CARS BENFIT SNAPSHOTVersion Updated: 09/11/2018 Print Package: HIOS ID (Enrollment Code) 78124NY0980025-00 (SMT1) Plan Name: SimplyBlue Plus Platinum 2 Rating Region: Syracuse Rate

*Full Time Hired After 7/31/2016

CARS BENFIT SNAPSHOT *For Full-Time Employees

Paid Time Off (PTO)

CARS’ provides Paid Time Off (PTO) benefits to full time staff. Accrual of PTO is based on years of service and job classifications as follows: Non-Exempt Staff:

• 0-3 years = 8.75 hours per month


• 6+ years = 15.00 hours per month Exempt Staff:


• 2+ years = 15.00 hours per month

Holiday Time

CARS’ offers ten (10) paid Holidays per year in accordance with the schedule established by the CARS Management Team. Holiday pay is limited to 7 hours per holiday. Staff working the designated agency holidays will be compensated at “time and one-half”. In addition, they will still be able to take another paid day off for the holiday.

Health Insurance

CARS’ sponsors a “platinum” group health insurance plan through Excellus Blue Cross Blue Shield of Central New York. CARS’ pays for a portion of the premium based on the employee’s length of service and employment. Employees are eligible to enroll the 1st day of the month after their hire date. If you choose not to enroll, you will only be allowed to enroll during our open enrollment period in late November for coverage beginning the 1st of the new year unless you experience a qualifying life event. Premiums can be deducted on a per-tax bais if the employee chooses to particiate in the Premium Only Plan outlined below. A detailed plan summary and premium rate sheet is available upon request.

Dental Insurance

CARS’ sponsors a “platinum” group health insurance plan through Excellus Blue Cross Blue Shield of Central New York. CARS’ pays for a portion of the premium based on the employee’s length of service and employment. Employees are eligible to enroll the 1st day of the month after their hire date. If you choose not to enroll, you will only be allowed to enroll during our open enrollment period in late November for coverage beginning the 1st of the new year unless the employee experiences a qualifying life event. Premiums can be deducted on a per-tax basis if the employee chooses to participate in the Premium Only Plan outlined below. A detailed plan summary and premium rate sheet is available upon request.


Premium Only Plan

Employees can choose to have health and dental insurance premiums withheld from pay on a pre-tax basis. Estimated savings from utilizing this plan are approximately 28% of the total premium.

Life Insurance

CARS’ sponsors a group life insurance plan that offers $100,000.00 of term life insurance coverage. Employees are eligible to enroll the 1st day of the month after their hire date. If the employee declines enrollment at the time of hire, and wants to enroll at a later date, the employee’s application for enrollment will undergo medical underwriting by the insurance carrier. This means the employee will be asked to provide specific medical information to the carrier and the employee may be refused participation in the plan. Premiums are $2.50 per payroll period, deducted from pay on an after-tax basis. In accordance with IRS guidelines, the cost of life insurance provided by an employer in excess of $50,000.00 is taxable to the employee. However, the taxable portion is reduced by total premiums paid by the employee. This additional tax withholding is included on a payroll check during the month of December each year the employee is enrolled in the plan.

Enhance NYS Disability

NYS requires employers to carry disability insurance on its employees to provide a cash benefit in the event an employee becomes disabled as a result of a non-work-related accident, injury or illness. The minimum requirement for employers is to provide benefits of 50% of average weekly wages with a maximum benefit of $170 per week for up to 26 weeks. CARS’ provides an Enhanced NYS Disability policy for its employees that provides a benefit of 60% of average weekly wages with a maximum benefit of $250 per week for up to 26 weeks. CARS’ provides Enhanced NYS Disability coverage for its employees at no charge. Coverage begins with the first day of employment.

Long-Term Disability

CARS’ sponsors a long-Term Disability plan that provides cash benefits after an employee has been disabled for at least 6 months (when coverage under the Enhanced NYS Disability policy has reached the maximum allowed). Employees are eligible to enroll the 1st day of the month after their hire date. Premiums are $2.50 per payroll period, deducted from pay on an after-tax basis. If the employee declines enrollment at the time of hire, and wants to enroll at a later date, the employee’s application for enrollment will undergo medical underwriting by the insurance carrier. This means the employee will be asked to provide specific medical information to the carrier and the employee may be refused participation in the plan.


401K Retirement Plan

CARS’ sponsors a 401 (k) retirement plan administered by Benefit Plans Administrative Services (BPAS). Employees may contribute to the plan on a pre-tax basis beginning with the first day of employment. *CARS’ provides a match of all employee funds invested in the plan after completion of one year of service that consists of at least 1000 hours. Employees must be at least 21 years of age to receive the matching contribution. Matching contributions by CARS are made according to a schedule that is based on years of service and employment classification.

Non-Exempt *1-2 years 30%

3-5 years 40%

5+ years 50%

Exempt *1-2 years 50%

3-5 years 60%

5+ years 70%

Employee Assistance Program

CARS’ provides an Employee Assistance Program to its staff members through Family and Children Services of Ithaca. The EAP offers (6) six confidential counseling sessions to help with difficult situations. This benefit is provided free of charge and there is no waiting period for eligibility. EAP services are available by calling an intake coordinator at 1-607-273-7494. Please let the intake coordinator know you are a staff member at CARS.

Medical Flexible Spending Plan

CARS’ sponsors a Medial Flexible Spending Plan (FSA) to allow employees to set aside funds on a pre-tax basis to cover expenses not cover by medical insurances. The maximum amount allowed under IRS regulations is $2,700.00 per year. CARS’ makes a $250.00 contribution to the FSA on behalf of the employee. The full contribution occurs on January 1st of each year. For employees hired after January 1st, they will receive a pro-rated contribution on the 1st of the month after their hire and if they sign up for the FSA plan.

Family and Medical Leave

CARS’ provides Family and Medical Leave (FML) for employees who have worked for CARS for at least 12-months and have worked at least 1,250 hours in the 12-month period. A maximum of 12 weeks FML is available when there is a qualifying event, such as:

1) A birth, adoption or foster care placement of a child. 2) The care of a son, daughter, spouse, parent or domestic partner with a

serious health condition. 3) The employee’s own serious health condition.

See Section 601 of the Personnel Manual for a complete description of this benefit.


Paid Family Leave

In accordance with the New York State Paid Family Leave Program (PFL), CARS’ provides eligible employees with job-protected, paid leave to bond with a new child, care for a loved one with a serious health condition or to help relieve family pressures when someone is called to active military service. To be eligible for New York State Paid Family Leave, employees must either:

• Regularly work 20 or more hours per week for at least 26 consecutive weeks; or

• Work less than 20 hours per week and have worked at least 175 days in a 52-week period (the number of hours worked for each day is not relevant).

If an employee is eligible, PFL offers the following benefit -

Effective Date

Maximum Leave Duration

Monetary Benefit

1/1/2019 10 Weeks 55% of the employee’s average weekly wage or 55% of the state average weekly wage, whichever is less



See Section 601 of the Personnel Manual for a complete description of this benefit.

Bereavement Leave

CARS’ provides up to five (5) days of bereavement leave to attend the funeral, calling services and/or take care of personal matters related to the death of a member of your immediate family. Immediate family is defined as a parent, spouse, child, spouse's child by a former marriage, brother, sister, grandparents or spouse's parents or domestic partner.

XXX See Rate ScheduleXXX See Rate ScheduleXXX See Rate ScheduleXXX See Rate ScheduleXXX See Rate Schedule

Quote Effective: 01/01/2019 - 03/31/2019

Version Updated: 09/11/2018

Print Package: HIOS ID (Enrollment Code) 78124NY0980025-00 (SMT1)

Plan Name: SimplyBlue Plus Platinum 2

Rating Region: Syracuse

Rate

For the Benefits described in the Agreement, the Plan will charge and Group will pay the following premium rates:

Single $843.92

Subscriber & Spouse $1,687.84

Subscriber & Child(ren) $1,434.66

Family $2,405.17

Dependent Coverage To Age 26, Pediatric Dental Coverage Yes, Domestic Partner Coverage Yes, Family Planning Coverage Yes

Rates quoted herein are subject to change due to our implementation of the provisions of the Federal Patient Protection and Affordable Care Act.

The Sales Representative providing this quote is a New York State licensed insurance producer employed by Excellus Health Plan. The individual represents Excellus Health Plan in this transaction and will be compensated by Excellus Health Plan in part based on this sale. Theamount of compensation is based on a number of factors, including the contract selected and the volume of sales. You may request information about the expected compensation from your Sales Representative.

*The NYS Department of Financial Services has approved our rate filing for quarterly community rates. All Rates will be considered to be on a 12 month period from the effective date of coverage unless otherwise instructed by Excellus Health Plan. The aboverates are effective for the Initial Term of the Agreement. Rates for any Renewal Term will be provided to Group in a rate renewal notice.

Please complete this section if you have selected a plan that does not include pediatric dental coverage. A). Have you obtained dental coverage, not offered by Excellus BCBS, that provides essential pediatric dental benefits through a NY State of Health certified dental plan? Yes No B.) If you answered 'yes', please provide the name of the company issuing the essential pediatric dental coverage. __________________________________________If you answered 'no' please be aware the ACA requires essential pediatric dental coverage.

Application

Summary of Benefits & Coverage

Summary of Benefits and Coverage (SBC) for this product has been received. Group is responsible for distributing the SBC to all eligible employees in accordance with PPACA requirements.

Signature: __________________________________ Title: Date:

Group Name: Total Employees: Total Eligible:

Coverage Effective Date:

Broker:

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http://compare.excellusbcbs.com/bod/applicationhios.php?packageid=78124NY0980025-00&segment=small&enrollmentcode=SMT1&planname=SimplyBlue Plus Platinum 2&applicationyear=2019

http://excellusbcbs.com/wps/portal/xl/poc?uri=sbc:PlanId=78124NY0980025-00

SimplyBlue Plus Platinum 2

Plan Overview

Plan ID 78124NY0980025-00 (SMT1)

Plan Name SimplyBlue Plus Platinum 2

Aggregation Design Individual Aggregation

Plan Highlights Predictable out-of-pocket costs without a deductible, includes ExerciseRewards.

Plan Type Copay

HSA Eligible No

Quote Effective 01/01/2019 - 03/31/2019

Plan features

Primary Care Physician(PCP)

Not Required

Referrals Not Required

Out of network benefits Covered at 80%, subject to the deductible

Out of area benefits Coverage provided worldwide through our BlueCard® Network

Student/Dependentcoverage

Qualified dependents are covered to age 26

Domestic partner Covered

Wellness Incentives ExerciseRewards® receive $600 a year toward qualified fitness facility dues and/or fitness classes and save on Gym memberships with Active&Fit Direct™.

Plan cost-sharing highlights

Plan cost-sharinghighlights

In-Network Out-of-Network

Primary Care Office Visit $15 copay per visit Covered at 80%, subject to the deductible

Specialist Office Visit $25 copay per visit Covered at 80%, subject to the deductible

Coinsurance None Covered at 80%

Deductible None Out-of-Network: $500 Individual / $1,000 Family

Out of pocket maximum In-Network: $6,350 Individual / $12,700 Family Out-of-Network: $6,350 Individual / $12,700 Family

Lifetime maximum None None

Plan Benefits

Preventive HealthcareServices


Well child visits Covered In Full Covered at 80%, subject to the deductible

Adult routine physicalexams

Covered In Full Covered at 80%, subject to the deductible

+Adult immunizations Covered In Full Covered at 80%, subject to the deductible

+Mammography Covered In Full Covered at 80%, subject to the deductible

+Pap smear Covered In Full Covered at 80%, subject to the deductible

Routine GYN Exam Covered In Full Covered at 80%, subject to the deductible

+Prostate cancerscreening

Covered In Full Covered at 80%, subject to the deductible

+Colonoscopy Preventive screenings covered in full Covered at 80%, subject to the deductible

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+Family Planning Services Covered in full Covered at 80%, subject to the deductible

Physician OfficeServices


Diagnostic office visits $15 PCP copay; $25 Specialist copay per visit Covered at 80%, subject to the deductible

Telemedicine Visits $15 PCP copay; $25 Specialist copay per visit. MDLive Provider: $10 copay per visit Covered at 80%, subject to the deductible

Diagnostic x-rays $25 copay per visit Covered at 80%, subject to the deductible

Advanced ImagingServices

$100 copay per visit Covered at 80%, subject to the deductible

Diagnostic laboratory andpathology


Allergy tests $15 PCP copay; $25 Specialist copay per visit Covered at 80%, subject to the deductible

Allergy injections $15 PCP copay; $25 Specialist copay per visit Covered at 80%, subject to the deductible

Chemotherapy $15 copay per visit Covered at 80%, subject to the deductible

Radiation therapy $25 copay per visit Covered at 80%, subject to the deductible

Maternity Services In-Network Out-of-Network

Prenatal care Covered in full (Cost share may apply to ultrasounds, lab work and sick visits) Covered at 80%, subject to the deductible per admission

Hospital care for mom(including delivery)

Subject to $250 copay per admission Covered at 80%, per admission, subject to the deductible

Newborn nursery care Covered In Full Covered at 80%, per admission, subject to the deductible

Prescription Drug In-Network Out-of-Network

Prescription DrugCoverage

$5/$30/$50 Not Covered

Inpatient HospitalBenefits


Hospital benefits Subject to $250 copay per admission for unlimited days Covered at 80%, per admission for unlimited days, subject to the deductible

Physician visits in thehospital

Covered In Full Covered at 80%, subject to the deductible per admission

Inpatient physicalrehabilitation

Subject to $250 copay per admission for up to 60 days per contract year Covered at 80%, per admission for up to 60 days per contract year, subject to the deductible

Surgery Covered In Full Covered at 80%, subject to the deductible per admission

Anesthesia Covered In Full Covered at 80%, subject to the deductible per admission

Emergency Care In-Network Out-of-Network

Emergency room care $150 copay per visit $150 copay per visit

Freestanding urgent carecenter


Ambulance $150 copay $150 copay

Outpatient HospitalBenefits


Diagnostic x-rays $25 copay per visit Covered at 80%, subject to the deductible

Advanced ImagingServices


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Diagnostic laboratory andpathology


Surgical Care Facility Fee $150 copay per visit Covered at 80%, subject to the deductible

Chemotherapy $15 copay per visit Covered at 80%, subject to the deductible

Radiation Therapy $25 copay per visit Covered at 80%, subject to the deductible

Mental Health andSubstance Use


Inpatient mental healthcare

Subject to $250 copay per admission for unlimited days Covered at 80%, per admission for unlimited days, subject to the deductible

Outpatient mental healthcare


Inpatient substance use Subject to $250 copay per admission for unlimited days Covered at 80%, per admission for unlimited days, subject to the deductible

Outpatient substance use $25 copay per visit Covered at 80%, subject to the deductible

Other Services In-Network Out-of-Network

Diabetic drugs, insulin, andsupplies

$15 copay per 30 day supply Covered at 80%, subject to the deductible

Skilled nursing facility Subject to $250 copay per admission for up to 200 days per year Covered at 80%, per admission for up to 200 days per year, subject to the deductible

Home care $15 copay per visit for 40 visits per year Covered at 80%, for up to 40 visits per year, subject to the deductible

Hospice Subject to $250 copay per admission for up to 210 days per year Covered at 80%, for up to 210 days per year, subject to the deductible

Outpatient therapy $25 per visit for physical, speech and occupational therapy for up to 60 visits per contract year Covered at 80%, subject to the deductible for physical, speech and occupational therapy for up to 60visits per contract year

Durable medicalequipment

Covered at 50% Covered at 50%, subject to the deductible

External prosthetics Covered at 50% Covered at 50%, subject to the deductible

Chiropractic $25 copay per visit Covered at 80%, subject to the deductible

Acupuncture Not Covered Not Covered

Hearing Aids Covered at 50% for a single purchase once every 3 years Covered at 50%, subject to the deductible for a single purchase once every 3 years

Vision Benefits In-Network Out-of-Network

Adult Routine Vision Exam $25 copay per visit for one routine exam every year Covered at 80% for one routine exam every year, subject to the deductible

Adult Diagnostic Vision $25 copay per visit Covered at 80%, subject to the deductible

Adult Eyewear Eyewear Reimbursement of $60 per year Eyewear Reimbursement of $60 per year

Pediatric Routine VisionExam

$25 copay per visit for one routine exam every year Covered at 80% for one routine exam every year, subject to the deductible

Pediatric Eyewear Covered at 50% for one purchase per plan year Covered at 50%, subject to the deductible for one purchase per plan year

Dental Benefits In-Network Out-of-Network

Adult Dental Care Not Covered Not Covered

Pediatric Dental:Preventative & Routine

Preventive covered at 100%. Routine covered at 80% Preventive covered at 100%, subject to balance billng. Routine covered at 80%,subject to thedeductible and balance billing

Pediatric Major DentalCare & Medical Ortho

Covered at 50% Covered at 50%, subject to the deductible and balance billing

Accidental Dental - $150 copay per visit for accidental injury to sound, natural teeth and for care due to congenital disease Covered at 80% for accidental injury to sound, natural teeth and for care due to congenital disease or

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Outpatient Surgical or anomaly anomaly, subject to the deductible

This is not a contract. It is intended to highlight the coverage of this program. Benefits are determined by the terms of the contract. All benefits are subject to medical necessity. All day and visit limits are combined limits for both in and out of network benefit. +Preventive Services coverage required by theFederal Patient Protection and Affordable Care Act are not quoted herein. Please refer to the United States Preventive Services Task Force list of items and services rated "A" or "B" that are covered pursuant to the Federal Patient Protection and Affordable Care Act requirements.

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CMS Form 10182‐CC Updated April 1, 2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850.

1

Important Notice from Ithaca Alpha House Center, Inc. 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 Ithaca Alpha House Center, Inc. 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 thiscoverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO orPPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level ofcoverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. Ithaca Alpha House Center, Inc. has determined that the prescription drug coverage offered by Excellus BlueCross Blue Shield is, on average for all plan participants, expected to pay out as much as standard Medicareprescription drug coverage pays and is therefore considered Creditable Coverage. Because your existingcoverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if youlater 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 Ithaca Alpha House Center, Inc. coverage will be affected. See pages 7- 9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance (available at http://www.cms.hhs.gov/CreditableCoverage), which outlines the prescription drug plan provisions and options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D.

If you do decide to join a Medicare drug plan and drop your current Ithaca Alpha House Center, Inc. coverage, be aware that you and your dependents may not be able to get this coverage back. To confirm, check with your Human Resources department.

CMS Form 10182‐CC Updated April 1, 2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850.

2

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 Ithaca Alpha House Center, Inc. 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 Ithaca Alpha House Center, Inc. changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage: Visit 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: September 22, 2015 Name of Entity/Sender: Ithaca Alpha House Center, Inc.-Susan Oaks

Address: P. O. Box 724, Trumansburg, NY 14886 Contact Information: [email protected]

New Health Insurance Marketplace Coverage Options and Your Health Coverage

Form Approved OMB No.

PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the HealthInsurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employmentbased health coverage offered by your employer.

What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The

Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible

for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance

coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or

offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on

your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible

for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be

eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does

not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your

employer that would cover you (and not any other members of your family) is more than 9.5% of your household

income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the

Affordable Care Act, you may be eligible for a tax credit.1

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your

employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer

contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for

Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-

tax basis.

How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or

contact Susan Oaks, CARS’ Chief Financial Officer @ (607) 387-5535 X14 or [email protected].

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the

Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health

insurance coverage and contact information for a Health Insurance Marketplace in your area.

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered

by the plan is no less than 60 percent of such costs.

Health Insurance Marketplace Coverage Options

PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an

application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.

1. Employer nameIthaca Alpha House Center, Inc. DBA Cayuga Addiction Recovery Services

2. Employer Identification Number (EIN)16-0991369

3. Employer addressPO Box 724

4. Employer phone number(607)391-1022

5. CityTrumansburg

6. StateNY

7. ZIP code14886

8. Who can we contact about employee health coverage at this job?Lydia Wickham, Director of Human Resources

9. Phone number (if different from above) 10. Email [email protected]

Here is some basic information about health coverage offered by this employer:

• As your employer, we offer a health plan to:

All employees

Some employees

Eligible employees are: Employees who have completed 90 days of full time employment

• With respect to dependents:

We do offer coverage

Eligible dependents are: Spouse and/or domestic partner and eligible dependents to age 26

We do not offer coverage.

If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended

to be affordable, based on employee wages.

** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.

X

X

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Click Here to Enroll

Family & Children’s Service of Ithaca

EMPLOYEE ASSISTANCE PROGRAM

30 YEARS OF SERVICE TO OUR COMMUNITY

127 WEST STATE STREET | ITHACA, NY 14850

DEPRESSION & ANXIETY

ELDERCARE ISSUES

FAMILY ISSUES

GRIEF & LOSS

JOB STRESS

LIFE TRANSITIONS

MARITAL & RELATIONSHIP CONCERNS

PARENTING & CHILDREN CONCERNS

SEPARATION & DIVORCE

SUBSTANCE ABUSE CONCERNS

Free, confidential assessment and consultation.

Short-term counseling. Appointments provided within an average of 5

business days, meeting and exceeding industry standards.

Information & referral for employees, spouses or domestic partners and

dependent children.

Availability of 30 plus clinical staff with Masters or PhDs from our clinical

program, which is licensed by the New York State Office of Mental Health.

Convenient locations in Ithaca plus a well established affiliate network in

surrounding counties and more than 100 additional providers nationwide.

Unmatched in care,

quality and scope.

Timely, professional support

when and where you need it.

Seamless coordination for employee emergencies

Same day crisis appointments available.

24-hour live answering service with clinical backup.

Established relationship and protocol with Cayuga Medical Center for inpatient

admissions.

After EAP services, individuals needing additional support can transfer

seamlessly into on-going treatment through F&CS’s clinical program.

Rich array of professionals services and priority access for

employees!

Family & Children’s Service’s EAP provides counseling services to

individuals, couples and families tailored to your personal,

family, or workplace issues.

Services For Individuals

EMPLOYEES We Can Help You With This!

Services For

Individuals

EAP ORIENTATION FOR EMPLOYEES

SUPERVISOR AND

LEADERSHIP TRAINING EAP COMMUNICATION

AND AWARENESS MATERIAL DISTRIBUTION

MANAGEMENT

COMMUNICATION AND CONSULTATION

UTILIZATION REPORTS

Professional Development Workshops

EMPLOYERS

Family & Children’s Service’s EAP provides services to over 50 local organizations covering 15,000 employees and their households.

Management and Human Resource Consultations: We can help you

implement business practices around assessing, documenting and addressing performance issues within the framework of the your personnel policies.

Condition of Employment Services: We provide the employer with support for referring an employee as a result of serious performance problems that jeopardize his or her employment.

Onsite Critical Incident Stress Management Services: We have a team of clinical professionals trained in post-traumatic stress disorder and critical incident interventions to provide support for employees experiencing a critical incident in the workplace.

Worksite orientations for employees and supervisors at times convenient for

you. We also provide promotional materials and can offer articles for employer’s internal newsletters or other internal communications.

Quarterly newsletters on topics relevant to today’s workplace.

Trainings: We offer customized trainings at the worksite on a variety of work/life topics.

Discounts: We offer our clients

discounts to the agency’s public EAP Spring and Fall Workshop Series.

Leadership Services: We offer customized coaching and development services for professional staff.

We Can Help You With This!

Services For

Organizations

In 2015, 25% of our EAP referrals were for In 2015, 25% of our EAP referrals were for

children! children!

Linda Bryan, MPS, PHR EAP Director

Please call for more information and a free quote!

Centers

Gadabout Transportation Services

Holt Architects

Human Services Coalition of Tompkins County

Ithaca Waldorf School

Ithaca Community Childcare

JM Murray Center

Kendal at Ithaca

Lifelong

Madison Cortland ARC

McGraw House

Mental Health Association of Tompkins County

Mettler Toledo Hi-Speed

Newfield Central School District

Ongweoweh Corp.

Pall Trinity Micro Corp.

Planned Parenthood of the Southern Tier

Renovus Energy

Rheonix

Southern Tier AIDS Program

Stewart Howe Alumni Service

Taitem Engineering

Tompkins Community Action

Tompkins Cortland Community College

Tompkins Cortland Community College Faculty/Student Association

TC3 Farm and Bistro

Tompkins County

Tompkins County Chamber of Commerce

Tompkins County Public Library

Town of Ithaca

Therm, Inc.

Transonic Systems, Inc.

TST BOCES

United Way of Tompkins County

Village of Dryden

Advion Biosciences

Alcohol and Drug Council of Tompkins County

All Tile and Stone

Alternatives Federal Credit Union

Boyce Thompson Institute

Cancer Resource Center of the Finger Lakes

Catholic Charities of Tompkins County

Cayuga Addiction and Recovery Services

Cayuga Medical Center

Child Development Council of CNY

City of Ithaca

Coddington Road Community Center

Cornell Cooperative Extension

CFCU Community Credit Union

Cortland County

Cortland Regional Medical Center

Dryden Mutual Insurance Company

Evaporated Metal Films

Finger Lakes Library System

Finger Lakes Fire & Casualty Company

First National Bank of Groton

Franziska Racker Centers

Gadabout Transportation Services

HOLT Architects

Human Services Coalition of Tompkins County

Ithaca Waldorf School

Ithaca Community Childcare

JM Murray Center

Kendal at Ithaca

Kionix, Inc.

Lansing Central School District

Lansing Instrument Corp.

We’ve got these employers covered.

Let us do the same for you!

FORMS

FAP-100EXSMGRP 9/13 Return Original to Excellus BlueCross BlueShield, at above address – Copy: Employer Group

P.O. Box 22999, Rochester, NY 14692 A nonprofit independent licensee of the BlueCross BlueShield Association

Instructions on last page. All Dates = mm/dd/yy PLEASE PRINT CLEARLY 1 – Group Employer Information This section should be completed by the Group Benefits Administrator. This application cannot be processed without this information and a signature. Please use blue or black ink, print one character per box Subscriber Status: Group # Subgroup # Class# Active Retired COBRA Cancelled

Please indicate reason for COBRA: Employer Name Left Employ/Retirement Death of Spouse

Divorce/Legal Separation Dependent Reached Max Age

Association/Chamber Name (if applicable) Loss of Student Status Other ___________________

Effective Date COBRA Effective Date Group Administrator Signature/DateX Hire/Rehire Date Retired Effective Date

Dental Group # Subgroup #

Was the employee subject to a waiting period before enrolling in your employer health plan? No Yes If yes, what was the start date: and end date 2 – Subscriber Plan Selection Department # Employee #

Please use blue or black ink, print one character per box. Check applicable plan(s).

SimplyBlue Plus

Healthy New York

Please check coverage type and person(s) to be covered:

Medical single sub & spouse sub & dependent(s) family Dental single sub & spouse sub & dependent(s) family

Dental Dental Blue Classic (DI); Dental Blue Options (DJ); Univera Dental Traditions (DI); Univera Dental Select (DJ); Dental (DE)

3 – Reason for Enrollment/Change Subscriber, please indicate the reason for this enrollment or change.

New Hire COBRA Retirement Loss of Coverage Domestic Partner Open Enrollment Address/Phone Number Last Name Age 65+ Remove Dependent Change in Student Status Medicare Eligible / Please indicate reason for Medicare eligibility: Newborn Disability End Stage Renal Disease Add Dependent / Please indicate reason for adding dependent: Adoption Marriage Marital Status Change

4 – Subscriber Information Please complete both sides of this application. The subscriber signature is required in order to process the application. Subscriber’s Last Name Subscriber’s First Name

Middle Initial Title E-mail Address

Mailing Address Apt or Suite

City State Zip

Work Phone Number Home Phone Number Cell Phone Number- - / - - / - -

Date of Birth Gender Social Security NumberM F - -

Marital Status: Single Married Legally Separated Divorced/ Marital Status Event Date

GROUP ENROLLMENT FORM

DO NOT USE – FOR INTERNAL PURPOSES ONLY

HIOS ID#________________________________EC_____________________________________

78124NY0980026-00SAAZ


Page 1 of 4


Medicare Number (if applicable) Part A Effective Date Part B Effective Date

If Medicare eligible due to ESRD please check type of dialysis: Self administered Facilitated Date started 5 – Other Coverage Information Have you ever been a member of Excellus BlueCross BlueShield? Yes NoIn addition, please provide a copy of your “Certificate of Coverage” from your former health insurance carrier or employer. Are you or any member of your family enrolled in any other health or dental insurance policy (including Medicare or Medicaid)?Health? No Yes /Dental? No Yes If answering “Yes”, are you keeping the additional health or dental coverage? Health? No Yes / Dental? No Yes Who did the other plan cover? Self Spouse Children Other insurance carrier name: Other insurance name of policyholder: Policy ID Number: Effective Date Termination Date

6 – Cancellation Information Please indicate who is being cancelled and the reason for cancellation (reason listing on page 4). Subscriber Medical /Reason___________________________________________ Date

Dental /Reason___________________________________________ Date Dependent (list each dependent in section 7)

Medical / Reason __________________________________________ Date Dental / Reason___ ______________________________________ Date

7 – Dependent Information Please provide all information for each person to be covered. Subscriber’s Last Name Subscriber’s First Name

Spouse/Domestic Partner Last Name Spouse/Domestic Partner First Name M.I.

Male Date of Birth Social Security Number Are you enrolling as a Domestic Partner? Female - - Yes No

Medicare Number (if applicable) Part A Effective Date Part B Effective Date

Dependent’s Last Name Dependent’s First Name M.I.

Male Date of Birth Social Security Number Is your over-age dependent handicapped or disabled? Yes Female - - (See last page for additional information) No

Is Dependent a full time student? No Yes If yes, please indicate college/university name: College/University Name Expected Graduation Date Credit hours

A. Have you obtained stand-alone dental coverage that provides a pediatric dental essential health benefit through a New York Health Benefit Exchange-certified stand-alone dental plan offered outside the New York Health Benefit Exchange? Yes No B. If you answered “yes”, please provide the name of the company issuing the stand-alone dental coverage.___________________________________ If you answered “no”, we will provide you coverage of the pediatric dental essential health benefit. 8 – Release/Signature Subscriber signature required. You must sign and date this form to be eligible for insurance. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation. I have thoroughly read, understand and agree to comply with the terms of the Release on the back. Subscriber Signature_____________________________________________Date________________________

Page 2 of 4


P.O. Box 22999, Rochester, NY 14692 A nonprofit independent licensee of the BlueCross BlueShield Association Instructions on last page. All Dates = mm/dd/yy PLEASE PRINT CLEARLY 9 – Additional Dependents Please provide all information for each person to be covered. Subscriber’s Last Name Subscriber’s First Name













GROUP ENROLLMENT FORM

Page 3 of 4


Instruction Page Reason for Enrollment/Change: Check the appropriate action in the space provided. An event is a specific occurrence, due to change in status, marriage, divorce, birth or adoption, group's anniversary date, or rate change. Your request must be received within 30 days of the event date. Please see your Group Administrator/Representative for events that fall outside the 30-day period. If New Hire, Open Enrollment, Add/Remove Dependent or Loss of Coverage, you must also check coverage type and persons to be covered, and Dependent Information section. Cancel RequestTo Cancel an Employee/Subscriber using the Group Enrollment Form:

To Cancel a Dependent using the Group Enrollment Form:

check Subscriber box check Products to be cancelled (Medical, Dental) indicate Cancellation Date in space provided complete Subscriber Information

check Dependent box check Products to be cancelled (Medical, Dental) indicate Cancellation Date in space provided complete Subscriber Information complete Dependent Name and Dependent Birth date

Cancel Subscriber Reasons Cancel Dependent Reasons

Left Employer/No Longer Eligible Commercial COBRA Begin Date COBRA Handicapped/Disabled Date Transfer to Traditional Transfer to HMO Transfer to POS

COBRA End Date Subscriber Request Subscriber Deceased Spouse's Insurance Medicaid Medicare

Marriage – when permitted by law Dependent Over Age Deceased Ineligible Student

COBRA Begin Date Subscriber Request Divorce Medicare

COVERAGE TYPE All products may not be applicable to your employer group. Please check with your Group Administrator/Representative. SUBSCRIBER If you or your dependents are Medicare eligible, complete the questions regarding Medicare Coverage.

FAMILY MEMBER INFORMATION If there are more than seven dependents please use an additional form. QUALIFIED GUIDELINES: A legal spouse (An ex-spouse no longer qualifies as of the date court documents are stamped and filed with the court) Must be under the eligible child age for your employer group:

- natural, adopted or stepchild Other: Please contact your Group Administrator/Representative for the appropriate form. These dependents have additional eligibility

requirements.Dependents pending adoption, for whom you are the legal guardian, and/or a handicapped or disabled dependent who is over thedependent age for your employer group.

RELEASE I am applying to enroll myself and my eligible dependents, if any, under the medical and/or dental contract. In the event that a premium contribution is required of me, I agree to pay the premium amounts applicable to the contract under which I am covered. I

authorize my employer to deduct from my payroll such applicable amounts and to remit them to Excellus BlueCross BlueShield. If this application is made on behalf of a minor, the responsible party must complete the application. By accepting this contract, I grant permission to Excellus BlueCross BlueShield to submit charges to and/or recover payment from any other insurance

carrier acting as my primary insurer. I authorize Excellus BlueCross BlueShield to request and receive medical or dental information regarding me or my covered dependents from my

healthcare practitioner or healthcare institution either orally or in writing and to use this information for providing coverage. Providing coverageincludes: processing claims, reviewing grievances or complaints involving care and quality assurance reviews of care, whether based on a specificcomplaint or a routine audit of randomly selected cases. In the use of data for these purposes, we may transmit personal information to third partieswith which we contract, including pharmacy benefit managers, disease management vendors or surveyors.

I hereby represent that all information furnished by me hereon is true and complete to the best of my knowledge. PREFERRED PROVIDER ORGANIZATION (PPO)

I understand that the Preferred Provider Organization (PPO) coverage is comprised of an in-network benefit that is dependent on the utilization ofmedical providers who participate with the PPO and an out-of-network benefit which provides coverage for services of medical providers who do notparticipate with the PPO. I understand that the in-network benefit provides the highest level of coverage under the plan.

(Applies to Dental Only) The certificate or contract for which application is being made may impose a waiting period on member(s) up to twelve (12) months for preexisting conditions, subject to the provisions of applicable law including creditable coverage requirements. The certificate or contract document will describe any applicable waiting periods.

GROUP EMPLOYER INFORMATION This section to be completed and signed by the Employer Group Administrator/Representative. Complete only the coverage section (Medical/Dental) that is applicable to the employee's request.

If you have any questions, please contact your Group Administrator/Representative. Or, visit us at:

www.excellusbcbs.com

Page 4 of 4

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Waiver of Group Coverage

Company Name: Ithaca Alpha House Center, Inc. DBA Cayuga Addiction Recovery

Employee Name:

Please Check All that Apply:

D I waive my employer's group health insurance coverage for myself and my dependents

D I waive my employer's group dental insurance coverage for myself and my dependents

Reason for Waiving Coverage - Please Check One:

D Covered through spouse's employer

D Covered through a parent's employer

D Under 65 retiree covered by previous employer's insurance program

D Other: please specify ______________________ _

Please Read and Sign Below:

In waiving coverage, I understand that I and/or my dependents may enroll under this plan

in the future only as the result of certain qualifying event. For example:

• Within 30 days of involuntary loss of other group coverage

• At the time of my employer's open enrollment

Signature Date

Waiver of Other Coverage

Please Check All That Apply

Life Insurance

Long Term Disability

Flex Spending Account

_____________________________________________Signature

______________________________Date

Documents

CARS BENFIT SNAPSHOTVersion Updated: 09/11/2018 Print Package: HIOS ID (Enrollment Code) 78124NY0980025-00 (SMT1) Plan Name: SimplyBlue Plus Platinum 2 Rating Region: Syracuse Rate