRASKA – Medicaid PENNSYLVANIA – Medicaid Website: http://www.ACCESSNebraska.ne.gov Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-1178

Website:http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htm Phone: 1-800-692-7462

NEVADA – Medicaid RHODE ISLAND – Medicaid Medicaid Website: https://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900

Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347

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To see if any other states have added a premium assistance program since January 31, 2019, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137

SOUTH CAROLINA – Medicaid VIRGINIA – Medicaid and CHIP Website: https://www.scdhhs.gov Phone: 1-888-549-0820

Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program Phone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid WEST VIRGINIA – Medicaid Website: http://gethipptexas.com/ Phone: 1-800-440-0493

Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002

VERMONT– Medicaid WYOMING – Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531

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NOTES

39

NOTES

40

This guide describes benefits offered through Hugh Chatham Memorial Hospital. In the event of any discrepancy between what is written here in the plan document and insurance certificates, the plan document and insurance certificates will govern. Changes in the tax laws or other requirements might cause changes in the plan. Hugh Chatham Memorial Hospital reserves the right to amend or terminate the plan or any benefits under the plan at any time.

While every effort has been made to be as accurate as possible in developing the enclosed information, the official plan documents prevail in all cases. This is not a legal document. It is a brief summary of benefits and is no considered “Evidence of Coverage.” Please refer to the policy/plan documents for a complete description of the controlling terms, coverage, exclusions, limitations, and conditions of coverage. In case of any discrepancy between the information and the policy/plan documents, the policy/plan documents will prevail.

Hugh Chatham Memorial Hospital reserves the right to terminate, suspend, withdraw, or modify the benefits described in the policy/plan documents in whole or in parts, at any time. No statement in this or any other document and no oral representation should be construed as a waiver of this right. This summary is the confidential property of Hugh Chatham Memorial Hospital.