Employee Benefits Guide · 2020. 7. 26. · In case of discrepancy between the Benefits Guide and the actual plan ... –Affidavit Required - Natural, adopted, foster or step child(ren)

The information in this Benefits Guide is presented for illustrative purposes only. The text contained in this Guide was taken

from various plan documents and/or benefit information. While every effort was taken to accurately report your benefits,

discrepancies or errors are always possible. In case of discrepancy between the Benefits Guide and the actual plan

documents the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability

and Accountability Act of 1996. If you have any questions about this guide, contact Human Resources. 08/03/2017 AD

Employee Benefits Guide

October 1, 2017 – September 30, 2018

The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.

TABLE OF CONTENTS

Open Enrollment 3

Making Changes To Your Benefits 3

Who Is Eligible? 3

Medical 4

Pre-tax Spending Accounts (FSA/DCA) 9

Dental 11

Vision 14

Life Insurance 15

Disability 18

Legal / ID Theft Services 19

Pet Insurance 21

Voluntary Products 22

Employee Assistance Program (EAP) 24

Individual Mandate 25

Marketplace Notice 26

Annual Notices 27Women’s Health & Cancer Rights Act of 1998

Newborns’ Act

Right to Receive a Notice of Privacy Practices

Addendum A – Medicaid and CHIP

Addendum B – Medicare Part D

Glossary 30

Contacts 31

Page 2

If you (and/or your dependent) have Medicare or

will become eligible for Medicare in the next 12

months, a Federal law gives you more choices

about your prescription drug coverage. Please

see Addendum B on page 29 for more details.

Ravago Americas, LLC is pleased to offer you the following

benefit options. This guide provides an overview of the

benefit plans and programs available to you as well as

informational tools to optimize your coverage. As you

consider your benefit options, take an active role in

understanding any changes to your needs and seize this

opportunity to make any necessary updates. If you have any

questions or require additional information please reference

the contacts page in this guide.

ENROLLMENT CHECKLIST

✓ Review your benefit options

✓ Verify your provider(s) are contracted in the network

✓ All employees are required to attend an enrollment

appointment with an Explain My Benefits counselor

by calling the appropriate number located on the

contacts page

✓ Complete Evidence of Insurability (EOI), if applicable

What’s New!• The Flexible Spending Account (FSA) vendor is

changing from ADP to MedCom

• The carrier for Accident, Critical Illness and Hospital

Indemnity is changing from Aflac to Voya

• New Benefit! – Pet insurance through ASPCA

• New Benefit! – Legal services through LegalShield

• New Benefit! – Identity theft services through

IDShield

Good News!We will continue to utilize United Healthcare for medical,

Cigna for dental and vision, Voya for life insurance and

disability.

OPEN ENROLLMENT

Each year, during the open enrollment period, you will have the opportunity to enroll in or make changes to

your benefit elections and dependents without a qualifying event. Once you have made your elections you

will not be able to change them until the next open enrollment period, unless you experience a qualifying

event.

WHO IS ELIGIBLE?

Full-time employees (working 30+ hours per week)

New hires are eligible for benefits on the 1st of the month following 30 days of employment.

Family members eligible for dependent coverage include:

- Legal spouse

- Domestic partner (Same and Opposite sex) – Affidavit Required

- Natural, adopted, foster or step child(ren)

- Child(ren) for whom court appointed or legal guardianship has been awarded

Eligible dependent children may be covered until:

- Medical: end of the calendar year they turn age 26

- Dental: end of the calendar year they turn age 26

- Vision: end of the calendar year they turn age 26

- Voluntary life: they turn age 26 (coverage ends on birthday)

- Voluntary products: end of the month they turn age 26

A handicapped dependent child may continue coverage beyond the age limit if determined to meet plan requirements.

MAKING CHANGES TO YOUR BENEFITS DURING THE PLAN

YEAR (QUALIFYING EVENT)

Per IRS code Section 125, once your benefits are effective you may not make changes to

your benefits until the next open enrollment period unless you experience a qualifying

event. Qualifying events that permit mid-year changes include:

- Marriage - Divorce

- Death of spouse, child or other qualified dependent - Legal Separation

- Birth or adoption of child - Change of dependent status

- Loss of other group coverage

- Change in employment status (employee, spouse, domestic partner or dependent)

- Change in residence due to an employment transfer

If you do not make changes within 30 days of the ‘qualifying event,’ you must wait until the following

open enrollment period. It is your responsibility to notify Human Resources within 30 days of the

qualifying event.



Page 4

MEDICAL INSURANCEUnited Healthcare – www.myuhc.com

Participating provider information can be found on the carrier’s website. For additional information concerning your

preventive care and what is covered please access www.uhcpreventivecare.com, enter your age and gender and

you will receive a full list of what is covered under preventive care.

IN-NETWORK BENEFITS Choice PlusPlan Coinsurance 90%

Calendar Year Deductible Embedded

Individual / Family $200 / $600

Out of Pocket Max

Individual / Family $2,000 / $4,000

Deductible Applies To Out of Pocket Yes

Medical / RX Copays & Coinsurance Applies to Out of Pocket Yes

Office Charges

Office / Specialist Visit $20 / $30

Virtual Visits $10

Referral Required No

Preventive $0

Facility Charges

Convenience Care (i.e. CVS Minute Clinic) $20

Urgent Care $35

Emergency Room (In or out of network) $200

Inpatient Hospital 10% after deductible

Outpatient Hospital 10% after deductible

Physician Fees 10% after deductible

Independent Facility Charges

Labs (LabCorp) / X-rays / Complex Diagnostic Imaging $0

Mental Health

Inpatient Facility 10% after deductible

Physician Visit $0

Prescription Drugs: Mandatory Generic

Deductible $0

Preventive $0

Tier 1 $6

Tier 2 $25

Tier 3 $40

Specialty (GH, Self Injectable, etc) Applicable Cost Share

Mail Order - 90 day supply 2 x retail copay

OUT-OF-NETWORK BENEFITS

Plan Coinsurance 70%

Calendar Year Deductible

Individual / Family $500 / $1,500

Out of Pocket Max

Individual / Family Unlimited

Office / Facility Charges 30% after deductible

Balance Billing Yes

BI-WEEKLY PAYROLL DEDUCTIONS

Annual Salary < $45,000$45,000 -

$75,000

$75,000 –

$125,000$125,000 +

Employee $27.69 $32.54 $40.66 $54.20

Employee + Spouse $60.51 $72.62 $90.77 $121.02

Employee + Child(ren) $50.24 $60.29 $75.34 $100.47

Employee + Family $73.37 $88.03 $110.05 $144.62

http://www.myuhc.com/http://www.uhcpreventivecare.com/


The United Healthcare NurseLine is a health services solution in which members are connected with a health

care expert, who helps guide them to resources and more effective use of care, including:

• Help answer clinical concerns, facilitate referrals to relevant health and wellness programs, and provide

condition management and treatment-decision counseling

• Identify premium providers and even schedule appointments

• Coaching on medication adherence and education on drug

interactions or medication alternatives

• Preventive care information, healthier lifestyle coaching and

referrals to wellness coaching and behavioral

When you enroll in the medical plan, you and your dependents will have

access to an experienced registered nurse, 24 hours a day, seven days a week. There is no additional cost

and it can give you the peace of mind you need.

Call the number on your medical card or login to www.myuhc.com to get in touch with a NurseLine.

Page 5

The more you know about health care costs and the options you have, the easier it may be for you to make

better decisions. When you register on www.myuhc.com, you will have access to tools and information to help

you manage and improve your health. You can download the UHC Health4Me mobile application and have

instant access to your health information – anytime / anywhere.

• Download ID Cards

• Find a provider

• Track your claims

• Compare and buy prescriptions

• Compare treatment costs

• Wellness information and much more

MYUHC.COM

NURSELINE

http://www.myuhc.com/http://www.myuhc.com/


Use virtual visits when:• Your doctor is not available

• You become ill while traveling

• You are considering visiting a

hospital emergency room for a

non-emergency health condition

Not good for:• Anything requiring an exam or test

• Complex or chronic conditions

• Injuries requiring bandaging or

sprains/ broken bones

When you don’t feel well, or your child is sick, the last thing you want to do is leave the comfort of home to sit in a waiting

room. Now, you don’t have to. A virtual visit lets you see and talk to a certified medical professional from your mobile device

or computer without an appointment. Most visits take about 10-15 minutes and doctors can write a prescription, if needed,

that you can pick up at your local pharmacy. And, it’s part of your health benefits.

Conditions commonly treated through a virtual visit Doctors can diagnose and treat a wide range of non-emergency medical

conditions, including:

• Bladder infection/

Urinary tract infection

• Bronchitis

• Cold/flu

• Diarrhea

• Fever

• Migraine/headaches

• Pink eye

• Rash

• Sinus problems

• Sore throat

• Stomach ache

Access virtual visits

Log in to myuhc.com® and choose from provider sites where you can register

for a virtual visit. After registering and requesting a visit you will pay your portion

of the service costs according to your medical plan, and then you will enter a

virtual waiting room. During your visit you will be able to talk to a doctor about

your health concerns, symptoms and treatment options.

Get access to care online. Any where. Any time.

VIRTUAL VISITSUnited Healthcare – www.myuhc.com

Page 6

To learn more, login to myuhc.com or Health4Me

Accessing via www.myuhc.com

• Log in to www.myuhc.com

• You will see the Virtual Visit option on the home page

• Choose a Provider

Accessing via Health4Me

• Open Health4Me mobile application

• Click on Search

• Select Quick Care

• Click on Virtual Visits

http://www.myuhc.com/http://www.myuhc.com/http://www.myuhc.com/


WELLNESSUnited Healthcare – www.myuhc.com

Page 7

Real Appeal is included as part of your medical benefit plan and provided to you and your enrolled

dependents (18 and older) at no additional cost. It educates participants on eating healthy habits, staying

active – without turning their lives upside down.

Establish a plan for lasting weight loss. Nearly 7 out of 10 adults are considered overweight or obese.

UnitedHealthcare’s Real Appeal is working to reverse this trend, with tools and support to help participants lose

weight, feel good and prevent weight-related health conditions.

Real Appeal includes:

A personalized transformation coach for an entire year

Coaches guide participants through the program, step by step, customizing it to fit their needs, personal

preferences, goals and medical history

24/7 online support and mobile app.

Staying accountable to goals is easier than ever with:

• Customizable food, activity, weight and goal trackers

• Unlimited access to digital content, including streaming workout videos

• Success group support which lets participants chat with others who are doing the Real Appeal program

• The weekly Real Appeal All-Star Show featuring healthy tips from celebrities, athletes and health experts

• Weekly analysis, feedback and goal reporting

A success kit

All the gadgets participants need to help kick-start their weight loss and keep them going strong will be delivered

to their door after they attend their first group coaching session. It includes these helpful tools:

• Personal blender

• Digital food scale

• Measuring cups and spoons

• “Perfect” portion plate

• Resistance band

• Pedometer

• Real Appeal water bottle

• Electronic body weight scale

• Body tape measure

• Exercise DVD’s

• And more

http://www.myuhc.com/


GOOD HEALTH GATEWAY

Page 8

In just 4 Easy Steps, you can be on your way to better health and receive a monthly $45 Good HealthGateway Card which can be redeemed at over 60 premium retailers or used to make a charitabledonation.

Register on the Good Health Gateway Diabetes Care Rewards Program website.

Complete a brief phone interview with our Good Health Gateway Diabetes Nurse Educator to get your written Diabetes Health Action Plan® Care Guide to review and share with your doctor. Call (800) 643-8028 to schedule your interview.

Complete the basic requirements for managing your diabetes such as having important screenings and exams.

Have your health care provider complete the Good Health Gateway Provider

Confirmation Form and send to us, and you’ll receive your monthly reward every month you are up to date on the program requirements.

To learn more about the program and the basic requirements, call our HelpLine toll-free at (800) 643-8028, or register online at GoodHealthGateway.com.

Your participation is voluntary and confidential. The Good Health Gateway website is both private and secure. HIPAA privacy and security standards are used to ensure the security of your health care information.

(800) 643-8028GoodHealthGateway.com

Managing your diabetes has its own Rewards. Plus, we’ll give you a few more.

Improved health and well being

$45 monthly rewardsAvailable to members enrolled in a medical plan offered by RavagoAmericas LLC


Page 9

PRE-TAX SPENDING ACCOUNTS (FSA/DCA)Medcom – www.mywealthcareonline.com/medcom

Ravago Americas, LLC offers employees the option of making deposits into separate spending accounts for eligible

healthcare (including Medical, Dental and Vision) expenses and dependent care (including child care) expenses.

Information regarding your FSA can be found on the carrier’s website or by calling (800) 523-7542.

Your deductions cannot be changed or discontinued during the plan year

unless you experience a qualifying event.

Healthcare Reimbursement FSA: You must enroll/re-enroll to participate

In addition to using this account to make co-pays, co-insurance payments or deductible payments this program lets

employees pay for certain IRS-approved medical care expenses. The annual maximum amount is $2,600.

Some examples of reimbursable expenses include:

✓ Hearing exams, hearing aids

✓ Vision expenses such as: laser eye surgery (Lasik), contact lenses, eye examinations, and eyeglasses

✓ Orthodontia

✓ Chiropractic services

✓ Acupuncture

✓ Physical therapy

✓ Diabetic Supplies

Under the Patient Protection and Affordable Care Act (PPACA): Over-the-counter drugs and medicines are NOT

eligible expenses unless you have a doctor’s prescription.

Dependent Care FSA: You must enroll/re-enroll to participate

The Dependent Care FSA enables employees to use pre-tax dollars

to pay for eligible dependent care expenses that are necessary for you

(and your spouse) to work, actively look for work, or attend school

full time. Dependent care FSA can be used for the caring of children

under the age of 13 or dependent elders who live with you. The

annual maximum contribution to the Dependent Care FSA is $5,000

($2,500 if married and filing separately).

Examples of eligible expenses include:

✓ The cost of child or adult dependent care

✓ The cost for an individual to provide care either in or out

of your house

✓ Nursery schools and preschools (excluding kindergarten)

You should only contribute the amount of money you expect to pay out

of pocket for eligible expenses for the plan year. If you do not use the

money within the plan year it will not be refunded to you or carried

forward to a future plan year.

Use it or lose it.

Without FSA With FSA

Gross income $30,000 $30,000

FSA contributions $0 -$5,000

Gross income $30,000 $25,000

Estimated taxes

Federal -$2,550* -$1,776*

State -$900* -$750*

FICA -$2,295 -$1,913

After-tax earnings $24,255 $20,561

Eligible out-of- pocket

medical and

dependent care

expenses

-$5,000 $0

Remaining spendable

income$19,255 $20,561

Spendable income

increase-- $1,306

Under the Health Care Reimbursement FSA employees may carry over up to $500 of unused funds

into the next plan year and must be used in that year.

*Estimated taxes are subject to change and do not

always apply.

www.FSAStore.com is the only one-stop-shop stocked exclusively with FSA-eligible

products and services so there are no guessing games as to what is and isn't

reimbursable which is what consumers face every time they walk into a drugstore.

http://www.mywealthcareonline.com/medcomhttp://www.fsastore.com/


Page 10

www.NeedyMeds.org is a national non-profit

organization that maintains a website of free

information on programs that help people who need

assistance with the cost of medications and

healthcare costs.

Some resources available through NeedyMeds are:

• Patient Assistance Programs

• Free / Low Cost Clinics

• Diagnosis – Based Assistance

• State Programs

• Free Drug Discount Card

SAVINGS TIPS

Below are a few ideas on how to spend your dollars or save on prescriptions and medications.

Pharmacy discount programs. Before you pay for your

next prescription, check to see if they are available for

free or at a low cost. Pharmacies such as Walmart and

Costco offer prescription discount programs that allow

you to purchase medications for as low as $4 for a 30-

day supply. Publix pharmacies offer select free

antibiotics and diabetes medications.

Urgent Care vs Emergency Room (ER). The Emergency Room is meant for true emergencies such as life threatening

illnesses and injuries. The ER costs an average of three times more than a visit to the urgent care. In a non-life

threatening situation, you can most likely be treated at an urgent care. Urgent Care centers are available for non-life

threatening immediate care.Emergency Room Examples:

• Chest Pain

• Broken Bones

• Allergic Reactions

• Continuous Bleeding

• Head Injury

• Severe Shortness of Breath

• Deep Wounds

Urgent Care Examples:

• Coughs and Sore Throat

• Minor Injuries and Burns

• Ear / Sinus Infections

• Flu and Cold

• Sprains and Strains

• Fever

• Vaccinations

Convenience Care Clinic. Don’t pay more if you don’t

have to. Convenience care clinics are walk-in clinics

located in a supermarket, pharmacy or retail store, where

available, such as CVS Caremark, Walgreens and

Walmart. Services may be provided at a lower out-of-

pocket cost compared to urgent or emergency care as

they are subject to primary care office visit co-pays,

and/or coinsurance. Convenience care clinics are

available for non-life threatening immediate care.

Convenience Care Clinic Examples:

• Common Infections (e.g.: ear,

bladder, pink eye, strep throat)

• Flu Shots

• Minor Skin Conditions

• Pregnancy Tests

• Allergies

• Immunizations

• School Physicals

Good Rx. Stop paying too much for prescriptions. Start

saving now for free – no sign-up or credit card required.

Compare prices, print free coupons and save up to 80%

on your medications. Download the Mobile App or, visit

www.goodrx.com on any mobile phone.

www.Goodrx.com

Zenni Optical. Affordable, stylish frames starting at

$8.00. You can save on glasses with Zenni Optical.

Trendy, not spendy prescription glasses for men,

women and children as well as prescription sunglasses.

Find their selection and prices online at:

www.zennioptical.com.

http://www.needymeds.org/http://www.goodrx.com/http://www.zennioptical.com/


Page 11

DENTAL INSURANCECigna – www.mycigna.com

Participating provider information can be found on the carrier’s website.

BENEFITS In-Network Out-Of-Network

Co-Insurance

Preventive 100% 100%

Basic 100% 80%

Major 60% 50%

Orthodontia 50% 50%

Benefits Based on Contracted Rates 80th percentileBalance Billing No Yes

Calendar Year Deductible (Individual / Family) $50 / $150

Deductible Waived for Preventive Service Yes

Calendar Year Maximum $1,500 (per person enrolled)

Lifetime Orthodontic Maximum $1,500

SCHEDULE OF BENEFITS

Routine Exams (2 per calendar year) Preventive

Cleaning (2 per calendar year) Preventive

X-Rays

Bitewing Preventive

Full Mouth Preventive

Sealants (under age16) Preventive

Fillings

Amalgam Basic

Composite Resin Basic

Oral Surgery* Basic

Repairs Basic

Root Canal Basic

Periodontal Maintenance* Basic

Periodontal Surgery* Basic

Endosteal Implants Major

Crowns Major

Fixed Bridges Major

Full And Partial Dentures Major

Orthodontia Children up to age 19

*Co-insurance based on complexity of procedure

POLICY PROVISIONS

Late Entrant Penalties NoneBI-WEEKLY PAYROLL DEDUCTIONS

Employee $1.56

Employee + Spouse $3.29

Employee + Child(ren) $4.41

Employee + Family $5.94

http://www.mycigna.com/


Page 12

How to locate a provider.

If you currently have a Cigna plan and have registered,

log in to www.mycigna.com.

If you haven’t enrolled/registered yet, follow these easy steps to find a dentist near you.

• Go to www.cigna.com

• Click ‘Find a Doctor/Dentist’ at the top right of the screen

• Select the orange box that reads ‘If your insurance plan is offered through work’

• Choose which professional you are looking for: doctor, dentist or facility

• Enter the geographic location you want to search

• Select the appropriate plan:

Dental: Cigna Dental PPO

• Enter a name, specialty or other search word (Optional). Click SEARCH to see your results.

CIGNA.COM

http://www.mycigna.com/http://www.cigna.com/


Page 13

MYCIGNA MOBILE APP

The myCigna Mobile App gives you a simple way to personalize, organize and access your important health

information – on the go.

little app. BIG Features.

Health care professional directory• Search for a doctor or health care facility from the Cigna national network and compare quality-

of-care ratings

• Access maps for instant driving directions

ID cards• Quickly view ID cards (front and back) for entire family

• Easily print, email or scan right from smartphone

Claims• View and search recent and past claims

• Bookmark and group claims for easy reference

Drug search• Look up and compare actual costs are over 60,000 pharmacies nationwide

• Find closest pharmacy location using GPS

• Research medications and dosages

• Speed-dial Cigna Home Delivery Pharmacy

Account balances• Access and view health fund balances

• Review plan deductibles and coinsurance

Health wallet• Store and organize all important contact info for doctors, hospitals and pharmacies

• Add health care professionals to contact list right from a claim or directory search


Page 14

VISION INSURANCECigna – www.mycigna.com

Participating provider information can be found on the carrier’s website.

Members have access to a large

network of national independent

private practitioners and retail

providers, some of which include:

Independent practitioners and retail providers may not be available in all states or may change at anytime without notice.

IN-NETWORK BENEFITS

Vision Examination $20 copay

Single Lenses $0 copay

Bifocal Lenses $0 copay

Trifocal Lenses $0 copay

Progressive LensesProgressive lenses covered up to the bifocal lens

amount with 20% savings on the difference

Frame$150 retail allowance +

20% off over allowance

Contact Lens Exam & Fitting Deducted from contact allowance

Elective Contact Lenses – In lieu of frames $150 allowance

Laser Vision CorrectionHealthy Rewards program: 15% off standard pricing and

5% off promotional

Hearing AidsHealthy Rewards program includes hearing aids

discounts

OUT-OF-NETWORK BENEFITS Reimbursement up to:

Vision Examination $45

Single Lenses $32

Bifocal Lenses $55

Trifocal Lenses $65

Frame $83

Elective Contact Lenses – In lieu of frames $120

FREQUENCY – based on calendar year

Exams 12 months

Lenses/Contacts 12 months

Frames 24 months


Employee $3.74




http://www.mycigna.com/


Page 15

LIFE INSURANCEVoya – www.voya.com

BASIC LIFE/AD&D INSURANCE (EMPLOYER PAID)

Ravago Americas, LLC provides Basic Life and Accidental Death & Dismemberment (AD&D) Insurance through

Voya to all full time employees at no cost. Employees receive 2 x annual salary, not to exceed $900,000. Please be

sure to review your beneficiary information and contact your Human Resources department should you have any

changes throughout the year. When you terminate employment or insurance eligibility, you may apply for an

individual policy by converting the current policy in force. This allows for the transfer of your current coverage to an

individual policy. You must notify Human Resources within 30 days of termination or insurance eligibility. Should

you apply, please note that your premium rate may be different than the current rate.

Benefit Reduction Schedule: 35% at age 70, 55% at age 75

VOLUNTARY LIFE INSURANCE

Employees who would like to supplement their basic life insurance benefits may purchase additional coverage. If

you purchase coverage for yourself, you may also purchase coverage for your spouse and/or your dependent

children. To be eligible for coverage you must be actively at work, you and your dependents must be able to

perform normal activities and not be confined (at home, in a hospital, or in any other care facility). When you enroll

yourself and/or your dependents in this benefit, you pay the full cost through payroll deductions. Be sure to review

your beneficiary information and contact your Human Resources department should you have any changes. When

you terminate employment or insurance eligibility, you may apply for an individual policy by either converting or

porting (included under age 70) the current policy in force. Both provisions allow for the transfer of your current

coverage. Conversion changes your coverage to an individual policy while porting allows continuation of your

current group policy, but on an individual basis. You must notify Human Resources within 30 days of termination or

insurance eligibility. Should you apply for either option, please note that your premium rate may be different than

the current rate.

The Voluntary Life Insurance coverage minimums, maximums and guarantee issue (G.I.) amounts are as follows:

Voluntary Life Insurance Benefit Description

Employee

• Maximum Benefit: Up to 5 x annual salary not to exceed $500,000

($10,000 increments)

• Minimum Benefit: $10,000

• Guarantee Issue: Up to 3 x annual salary not to exceed $360,000

Benefit Reduction Schedule: Reduces by 35% at age 70, to 55% at age 75

Spouse /

Domestic Partner

• Maximum Benefit: Up to 100% of employee’s benefit amount not to exceed $250,000

($5,000 increments)

• Minimum Benefit: $5,000

• Guarantee Issue: Up to 100% of employee’s benefit amount not to exceed $50,000

Benefit Reduction Schedule: Reduces by 35% at age 70, to 55% at age 75

Child(ren)

• Maximum & Minimum Benefit: $10,000

(Birth – 14 days: $1,000)

(14 days to age 26: Full Benefit)

http://www.voya.com/


Page 16


Below is the cost for the Voluntary Life Insurance coverage. The rates/premium are age banded based on the

employee’s and spouse’s own age as of the first day of the plan year.

If the benefit amount you would like to select is over $100,000, select the benefit amount from the first column

(Coverage Amount) that when multiplied by another number results in the benefit amount you want. For

example: If you would like to elect $150,000 in coverage, use the $50,000 row rate which applies to your age

band and multiply by 3.

Note: Your actual payroll deduction may vary slightly due to rounding.

EMPLOYEE BI-WEEKLY PAYROLL DEDUCTIONS (NON-SMOKER)

Coverage

Amounts< 29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69

$10,000 $0.44 $0.51 $0.61 $0.83 $1.27 $1.93 $3.26 $5.10 $9.33

$20,000 $0.88 $1.02 $1.22 $1.65 $2.54 $3.87 $6.52 $10.19 $18.66

$30,000 $1.32 $1.52 $1.83 $2.48 $3.81 $5.80 $9.78 $15.29 $27.98

$40,000 $1.75 $2.03 $2.44 $3.30 $5.08 $7.74 $13.03 $20.38 $37.31

$50,000 $2.19 $2.54 $3.05 $4.13 $6.35 $9.67 $16.29 $25.48 $46.64

$60,000 $2.63 $3.05 $3.66 $4.96 $7.62 $11.60 $19.55 $30.57 $55.97

$70,000 $3.07 $3.55 $4.26 $5.78 $8.88 $13.54 $22.81 $35.67 $65.29

$80,000 $3.51 $4.06 $4.87 $6.61 $10.15 $15.47 $26.07 $40.76 $74.62

$90,000 $3.95 $4.57 $5.48 $7.44 $11.42 $17.40 $29.33 $45.86 $83.95

$100,000 $4.38 $5.08 $6.09 $8.26 $12.69 $19.34 $32.58 $50.95 $93.28

EMPLOYEE BI-WEEKLY PAYROLL DEDUCTIONS (SMOKER)

Coverage

Amounts< 29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69

$10,000 $0.66 $0.80 $1.01 $1.43 $2.29 $3.57 $5.99 $8.83 $15.44

$20,000 $1.31 $1.60 $2.02 $2.86 $4.59 $7.14 $11.98 $17.66 $30.89

$30,000 $1.97 $2.40 $3.03 $4.29 $6.88 $10.72 $17.97 $26.49 $46.33

$40,000 $2.62 $3.19 $4.04 $5.72 $9.18 $14.29 $23.96 $35.32 $61.77

$50,000 $3.28 $3.99 $5.05 $7.15 $11.47 $17.86 $29.95 $44.15 $77.22

$60,000 $3.93 $4.79 $6.06 $8.58 $13.76 $21.43 $35.94 $52.98 $92.66

$70,000 $4.59 $5.59 $7.08 $10.02 $16.06 $25.01 $41.94 $61.80 $108.10

$80,000 $5.24 $6.39 $8.09 $11.45 $18.35 $28.58 $47.93 $70.63 $123.54

$90,000 $5.90 $7.19 $9.10 $12.88 $20.64 $32.15 $53.92 $79.46 $138.99

$100,000 $6.55 $7.98 $10.11 $14.31 $22.94 $35.72 $59.91 $88.29 $154.43

It is the EMPLOYEE’s responsibility to complete and submit an Evidence of Insurability (EOI) form.

An Evidence of Insurability (EOI) form is required for coverage elections above the Guarantee Issue (GI)

or if coverage was previously waived or not elected during the initial eligibility period.

Note: Benefit coverage & payroll deductions for newly elected amount will not take effect until EOI is approved by the carrier.



Page 17


Below is the cost for the Voluntary Life Insurance coverage. The rates/premium are age banded based on the

employee’s and spouse’s own age as of the first day of the plan year.

If the benefit amount you would like to select is over $100,000, select the benefit amount from the first column

(Coverage Amount) that when multiplied by another number results in the benefit amount you want. For

example: If you would like to elect $150,000 in coverage, use the $50,000 row rate which applies to your age

band and multiply by 3.

Note: Your actual payroll deduction may vary slightly due to rounding.CHILD(REN) BI-WEEKLY PAYROLL DEDUCTION*

$ 10,000 $0.92

*Regardless of how many children you have.

SPOUSE BI-WEEKLY PAYROLL DEDUCTIONS (NON-SMOKER)

Coverage

Amounts< 29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69

$1,000 $0.04 $0.05 $0.06 $0.08 $0.13 $0.19 $0.33 $0.51 $0.93

$2,000 $0.09 $0.10 $0.12 $0.17 $0.25 $0.39 $0.65 $1.02 $1.87

$3,000 $0.13 $0.15 $0.18 $0.25 $0.38 $0.58 $0.98 $1.53 $2.80

$4,000 $0.18 $0.20 $0.24 $0.33 $0.51 $0.77 $1.30 $2.04 $3.73

$5,000 $0.22 $0.25 $0.30 $0.41 $0.63 $0.97 $1.63 $2.55 $4.66

$6,000 $0.26 $0.30 $0.37 $0.50 $0.76 $1.16 $1.96 $3.06 $5.60

$7,000 $0.31 $0.36 $0.43 $0.58 $0.89 $1.35 $2.28 $3.57 $6.53

$8,000 $0.35 $0.41 $0.49 $0.66 $1.02 $1.55 $2.61 $4.08 $7.46

$9,000 $0.39 $0.46 $0.55 $0.74 $1.14 $1.74 $2.93 $4.59 $8.39

$10,000 $0.44 $0.51 $0.61 $0.83 $1.27 $1.93 $3.26 $5.10 $9.33

SPOUSE BI-WEEKLY PAYROLL DEDUCTIONS (SMOKER)

Coverage

Amounts< 29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69

$1,000 $0.07 $0.08 $0.10 $0.14 $0.23 $0.36 $0.60 $0.88 $1.54

$2,000 $0.13 $0.16 $0.20 $0.29 $0.46 $0.71 $1.20 $1.77 $3.09

$3,000 $0.20 $0.24 $0.30 $0.43 $0.69 $1.07 $1.80 $2.65 $4.63

$4,000 $0.26 $0.32 $0.40 $0.57 $0.92 $1.43 $2.40 $3.53 $6.18

$5,000 $0.33 $0.40 $0.51 $0.72 $1.15 $1.79 $3.00 $4.41 $7.72

$6,000 $0.39 $0.48 $0.61 $0.86 $1.38 $2.14 $3.59 $5.30 $9.27

$7,000 $0.46 $0.56 $0.71 $1.00 $1.61 $2.50 $4.19 $6.18 $10.81

$8,000 $0.52 $0.64 $0.81 $1.14 $1.84 $2.86 $4.79 $7.06 $12.35

$9,000 $0.59 $0.72 $0.91 $1.29 $2.06 $3.22 $5.39 $7.95 $13.90

$10,000 $0.66 $0.80 $1.01 $1.43 $2.29 $3.57 $5.99 $8.83 $15.44

It is the EMPLOYEE’s responsibility to complete and submit an Evidence of Insurability (EOI) form.

An Evidence of Insurability (EOI) form is required for coverage elections above the Guarantee Issue (GI)

or if coverage was previously waived or not elected during the initial eligibility period.

Note: Benefit coverage & payroll deductions for newly elected amount will not take effect until EOI is approved by the carrier.



Page 18

STD SCHEDULE OF BENEFITS

Benefits Begin 8th day Accident / Sickness

Benefit Duration / Payable 25 weeks

Percentage of Income Replaced 60%

Maximum Weekly Benefit $2,000

Pre-Existing Condition Limitation None

SHORT TERM DISABILITY (EMPLOYER PAID)

Ravago Americas, LLC provides Short Term Disability (STD) insurance through Voya to all full time

employees at no cost. In the event you become disabled from a non work-related injury or sickness, disability

benefits are provided as a source of income. You must be actively at work on the day this coverage begins.

DISABILITY INSURANCEVoya – www.voya.com

LONG TERM DISABILITY (EMPLOYER PAID)

Ravago Americas, LLC provides Long Term Disability (LTD) insurance through Voya to all full time employees

at no cost. In the event you become disabled from an injury or sickness, disability benefits are provided as a

source of income. You must be actively at work on the day this coverage begins.

LTD SCHEDULE OF BENEFITS

Benefits Begin 181st day Accident / Sickness

Benefit Duration / Payable2 years (Own Occupation); Reducing Benefit Duration (RBD) to Social

Security Normal Retirement Age (SSNRA)

Percentage of Income Replaced 60%

Maximum Monthly Benefit $10,000

Pre-Existing Condition Limitation

Disabilities that occur during the first 12 months of coverage due to a

pre-existing condition that occurred during the 3 months prior to

coverage are excluded.



Page 19

LEGAL SERVICESLegalShield

Through LegalShield employees can talk to a lawyer on any personal legal matter, no matter how trivial or

traumatic, all without worrying about high hourly costs. Services include:

FAMILY

• Administrative Hearing

• Adoption

• Child Custody

• Conservatorship

• Divorce

• Domestic Violence Protection

• Elder Care Assistance

• Guardianship

• Immigration Assistance

• Incompetency Defense

• Juvenile Court Defense

• Name Change

• Parental Responsibility

ESTATE PLANNING

• Codicils (Will Modification)

• Living W ills

• Power of At torney

• Probate

• Trusts

• W ills

• Prenuptial Agreements

• School Hearings

FINANCIAL

• Affidavits

• Bankruptcy

• Civil Litigation

• Consumer Pro tection

• Debt Collection

• Identity Theft

• Medical/Medicare Disputes

• Personal Property Disputes

• Promissory Notes

• Small Claims Assistance

• Social Security Disputes

• Tax Audit Pro tection

• Veterans Benefits Disputes

AUTO

• Driver’s License Restoration

• Motor Vehicle Property Damage

• Moving Traffic Violations

• Traffic Tickets

HOME

• Boundary/Title Disputes

• Contractor Disputes

• Deeds

• Foreclosure

• Home Equity Loans

• Landlord/Tenant Issues

• Mortgages

• Property Tax Assessments

• Purchase/Sale of Home(primary or secondary)

• Refinancing

• Zoning Applications

GENERAL

• 24/7 Emergency Access

• Document Review

• Mobile App

• Office Consultation

• Telephone Advice

BI-WEEKLY PAYROLL DEDUCTION

$8.54


Page 20

IDENTITY THEFTIDShield

Have You Ever?

Worried about being a victim of identity

theft?

Worried about entering personal information

on-line

Been concerned about your child’s

identity?

Feared the security of your medical

information?

Lost your wallet? Been pursued by a collection agency

IDENTITY THEFT ISSUES ARE MORE COMMON THAN YOU THINK…

30 new identity theft victims per minuteIdentity thieves are hacking and stealing data at a

frightening rate—with 30 new victims of identity theft per

minute. Offer your employees coverage that will help

protect against and resolve identity theft issues.

Just 15% of identity theft activity is discoverableOnly 15% of the identity theft complaints received in 2014

would have created activity discoverable by credit

report monitoring, pointing to the importance of taking a

dual approach to help protect employees.

16 consecutive yearsIdentity theft was among the top consumer complaints

filed with the Federal Trade Commission for 16

consecutive years. Of the more than 2.5 million

consumer complaints logged, 13 percent were for

identity theft.

THE IDSHIELDSM

MEMBERSHIP INCLUDES:

Privacy MonitoringMonitoring your name, SSN, date of birth, email address

(up to 10), phone numbers (up to 10), driver license &

passport numbers, and medical ID numbers (up to 10)

provides you with comprehensive identity protection

service that leaves nothing to chance.

Security Monitoring / Social Media MonitoringSSN, credit cards (up to 10), and bank account (up to

10) monitoring, sex offender search, financial activity

alerts and quarterly credit score tracking keep you

secure from every angle. With the family plan, Minor

Identity Protection is included and provides monitoring

for up to 8 children under the age of 18.

ConsultationYour identity protection plan includes 24/7/365 live

support for covered emergencies, unlimited counseling,

identity alerts, data breach notifications and lost wallet

protection.

Full Service RestorationComplete identity recovery services by Kroll Licensed

Private Investigators and our $5 million service

guarantee ensure that if your identity is stolen, it will be

restored to its pre-theft status.IDShield Plans are available for Groups at individual or family plan rates. A family ratecovers the member, member’s spouse or domestic partner and up to 8 dependents up to theage of 26*.

*Dependents that are over 18, under 26, and either live at home or are a full timestudent, and have never been married will receive unlimited consultation and completerestoration by Kroll licensed private investigators. Monitoring is not available fordependents in this category.


Employee $3.46



Page 21

PET INSURANCEASPCA

Pet’s medical emergencies never happen when you expect them. Pet insurance reimburses you for covered

vet bills, so you can give your pet the best care possible. All plans include the ability to visit any vet in the US

and Canada, emergency visits and specialist visits, prescription medication, diagnostic procedures and tests,

veterinary exam fees, surgeries and hospitalizations, MRI, CCT scans, X-rays and more!

HOW TO ELECT COVERAGE

www.aspcapetinsurance.com/ravago

CODE: EB17RAVAGO

1. Select your reimbursement percentage

2. Choose your deductible

3. Choose your annual limit

4. Select Accident – Only Coverage if desired

5. Add preventive care if desired

Annual Limit

Annual Deductible

(Plan Year)

Reimbursement

80% 90%

$100 $250 $500

$5,000

$10,000

$15,000

$20,000

Unlimited

WHY ASPCA?

✓ Discounts Are Available

✓ No Upper Age Limits

All cats and dogs 8 weeks and older are eligible.

✓ Fast Reimbursements

Get reimbursed by direct deposit or check.

✓ No Networks

Visit any vet, specialist, or emergency clinic.

✓ Online Claims Management

Simple online claim submission, claim tracking, and account management.

✓ Friendly, Experienced Staff

We're proud to be one of the largest and oldest providers around.

Your pets are important to us because we're pet parents, too.

70%

Monthly Price Range*

Accident Only: $12 – $25

Accident / Illness: $30 – $50

*Monthly costs are subject to change based on employee’s benefit selection

http://www.aspcapetinsurance.com/ravago


Page 22

VOLUNTARY PRODUCTSVoya

ACCIDENT Accidents can happen to anyone, at any time. Accident Insurance will give you the freedom to spend the

benefit on what you need – medical costs after an accident, groceries, utilities, etc.

Key Features

- Benefits for common injuries like fractures and dislocations, burns, lacerations and concussions

- Benefits for emergency room visits, ambulance, hospital care, surgery and physical therapy

- Benefits paid regardless of any other insurance you may have

- Wellness Benefit

- Portable

HOSPITAL INDEMNITYEven with health insurance, hospital stays can be expensive. Hospital Confinement Indemnity Insurance

can help you pay for things like deductibles, transportation and rehabilitation costs that would usually come

out of your own pocket.

Key Features

- Benefits based on the number of days spent in a hospital, critical care unit or rehabilitation facility

- Benefits for outpatient and inpatient surgery, diagnostic tests and emergency room and rehabilitation

services

- Assistance with out-of-pocket expenses that may not be fully covered by health insurance


- Spend the benefits on what you need – coinsurance, lodging, child care

- Wellness Benefit

- Portable


Employee $4.26





Employee $12.35





Page 23

VOLUNTARY PRODUCTSVoya

CRITICAL ILLNESS (Cancer Included)

Being diagnosed with a critical illness can be devastating both personally and financially. Breathe easier

knowing Critical Illness Insurance can help you pay your out-of-pocket expenses and allow you to focus on

your health. Rates based on employee and spouse’s own age.

Key Features

- Lump-sum benefit when you are diagnosed with a covered illness

- Benefits for heat attack, stroke, kidney failure, coronary artery bypass and several others

- Spend benefits on what you need – medical expenses, groceries, utilities


- Wellness Benefit

- Portable

EMPLOYEE BI-WEEKLY PAYROLL DEDUCTIONS

Coverage

Amounts< 29 30-39 40-49 50-59 60-64 65-69 70+

$10,000 $2.54 $2.86 $5.22 $11.17 $17.12 $21.28 $24.23

$20,000 $5.08 $5.72 $10.43 $22.34 $34.25 $42.55 $48.46

$30,000 $7.62 $8.58 $15.65 $33.51 $51.37 $63.83 $72.69

SPOUSE BI-WEEKLY PAYROLL DEDUCTIONS

Coverage

Amounts< 29 30-39 40-49 50-59 60-64 65-69 70+

$5,000 $1.18 $1.45 $2.70 $5.15 $7.71 $9.67 $16.80

$10,000 $2.35 $2.91 $5.40 $10.29 $15.42 $19.34 $33.60

$15,000 $3.53 $4.36 $8.10 $15.44 $23.12 $29.01 $50.40

CHILD(REN) BI-WEEKLY

PAYROLL DEDUCTIONS

Coverage

Amounts< 26

$2,500 $0.32

$5,000 $0.65

$10,000 $1.29


Page 24

EMPLOYEE ASSISTANCE PROGRAM (EAP)

STAY AHEAD of Performance and Productivity Issues

The ComPsych EAP Difference

Also available through ComPsych:

Estate Guidance®

Helps you secure your future by overcoming the legal, financial and

emotional barriers to writing a will.

Family Source®

Provides help for a wide range of needs including child care, elder

care, education, adoption, pet care and personal convenience – all of

which, if left unaddressed, can distract you from your work

performance.

Financial Connect®

Professionals cover a broad range of personal financial issues

including debt management, family budgeting, tax questions,

retirement programs, real estate, investment options,

mortgages/loans/refinancing, money management, estate planning,

lease vs. buy, insurance, credit problems, bankruptcy.

IDResources®

Identity Theft restoration services to victims of ID theft.

Legal Connect ®

Provides immediate access to expertise and support services for

divorce, estate planning/wills, identity theft, lawsuits, bankruptcy,

personal injury, real estate, probate, adoption, landlord/tenant issues.

of Financial Concerns

of Work-Life Issues

of Legal Issues

> Free phone access 24 hours a

day to master’s and doctoral-

degreed clinicians

> Worldwide network of

psychologists, licensed clinical

social workers and other

master’s-degreed professionals

for in-person counseling

> Care management and follow up

on every case

> Award-winning Internet service

with full access to program

components

> Crisis intervention and support to

lessen the impact of traumatic

events

> Programs to address substance

abuse

(877) 533-2363

[email protected]

mailto:[email protected]


Individual Mandate

OverviewBeginning in 2014, the Affordable Care Act included a mandate for most individuals to have health insurance or potentially pay a

penalty for noncompliance. Individuals are required to maintain minimum essential coverage for themselves and their dependents.

Some individuals are exempt from the mandate or the penalty, while others may be given financial assistance to help them pay for the

cost of health insurance.

What type of coverage satisfies the individual mandate?“Minimum essential coverage”

What is minimum essential coverage?Minimum essential coverage is defined as:

• Coverage under certain government-sponsored plans

• Employer-sponsored plans, with respect to any employee

• Plans in the individual market,

• Grandfathered health plans; and

• Any other health benefits coverage, such as a state health benefits risk pool, as recognized by the HHS Secretary.

Minimum essential coverage does not include health insurance coverage consisting of excepted benefits, such as dental-only

coverage.

How does “Minimum Essential Coverage” differ from “Essential Health Benefits”?Essential health benefits were required to be offered by certain plans starting in 2014 as a component of the essential health benefit

package. They are also the benefits that are subject to the annual and lifetime dollar limit requirements.

This is different than minimum essential coverage, which refers to the coverage needed to avoid the individual mandate

penalty. Coverage does not have to include essential benefits to be minimum essential coverage.

What is the penalty for noncompliance?The penalty is determined by calculating the greater amount of either a flat dollar amount or set percentage of income. Beginning in

2017, penalties may increase based on the cost of living.

Who is exempt from the mandate?Individuals who have a religious exemption, those not lawfully present in the United States, and incarcerated individuals are exempt

from the minimum essential coverage requirement.

Are there other exceptions to when the penalty may apply?Yes. A penalty will not be assessed on individuals who:

• cannot afford coverage based on formulas contained in the law,

• have income below the federal income tax filing threshold,

• are members of Indian tribes,

• were uninsured for short coverage gaps of less than three months;

• have received a hardship waiver from the Secretary, or are residing outside of the United States, or are bona fide residents of

any possession of the United States.

Tax

Year

Pay whichever is greater

Flat dollar amount

OR

Percentage of income

(over tax filing threshold)

Per AdultPer Child

(under age 18)

2015$325 $162.50

2.0%(maximum of $975 per family)

2016$695 $347.50

2.5%(maximum of $2,085 per family)

2017 Fees are the same as 2016

Page 25


Health Insurance Marketplace Coverage Options

Page 26

Form ApprovedOMB No. 1210-0149

In 2014 a new option to buy health insurance began: the Health Insurance Marketplace. To assist you as you

evaluate options for you and your family, this notice provides some basic information about the Marketplace and

employment based 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 November 1, 2017 and ends on December 15, 2017. You can get coverage

through the Marketplace for 2017 if you qualify for a special enrollment period or are applying for Medicaid or the

Children’s Health Insurance Program (CHIP). Here are some important dates:

November 1, 2017: Open Enrollment starts

December 15, 2017: Last day to enroll or change 2018 health plan

January 1, 2018: 2018 Insurance coverage begins

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 9.69% 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 your Human Resources department.

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.

http://www.healthcare.gov/


Page 27

Annual Notices

Women’s Health & Cancer Rights Act of 1998

Did you know that your medical plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for

mastectomy-related services, including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses,

and complications resulting from a mastectomy, including lymphedema? For more information regarding this benefit, contact customer

service at the number listed on the back of your medical ID card.

The Newborns’ and Mothers’ Health Protection Act (the Newborns’ Act)

Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in

connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours

following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after

consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case,

plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a

length of stay not in excess of 48 hours (or 96 hours).

Your Right to Receive a Notice of Privacy Practices

Ravago Americas, LLC is subject to the HIPAA privacy rules. In compliance with these rules, it maintains a Notice of Privacy

Practices. You have the right to request a copy of its Notice of Privacy Practices by contacting the medical insurance company. (See

telephone number on your medical ID card).

Addendum A – 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 ofstates is current as of January 31, 2017. 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: [email protected]

Medicaid Eligibility:

http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: http://dch.georgia.gov/medicaid

- 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

COLORADO – Health First Colorado (Colorado’s Medicaid

Program) & Child Health Plan Plus (CHP+)IOWA – Medicaid

Health First Colorado Website:

https://www.healthfirstcolorado.com/

Health First Colorado Member Contact Center:

1-800-221-3943/ State Relay 711

CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus

CHP+ Customer Service: 1-800-359-1991/

State Relay 711

Website:

http://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp

Phone: 1-888-346-9562

http://www.healthcare.gov/http://www.insurekidsnow.gov/http://www.askebsa.dol.gov/http://myalhipp.com/http://flmedicaidtplrecovery.com/hipp/http://myakhipp.com/mailto:[email protected]://dhss.alaska.gov/dpa/Pages/medicaid/default.aspxhttp://dch.georgia.gov/medicaidhttp://myarhipp.com/http://www.in.gov/fssa/hip/http://www.indianamedicaid.com/https://www.healthfirstcolorado.com/http://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp


Page 28

Addendum A – Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) - CONTINUATION

To see if any other states have added a premium assistance program since January 31, 2017, 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/ebsa www.cms.hhs.gov

1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

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://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Page

s/default.aspx Phone: 1-877-598-5820, HMS Third Party Liability

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

VIRGINIA – Medicaid and CHIP

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

KANSAS – Medicaid0 NEW HAMPSHIRE – Medicaid

Website: http://www.kdheks.gov/hcf/

Phone: 1-785-296-3512

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf

Phone: 603-271-5218

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP

Website: http://chfs.ky.gov/dms/default.htm

Phone: 1-800-635-2570

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

LOUISIANA – Medicaid NEW YORK – Medicaid

Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331

Phone: 1-888-695-2447

Website: https://www.health.ny.gov/health_care/medicaid/

Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – Medicaid

Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html

Phone: 1-800-442-6003 TTY: Maine relay 711

Website: https://dma.ncdhhs.gov/

Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid

Website: http://www.mass.gov/eohhs/gov/departments/masshealth/

Phone: 1-800-462-1120

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/

Phone: 1-844-854-4825

MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP

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.insureoklahoma.org

Phone: 1-888-365-3742

MISSOURI – Medicaid OREGON – Medicaid

Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

Phone: 573-751-2005

Website: http://healthcare.oregon.gov/Pages/index.aspx

http://www.oregonhealthcare.gov/index-es.html

Phone: 1-800-699-9075

MONTANA – Medicaid PENNSYLVANIA – Medicaid

Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP

Phone: 1-800-694-3084

Website:http://www.dhs.pa.gov/provider/medicalassistance/healthin

surancepremiumpaymenthippprogram/index.htm

Phone: 1-800-692-7462

NEBRASKA – Medicaid RHODE ISLAND – Medicaid

Website:

http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Page

s/accessnebraska_index.aspx

Phone: 1-855-632-7633

Website: http://www.eohhs.ri.gov/

Phone: 401-462-5300

NEVADA – Medicaid SOUTH CAROLINA – Medicaid

Medicaid Website: https://dwss.nv.gov/

Medicaid Phone: 1-800-992-0900

Website: https://www.scdhhs.gov

Phone: 1-888-549-0820

http://www.dol.gov/ebsahttp://www.cms.hhs.gov/http://dss.sd.gov/http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-programhttp://gethipptexas.com/http://www.dhhr.wv.gov/bms/Medicaid Expansion/Pages/default.aspxhttps://medicaid.utah.gov/http://health.utah.gov/chiphttps://www.dhs.wisconsin.gov/publications/p1/p10095.pdfhttp://www.greenmountaincare.org/https://wyequalitycare.acs-inc.com/http://www.coverva.org/programs_premium_assistance.cfmhttp://www.coverva.org/programs_premium_assistance.cfmhttp://www.kdheks.gov/hcf/http://www.dhhs.nh.gov/oii/documents/hippapp.pdfhttp://chfs.ky.gov/dms/default.htmhttp://www.state.nj.us/humanservices/dmahs/clients/medicaid/http://www.state.nj.us/humanservices/dmahs/clients/medicaid/http://www.njfamilycare.org/index.htmlhttp://dhh.louisiana.gov/index.cfm/subhome/1/n/331https://www.health.ny.gov/health_care/medicaid/http://www.maine.gov/dhhs/ofi/public-assistance/index.htmlhttps://dma.ncdhhs.gov/http://www.mass.gov/eohhs/gov/departments/masshealth/http://www.nd.gov/dhs/services/medicalserv/medicaid/http://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/medical-assistance.jsphttp://www.insureoklahoma.org/http://www.dss.mo.gov/mhd/participants/pages/hipp.htmhttp://healthcare.oregon.gov/Pages/index.aspxhttp://www.oregonhealthcare.gov/index-es.htmlhttp://dphhs.mt.gov/MontanaHealthcarePrograms/HIPPhttp://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htmhttp://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/accessnebraska_index.aspxhttp://www.eohhs.ri.gov/https://dwss.nv.gov/https://www.scdhhs.gov/


Page 29

Addendum B - Medicare Part D Notice of Creditable Coverage

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).

Important Notice from Ravago Americas, LLC

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 Ravago

Americas, LLC 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. Ravago Americas, LLC has determined that the prescription drug coverage offered through United Healthcare 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 through December 7th. However, if you

lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment

Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current coverage will not be affected. If you do decide to join a Medicare drug plan and drop your current

coverage, be aware that you and your dependents will be able to reenroll in our program during the next open enrollment period.

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 Ravago Americas, LLC 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 Ravago Americas, LLC 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).

CMS Form 10182-CC Updated April 1, 2011

Date: 10/01/2017

Name of Entity/Sender: Ravago Americas, LLC

Contact--Position/Office: Donna Comey – Director of Human Resources

Address: 1900 Summit Tower Blvd, Suite 900

Orlando, FL 32810

Phone Number: (407) 475-9717

http://www.medicare.gov/http://www.socialsecurity.gov/


Page 30

GLOSSARY OF TERMSBalance Billing – When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the

provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may

not balance bill you for covered services.

Coinsurance – The portion of the cost for care received for which an individual is financially responsible, which is usually calculated as a

percentage (such as 20%). Often coinsurance applies after a specific deductible has been met and may be subject to an individual

out-of-pocket. For example, if the plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance

payment of 20% would be $20. The plan pays the rest of the allowed amount.

Copayment – A payment you make at the time that selected services are rendered and no additional payment is required. Copayments

are typically flat amounts (for example, $15), covering such items as office visits, prescriptions, and emergency care.

Covered Expenses – Health Care expenses that are covered under your health plan.

Deductible – The amount of eligible expenses you must pay, out of pocket each plan year, before the plan begins to pay. The deductible

may not apply to all services.

Embedded Deductible: An embedded deductible is an individual deductible level within a family contract. For example, if there is a

family deductible of $3,000 with an individual embedded deductible of $1,500, when any one individual family member reaches

$1,500 in expenses, their benefit plan coverage takes effect.

Non-embedded Deductible: An non-embedded deductible requires that the entire family deductible be met before benefit plan

coverage takes effect by any one or combination of family members.

Evidence of Insurability – A medical questionnaire which is used to determine whether an applicant will be approved or declined

coverage.

Guarantee Issue - The amount which is available without providing an Evidence of Insurability (EOI). An EOI will be required for any

amounts above this, for late enrollees or increases in insurance.

In-Network – Care received from physicians, facilities or suppliers that are contracted with the insurer to provide services on a negotiated

discount basis.

Late Entrant – A member that becomes insured more than 30 days after initial eligibility or becomes insured again after previously

waiving coverage.

Mandatory Generic – When you request a brand name drug when there is a generic equivalent, you pay the generic copay plus the cost

difference between the brand and generic drug. Dispense as written (DAW) may be allowed. With DAW you will not be charged a

cost difference.

Out-of-Network – Care received from physicians, facilities or suppliers that are not contracted with the insurer to provide services on a

negotiated discount basis.

Out-of-Pocket Expense – Amount you must pay toward the cost of health care services. This may include deductibles, copayment and/or

coinsurance.

Out-of-Pocket Maximum – The maximum dollar amount a member is required to pay out of pocket during a benefit period. Plans may

vary but deductibles and coinsurance may apply toward meeting the out-of-pocket maximum.

Preferred Provider – A provider who has a contract with your carrier/vendor to provide services to you at a discount.

Pre-existing Condition – Any Injury or Sickness for which you received medical treatment, advice or consultation, care or services

including diagnostic measures, or had drugs or medicines prescribed or taken in the X months prior to the day you become insured.

For example: Disabilities that occur during the first 6 months of coverage due to a pre-existing condition that occurred during the 3

months prior to coverage are excluded.

Provider – A physician (medical, dental or vision), health care professional or health care facility licensed, certified or accredited as

required by state law.

Prior Authorization/Pre-Service Notification – The decision by the plan or health insurer that a health care service, treatment plan,

prescription drug, medical equipment, or other health care services defined in the certificate of coverage, is medically necessary. The

plan may require preauthorization for certain services before receiving them, except in an emergency.

UCR (Usual, Customary & Reasonable) – The amount paid for a service in a geographic area based on what providers in the area

usually charge for the same or similar service. The UCR amount is sometimes used to determine the allowed amount.


Page 31

Benefit / Contact Carrier / Resource Phone Website / Email

Medical United Healthcare (866) 844-4864 www.myuhc.com

Dental Cigna (800) 244-6224

www.mycigna.com

Vision Cigna (800) 478-7557

Flexible Spending

Account (FSA)Medcom (800) 523-7542 www.mywealthcareonline.com/medcom

Life Insurance

Voya

(888) 238-4840

www.voya.com

Disability (800) 328-4090

Legal Services LegalShield (800) 654-7757 www.benefits.legalshield.com/ravago

Identity Theft Services IDShield (888) 494-8519 www.idshield.com

Pet Insurance ASPCA

(877) 343-5314

CODE:

EB17RAVAGO

www.aspcapetinsurance.com/ravago

Employee Assistance

Program (EAP)ComPsych (877) 533-2363 [email protected]

Voluntary Products Voya (877) 236-7564 https://claimscenter.voya.com

Danielle Donofrio Ravago Americas, LLC (407) 875-6697 [email protected]

Explain My Benefits

Open Enrollment (407) 329-3714

www.explainmybenefits.biz/ravagoOngoing Support after

August 31, 2017

(321) 296-8060

Option 1

Debbie Cox Brown & Brown of FL (321) 214-2399 [email protected]

CONTACTS

This guide is provided to you by:
http://www.myuhc.com/http://www.mycigna.com/http://www.mywealthcareonline.com/medcomhttp://www.voya.com/http://www.benefits.legalshield.com/ravagohttp://www.idshield.com/mailto:[email protected]://claimscenter.voya.com/mailto:[email protected]://www.mutualofomaha.com/mailto:[email protected]

Documents

Employee Benefits Guide · 2020. 7. 26. · In case of discrepancy between the Benefits Guide and the actual plan ... –Affidavit Required - Natural, adopted, foster or step child(ren)