For Your Beneﬁ tDocs/Matrix 2017 … · EMPLOYEE BENEFITS GUIDE January 1, 2017 - December 31, 2017 For Your Beneﬁ t

EMPLOYEE BENEFITS GUIDEJanuary 1, 2017 - December 31, 2017

For Your Benefi t

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2017 Open Enrollment: Your Benefi t Election Enrollment ChecklistBe prepared - review and use this enrollment checklist prior during this open enrollment period.

• Read the 2017 Employee Benefi ts Guide and other plan highlights or FAQ’s to assist with your benefi t electi on decisions (refer to Document Library in the online enrollment portal).

• Att end an on-site Open Enrollment Meeti ng or Webinar or view the recorded version available on Matrix Connect.• Call the Matrix Benefi ts Call Center if you have any questi ons or to learn more about your personal opti ons.• Have your electi on decisions made before going to the on-line enrollment website or before calling the Matrix Benefi ts Call Center.• Make your benefi ts electi ons for 2017 during your enrollment window of November 16 - 29, 2016. Please note: If you do not make

a selecti on, you will be defaulted into only 100% employer-paid benefi ts (Basic Life/AD&D, Long Term Disability and Employee Assistance Program).

• Benefi t electi ons must be made either online or calling the Benefi ts Center on or prior to November 29th:• www.cbizesc.com/matrixmedicalnetwork• Call 1-888-287-6934

• Be sure to have your dependent informati on, such as their social security number, name as it appears on their social security card and date of birth, at your fi ngerti ps in order to enroll your dependent(s) in benefi ts and to designate your life insurance benefi ciary.*

• Review any previous informati on you had entered for your dependents to make sure it accurately refl ects their social security number, name as it appears on the social security card and their birthday.*

• Aft er making your electi ons, carefully review your benefi t electi ons, confi rm and print off your enrollment confi rmati on statement. If you call in to make your electi ons ask to have the enrollment confi rmati on statement emailed to you.

• You may change any electi on prior to the end of the open enrollment period on November 29th. Aft er that all benefi ts electi ons will be in force for 2017 unless you experience a qualifi ed life event.

*IMPORTANT INFORMATION: The informati on you enter for your dependents is reported on the annual 1095c form, if you elect medical coverage, as required by the IRS. If names or numbers do not match up to their system it will reject the submission.

New Hires: Your Benefi t Election Enrollment Checklist• Read the 2017 Employee Benefi ts Guide and other plan highlights or FAQ’s to assist with your benefi t electi on decisions (refer to

Document Library in the online enrollment portal).• View the recorded Benefi ts overview presentati on available on Matrix Connect.• Call the Matrix Benefi ts Call Center if you have any questi ons or to learn more about your personal opti ons.• PROMPT ON-LINE ENROLLMENT AT LEAST 15 DAYS BEFORE YOUR EFFECTIVE DATE WILL BETTER ENSURE YOUR BENEFITS WILL BE

AVAILABLE TO YOU ON YOUR EFFECTIVE DATE. However, you do have 31 days from your eff ecti ve date to make your benefi t electi ons - although waiti ng to enroll unti l aft er your actual eff ecti ve date is not recommended. It is important for you to understand that failure to enroll by this deadline means you will not have benefi ts and will not be able to elect benefi ts unti l the next annual open enrollment period, unless you experience a qualifying event.

• Have your electi on decisions made before going to the on-line enrollment website or before calling the Matrix Benefi ts Call Center.• Benefi t electi ons must be made either online or calling the Benefi ts Center:

• www.cbizesc.com/matrixmedicalnetwork• Call 1-888-287-6934

• Be sure to have your dependent informati on, such as their social security number, name as it appears on their social security card and date of birth, at your fi ngerti ps in order to enroll your dependent(s) in benefi ts and to designate your life insurance benefi ciary.*

• Aft er making your electi ons, carefully review your benefi t electi ons, confi rm and print off your enrollment confi rmati on statement. If you call in to make your electi ons ask to have the enrollment confi rmati on statement emailed to you.

• All benefi ts electi ons will be in force for 2017 unless you experience a qualifi ed life event.

*IMPORTANT INFORMATION: The informati on you enter for your dependents is reported on the annual 1095c form, if you elect medical coverage, as required by the IRS. If names or numbers do not match up to their system it will reject the submission.

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TABLE OF CONTENTSImportant Benefi t Contact Informati on ............................................4

Benefi t Eligibility & Your Benefi ts Online .........................................5

Changing Your Coverage ...................................................................6

Health Terminology/Understanding Your Benefi ts ...........................7

YOUR BENEFITS

Medical

- Medical Benefi ts ........................................................................8

- Health Savings Account (HSA) ..................................................10

Other UnitedHealthcare Features ..................................................13

Employee Assistance Program........................................................17

Dental ............................................................................................18

Vision .............................................................................................19

2017 Employee Per Pay Period Cost Summary ...............................20

Flexible Spending Accounts & Transportati on ................................21

Life & Supplemental Life ................................................................22

STD & LTD ......................................................................................23

Legal and Identi ty Theft ..................................................................24

Other Voluntary Benefi ts ................................................................25

Legal Noti ces ..................................................................................26

Marketplace Coverage Opti ons ......................................................35

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Welcome to Matrix Medical Network! As a Matrix Medical Network employee, you have access to a comprehensive package of benefi ts for you and your family to include the following:

Here’s How it Works • Step 1: Visit www.cbizesc.com/matrixmedicalnetwork • Step 2: Review your opti ons and learn more about benefi ts available in 2017• Step 3: Choose the coverage you want at a cost that best meets your needs

Your Benefi t Opti onsYou’ll be able to choose from a wide variety of plans that off er quality coverage with a range of costs, including medical, dental, vi-sion, life, disability, and more. We encourage you to take the ti me to understand all of your opti ons and then make the best decisions for you and your family. To learn more, visit: www.cbizesc.com/matrixmedicalnetwork.

Need Assistance?If you have questi ons or need assistance enrolling in benefi ts, call the Matrix Benefi ts Call Center at 888.287.6934 to speak with a ben-efi t counselor. Matrix Benefi ts Call Center hours are 8:30 am to 5:00 pm CST, Monday through Friday. **During open enrollment the call center hours are from 8:30 am to 6:00 pm CST.**

Acti on RequiredTake an acti ve role during your annual open enrollment period. You must re-enroll for all benefi ts during open enrollment from Wednesday, November 16 to Tuesday, November 29, 2016. Go to www.cbizesc.com/matrixmedicalnetwork to enroll or call the Matrix Benefi ts Call Center at 888.287.6934.

For new hires/newly eligible You can enroll in and make changes to your benefi t coverages aft er your date of hire and during your fi rst 31 days of employment. If you do not make a selecti on, you will be defaulted in 100% employer-paid benefi ts only. Prompt enrollment at least 15 days before your benefi t eff ecti ve date will bett er ensure your benefi ts will be available to you on your eff ecti ve date.

Important Contact Informati onIf you have questi ons about your benefi ts or need assistance with enrolling for benefi ts, call the Matrix Benefi ts Call Center at 888.287.6934. To contact a health plan directly, refer to informati on below:

• Group Life & AD&D• Voluntary Life Insurance• Disability

• Medical• Dental• Vision

• Employee Assistance Program (EAP)• Legal & Identi ty Theft • Flexible Spending Accounts

WHO WHAT PHONE WEBSITE

UnitedHealthcare MedicalPremium Tier 1 and Choice Plus Networks 844.490.5777 www.myuhc.com

Deer Oaks Employee Assistance Program888.993.7650When prompted, reference company name: Matrix Medical Network

www.deeroakseap.comLog on: MatrixPassword: Matrix

VSP Voluntary Vision Plan 800.877.7195 www.vsp.com

MetLife Dental“PDP Plus” Network 800.275.4638 www.metlife.com/mybenefi ts

Prudenti al Life Claims Disability Claims

800.778.3827800.842.1718

www.prudenti al.com/mybenefi tswww.prudenti al.com/mybenefi ts

MetLaw (Hyatt Legal) Voluntary Legal 800.821.6400 www.legalplans.comInfoArmor Identi ty Theft Protecti on 800.789.2720 www.myprivacyarmor.com

Discovery Benefi tsHealth Savings AccountsFlex Spending AccountsTransportati on Account

866.451.3399 www.discoverybenefi ts.com

Allstate Criti cal Illness , Accident, Hospital Indemnity 800.348.4489 www.allstatebenefi ts.com/mybenefi ts

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Benefi t EligibilityAll regular employees who work at least 30 hours per week, as defi ned by the measurement period per ACA guidelines, are eligible for benefi ts following the waiti ng period. Dependents eligible for coverage include your spouse and children up to age 26. When approved, your unmarried dependent child(ren) of any age who are disabled and rely on you for support are also eligible for coverage. You are eligible for benefi ts the fi rst day of the month following date of hire, re-hire, or moving into benefi t eligible status. If you are hired on the fi rst day of the month, your benefi ts start that day.

For New Hires/Newly Eligible PROMPT ON-LINE ENROLLMENT AT LEAST 15 DAYS BEFORE YOUR EFFECTIVE DATE WILL BETTER ENSURE YOUR BENEFITS WILL BE AVAILABLE TO YOU ON YOUR EFFECTIVE DATE.

Dependent Eligibility Verifi cati on Process• You will be required to provide proof of eligibility of your dependents (spouse/domesti c partner and children up to age 26) that

your are enrolling in the various benefi t off erings.• Enrollment of your dependent(s) WILL NOT BE CONSIDERED FINAL UNTIL you have completed the required dependent verifi cati on

audit and provided corresponding proof (documentati on) of your dependent’s eligibility.• Be on the lookout for your audit lett er, if applicable, that will be mailed to home address shortly aft er you complete your enrollment.• For 2017 Open Enrollment, you should receive an audit lett er in mid to late January mailed to your home.• You MUST respond by the established deadline noted in the audit lett er or your dependent enrollment(s) will be retroacti vely

cancelled/reversed.

When Benefi ts EndYour benefi ts will end on the last day of your employment (terminati on) or status change to non-benefi ts eligible, except for medical, dental and vision, which end on the last day of the month in which you were employed.

Annual Open Enrollment PeriodAnnual open enrollment is held in November of each year. Plan and electi on changes will be eff ecti ve January 1st.

Online Benefi t Informati on and Enrollment PortalMatrix Medical Network provides online access for our employees to enroll, change, and view benefi ts as well as view personal informati on. The portal provides employees with access to their benefi ts informati on 24 hours a day, 7 days a week, allowing you to review your own benefi ts at your convenience.

Once logged onto the portal you’ll be able to:• Enroll in benefi t plans• View benefi t electi ons• Print a confi rmati on statement• Change dependent and benefi ciary• Change your password • Access the Document Library which contains a wealth of plan details and

forms

Benefi t Eligibility

Your Benefi ts Online

From: Shireman, LeAnneTo: "Kevin"Cc: Benkert, ShellySubject: Matrix - one additiona changeDate: Friday, November 11, 2016 11:37:00 AMAttachments: image001.png

LeAnne Shireman, MHRM, PHR, SHRM-CP | Account ExecutiveCBIZ Benefits & Insurance Services, Inc1765 E Skyline Drive | Tucson, AZ 85718T 520.321.7546 | M 520.306-7041| F [email protected] | www.cbiz.com Ranked #1 U.S. Benefits Specialist, Business Insurance Magazine 2015Top 20 Broker in the U.S., Business Insurance Magazine 2015Ranked #1 Insurance Broker, Inside Tucson Business 2015

Please consider the environment before printing this e-mail. The information in this e-mail message may be privileged, confidential, and protected from disclosure. If you are not the intended recipient, any dissemination, distribution or copying is strictly prohibited. If you think that you have received this e-mailmessage in error, please e-mail the sender and delete all copies. Thank you.

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Changing Your CoverageWhen you fi rst become eligible for benefi ts, you will have the opportunity to review all your benefi t opti ons and then select those that best meet your needs. These benefi t electi ons will remain in place unti l the end of the current plan year (which ends December 31st of each year) unless you experience a qualifying event. Similarly, during each annual open enrollment you will have the opportunity to review and elect benefi t opti ons and these electi ons will remain in place unti l the end of the plan year (which ends December 31st of each year) unless you experience a qualifying event. A Qualifying Event (Q/E) is also referred to as a “Change in (family) Status”.

If you have a Change in Status during the plan year, you can make changes to your benefi ts within 31 days of the Q/E. In most cases, only changes consistent with the Change in Status can be made. The Matrix Benefi ts Call Center can explain in more detail the types of coverage changes you can make when you have a Change in Status. Following are some examples of Changes in Status:

• Employee’s change in marital status (marriage or divorce) or death of spouse• Birth, adopti on or death of a dependent child• Change in employee’s, spouse’s or dependent child’s employment status that aff ects

benefi t eligibility (for example full ti me to part ti me status; leave without pay)• Child becoming ineligible for coverage due to reaching limiti ng age of 26. Coverage

ends at the end of the month and COBRA will be off ered for eligible benefi ts.• Employee’s receipt of a qualifi ed medical child support order or lett er from the

Att orney General ordering the employee to provide (or allowing the employee to drop) medical coverage for a covered child

• Changes made by a spouse or dependent child during his/her annual enrollment period with another employer

• Becoming eligible or ineligible for Medicare or Medicaid• Signifi cant changes in or cancellati on of coverage• And specifi c to Dependent Care FSA: Change in day care costs due to a change in

provider, change in provider’s fees (if the provider is not a relati ve) or change in the hours the child needs day care

HIPAA Special Enrollment RightsUnder HIPAA, you are allowed to enroll in the Medical Plan without having to wait unti l the next Annual Open Enrollment period under certain conditi ons including “special enrollment.” The special enrollment period only applies to Medical Plans. If you later lose coverage under the other medical plan, in most cases you may enroll within 31 days of loss of the other coverage under the HIPAA Special Enrollment rules. However, SCHIP and certain HIPAA special enrollment conditi ons allow you 60 days to change your medical electi on if you become eligible or ineligible for Medicaid or state premium insurance. The Matrix Benefi ts Call Center can provide you with more details.

How and When May I Change My Elections

provider, change in provider’s fees (if the provider is not a relati ve) or change in the hours the child needs day care

You must report a Qualifying Event within 31 days of the event. Contact Matrix Benefi ts Call Center at 888.287.6934 to report

your Qualifying Event.

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Health Insurance Terminology/Understanding Your Benefi tsHere are some terms you will need to know to bett er understand and be able to select certain coverages.

Coinsurance or Cost SharingHow the cost of a health or dental expense is shared between you and the plan aft er you pay your deducti ble. Once you have sati sfi ed your specifi c benefi t defi ned plan year deducti ble, your plan begins to pay a percentage of covered expenses, this is your coinsurance obligati on. Your coinsurance will vary depending upon which benefi t plan opti on you elect and whether you use in-network or out-of-network providers or medical faciliti es.

CopaymentA fi xed dollar amount you pay for a physician’s offi ce visit, prescripti on drug or vision benefi ts. The remaining cost is covered by the plan. Copayments apply to the out of pocket maximums.

Deducti ble The amount of money you must fi rst pay toward health or dental expenses for each family member, each specifi c benefi t defi ned plan year, before the health or dental plan will make a payment for eligible benefi ts. Deducti ble amounts vary according to benefi t plan opti on you elect and whether you use in-network or out-of-network providers or medical faciliti es. Aft er you have paid your deducti ble, future eligible expenses are covered at the coinsurance percentage. In-network deducti bles and out-of-network deducti bles are not combined.

Out-of-Pocket Maximum The most you will have to spend each specifi c benefi t defi ned plan year for each covered family member; your deducti ble and coinsurance are included in your out of pocket maximum. Once you’ve met the out of pocket maximum on yourself or a covered dependent, the plan pays 100% of eligible expenses for you or your dependent for the rest of that plan year. In-network and out-of-network out of pocket maximums are not combined.

Health Savings Account (HSA)If enrolled in the High Deducti ble Health Plan, you are eligible to open an individual savings account (HSA) that you can put money into to save for future medical expenses. There are certain advantages to putti ng money into these accounts, including favorable tax treatment. The amount you choose to contribute into this account on a per pay period basis is deducted pre-tax.

PCP/SpecialistA primary care physician (PCP) is a general or family practi ti oner, an internal medicine doctor, a pediatrician or an obstetrician/gynecologist. All other doctors under these plans are considered specialists. You do not need a referral from your PCP to see a specialist.

Plan YearThe plan year for Matrix Medical Network runs between January 1st and December 31st each year. Prior to the beginning of each plan year, during open enrollment, you have the opportunity to review and change your benefi t electi ons.

Reasonable and CustomaryThe lowest of: the usual charge by the doctor, denti st or other provider of the services or supplies for the same or similar services or supplies, the usual charge of most other doctors, denti sts or other providers of similar training or experience in the same geographic area for the same or similar services or supplies, or the actual charge for the services or supplies.

Rx Tiers - Prescripti on DrugsA grouping of drugs that the plan can obtain at certain cost points. Tier 1 would be those drugs at a lower cost than Tier 2, Tier 3 or Tier 4.

Tier 4 is for specialty medicati ons. Specialty medicati ons are high cost medicati ons for complex or chronic conditi ons such as rheumatoid arthriti s, cancer, hepati ti s C and multi ple sclerosis.

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Your Medical Benefi ts - UnitedHealthcareAmong the most important decisions you will make is the type of medical insurance that is best for you and your family. This important insurance helps to protect you and your family from the fi nancial loss of a catastrophic illness or accident. Matrix Medical Network off ers you medical insurance coverage through UnitedHealthcare (UHC). Health Care Reform regulati ons require most Americans to have medical insurance or pay a federal tax penalty. It is important to be covered, either through your Matrix-sponsored plan or through another opti on available to you, such as your spouse’s employer benefi ts or a government program such as Medicare, Medicaid or The Marketplace. You may choose from 3 UHC medical insurance plans. Your in-network and out-of-network deducti bles and your annual out-of-pocket maximums are accumulated based upon each plan year (January 1 - December 31).

ADVANTAGE QUALIFIED HIGH DEDUCTIBLE HEALTH PLAN: YOU PAY Premium Tier 1 In-Network In-Network Out-of-Network Deductible (Non - Embedded) Employee/Family

$1,500/$3,000 Combined Med & Rx



Coinsurance **90%/10% 80%/20% 50%/50% Out of Pocket Maximum* - Employee/Family $3,000/$6,000 $3,000/$6,000 $6,000/$12,000 Preventative Office Visits Covered at 100% Covered at 100% Not Covered Non-Preventative Office Visits 10% coinsurance after deductible 20% coinsurance after deductible 50% coinsurance after deductible Virtual Healthcare Visits N/A 10% after deductible N/A Minor & Major Lab/X-ray Free Standing / Dr’s office Hospital Based

10% coinsurance after deductible 20% coinsurance after deductible


Hospital – Inpatient N/A 20% coinsurance after deductible 50% coinsurance after deductible Emergency Room N/A 20% coinsurance after deductible 20% coinsurance after deductible Urgent Care N/A 20% coinsurance after deductible 50% coinsurance after deductible Pharmacy Benefit - YOU PAY Rx Tier 1 N/A $10 copay after deductible $10 copay after deductible Rx Tier 2 N/A $35 copay after deductible $35 copay after deductible Rx Tier 3 N/A $60 copay after deductible $60 copay after deductible Rx Tier 4 (Specialty Rx) N/A $100 copay after deductible Not Covered

Rx Mail Order N/A Tiers 1 – 3: $25/$87.50/$150

after deductible N/A

CLASSIC PLAN: YOU PAY Premium Tier 1 In-Network In-Network Out-of-Network Deductible (Embedded) Employee/Family $1,250/$2,500 $1,250/$2,500 $2,500/$5,000 Coinsurance **90%/10% 80%/20% 50%/50% Out of Pocket Maximum* - Employee/Family $5,000/$10,000 $5,000/$10,000 $10,000/$20,000 Preventative Office Visits Covered at 100% Covered at 100% Not Covered Non-Preventative Office Visits 10% coinsurance after deductible 20% coinsurance after deductible 50% coinsurance after deductible Virtual Healthcare Visits N/A 10% after deductible N/A Minor & Major Lab/X-ray Free Standing / Dr’s office Hospital Based



Hospital – Inpatient N/A 20% coinsurance after deductible 50% coinsurance after deductible Emergency Room N/A 20% coinsurance after deductible 20% coinsurance after deductible Urgent Care N/A $50 copay 50% coinsurance after deductible Pharmacy Benefit - YOU PAY Rx Tier 1 N/A $10 copay $10 copay Rx Tier 2 N/A $35 copay $35 copay Rx Tier 3 N/A $70 copay $70 copay Rx Tier 4 (Specialty Rx) N/A $100 copay Not Covered Rx Mail Order N/A Tiers 1 – 3: $25/$87.50/$175 N/A

Note: Matrix contributes up to $400 employee only / $800 family per year to the employees Health Savings Account. These amounts are pro-rated based on date of eligibility and electi on of benefi t.

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The Medical Plan charts refl ect basic summary informati on only. Please refer to your Certi fi cate of Coverage for exact plan details. The Certi fi cate of Coverage can be found on the benefi ts site in the document library under Medical.

Note: Due to IRS regulati ons, parti cipants in the Advantage High Deducti ble Plan will be responsible for paying 100% of the cost of prescripti on medicati ons, regardless of ti er assignment, unti l they have sati sfi ed the plan’s annual deducti ble. If a parti cipant is enrolled along with dependents in the Advantage High Deducti ble Plan with HSA, they must fully meet their family deducti ble before benefi ts are paid.

Embedded Deducti ble - Is applicable when you are covering any dependents. With an embedded deducti ble, once the individual family member pays the individual deducti ble, UHC begins to pay coinsurance for covered medical expenses associated with this individual’s services even though the family deducti ble is not yet met.

* The annual out-of-pocket maximum includes the annual deducti ble, coinsurance and copayments, as applicable** Premium Tier 1 provider services only

Availability of Summary Health Information and Important Benefi t Annual NoticesAs an employee, the health benefi ts available to you represent a signifi cant component of your compensati on package. They also provide important protecti on for you and your family in case of illness or injury.

Your plan off ers a series of health coverage opti ons. Choosing a health coverage opti on is an important decision. To help you make an informed choice, your plan makes available a Summary of Benefi ts and Coverage (SBC), which summarizes important informati on about any health coverage opti on in a standard format, to help you compare across opti ons. An Employee Ben-efi ts Guide is also available to assist you in making benefi t decisions and contains important annual benefi t noti ces.

SBC’s and Employee Benefi ts Guide are available on the web at www.cbizesc.com/matrixmedicalnetwork, then click on the “Benefi ts” tab and go to the Document Library/Medical. A paper copy is also available, free of charge, by contacti ng your Hu-man Resources Department at [email protected].

PREMIUM PLAN: YOU PAY Premium Tier 1 In-Network In-Network Out-of-Network Deductible (Embedded) Employee/Family $800/$1,600 $800/$1,600 $2,400/$4,800 Coinsurance **90%/10% 80%/20% 50%/50% Out of Pocket Maximum* - Employee/Family $4,000/$8,000 $4,000/$8,000 $5,000/$10,000 Preventative Office Visits Covered at 100% Covered at 100% Not Covered

Non-Preventative Office Visits PCP @ $10 copay Spec @ $30 copay

PCP @ $20 copay Spec @ $45 copay 50% coinsurance after deductible

Virtual Healthcare Visits N/A $10 copay N/A Minor & Major Lab/X-ray Free Standing / Dr’s office Hospital Based



Hospital – Inpatient N/A 20% coinsurance after deductible 50% coinsurance after deductible

Emergency Room N/A

$125 copay 1st visit; $250 copay 2nd & 3rd visits;

$500 copay for all subsequent visits (copay waived if admitted)

$125 copay 1st visit; $250 copay 2nd & 3rd visits;

$500 copay for all subsequent visits (copay waived if admitted)

Urgent Care N/A $50 copay 50% coinsurance after deductible Pharmacy Benefit - YOU PAY Rx Tier 1 N/A $15 copay $15 copay Rx Tier 2 N/A $40 copay $40 copay Rx Tier 3 N/A $70 copay $70 copay Rx Tier 4 (Specialty Rx) N/A $100 copay Not Covered Rx Mail Order N/A Tier 1 – 3: $37.50/$100/$175 N/A

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TWO COMPONENTSHIGH

DEDUCTIBLE HEALTH PLAN

(HDHP)

What is a high deducti ble health plan? It’s an IRS qualifi ed medical Insurance plan that has a high deducti ble that protects you against catastrophic medical expenses. This is health insurance that does not cover fi rst dollar medical and Rx expenses (you must fi rst meet your deducti ble before medical or prescripti ons are covered). However in-network wellness exams and associated labs and procedures are not subject to the deducti ble and are covered at no cost to you.

What is a health savings account? In tandem with a HDHP, a Health Savings Account (HSA) is an individual savings account that you can put money into to save for future medical expenses. There are certain advantages to putti ng money into these accounts, including favorable tax treatment.

Advantage High Deductible Health Plan (HDHP) with Health Savings Account (HSA)

Advantages of Enrolling in a HDHP and Opening an HSA:• Security – Your high deducti ble insurance and savings put aside into your HSA protect you against high or unexpected medical bills• Flexibility – You can use the funds in your account to pay for current medical expenses, including expenses that your insurance

may not cover, or save the money in your account for future needs, such as: • Health insurance or medical expenses if unemployed • Medical expenses aft er reti rement (before Medicare) • Out-of-pocket expenses when covered by Medicare • Long-term care expenses and insurance• Savings – You can save the money in your account for future medical expenses and grow your account through future investments• Control – You make all the decisions about: • How much money to put into the account • Whether to save the account for future expenses or pay current medical expenses • Which medical expense to pay from the account • Whether to invest any of the money in the account • Which investments to make

INDIVIDUAL HEALTH

SAVINGS BANK ACCOUNT

(HSA)

HSA for those enrolled in the Advantage Plan - a Consumer pre-tax savings account funded by Employee & Employer

If you enroll in the Advantage Plan (High Deducti ble Health Plan), you are eligible to open an HSA through Discovery Benefi ts; key features include:

• You can make pre-tax contributi ons to the account to be used for eligible medical expenses• Matrix contributes to your HSA• Balance accumulates if not used (No use it or lose it!)• Funds are tax-free and remain yours even if you change jobs or reti re

Understanding How it WorksYour employer believes it is in your best interest to investi gate and fully evaluate the advantages of consumer driven healthcare available to you in the qualifi ed High Deducti ble Health Plan, referred to as the Advantage Plan, with the opti on of a Health Savings Account (HSA). It is important you fully understand this plan before electi ng it. This medical plan choice: (1) may allow you to pay less in monthly premiums (your payroll deducti ons from your paycheck for medical insurance will be signifi cantly less); (2) allows you the ability to save for future healthcare needs; and (3) allows you greater ability, and also greater responsibility in managing your healthcare dollars.

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Advantages of Enrolling in a HDHP and Opening an HSA (Conti nued)

• Portability – Accounts are completely portable, meaning you can keep your HSA even if you: • Change jobs • Change your medical coverage • Become unemployed • Move to another state • Change your marital status• Ownership – Funds remain in the account from year to year, just like an IRA. There are no “use it or lose it” rules for HSA’s• Tax Savings – An HSA provides you triple tax savings: • Tax deducti on when you contribute to your account • Tax-free earning through investment, and, • Tax-free withdrawals for qualifi ed medical expenses

Who can have an HSA?Any eligible employee can contribute to an HSA if they:• Have coverage under an HSA-qualifi ed “high deducti ble health plan” (HDHP)• Have no other fi rst-dollar medical insurance coverage; however, coverage under voluntary medical expense reimbursement

plans like Allstate’s accident, criti cal illness or hospital confi nement is allowed• Are not enrolled in Medicare• Cannot be claimed as a dependent on someone else’s tax return

Contributi ons to your HSA can be made by you, your employer, or both. The total contributi ons are limited annually. For 2017 the annual limits are $3,400 for individual and $6,750 for family. Annual catch-up contributi ons for employees age 55+ is an additi onal $1,000. Contributi ons to the account must stop once you are enrolled in Medicare. However, you can keep the money in your account and use it to pay for medical expenses tax-free.

Using your HSAYou can use the money in the account to pay for any “qualifi ed medical expense” permitt ed under federal tax law. This includes most medical care and services, and dental and vision care and also includes certain over-the-counter drugs with a prescripti on. Go to www.irs.gov/publicati ons/p502 for a complete listi ng of qualifi ed medical expenses.

Generally, you cannot use the money to pay for medical insurance premiums, except under specifi c circumstances, including:• Any health plan coverage while receiving federal or state unemployment benefi ts• COBRA conti nuati on coverage aft er leaving employment with a company that off ers health insurance coverage• Qualifi ed long-term care insurance• Medicare premiums and out-of-pocket expenses including deducti bles, co-pays, and coinsurance for: - Part A (hospital and inpati ent services) - Part B (physician and outpati ent services) - Part C (Medicare HMO and PPO plans) - Part D (prescripti on drugs)

You can use the money in the account to pay for medical expenses for yourself, your spouse, or your dependent children. You can pay for expenses for your spouse and dependent children even if they are not covered by your HDHP. Please note that medical expenses for a Domesti c Partner are not considered by the IRS as qualifi ed healthcare expenses.

Any amounts used for purposes other than to pay for “qualifi ed medical expenses” are taxable as income and subject to an additi onal 20% tax penalty. Examples include:• Medical expenses that are not considered “qualifi ed medical expenses” under federal tax law (e.g. cosmeti c surgery)• Other types of health insurance unless specifi cally described above• Medicare supplement insurance premiums• Expenses that are not medical or health-related

Aft er you turn age 65, the 20% additi onal tax penalty no longer applies. If you become disabled and/or enroll in Medicare, the account can be used for other purposes without paying the additi onal 20% penalty.

Advantage High Deductible Health Plan (HDHP) with Health Savings Account (HSA)

12

If you enroll in the Qualifi ed High Deducti ble Health Plan, you are eligible to establish a Health Savings Account. Matrix off ers a pre-tax, payroll deducti on HSA opti on through Healthcare Bank, the trustee associated with Discovery Benefi ts. To establish this HSA account you should elect to open your account on the enrollment website (www.cbizesc.com/matrixmedicalnetwork) during your initi al enrollment or during open enrollment. The amount you choose to defer into this account on a per paycheck basis is deducted pre-tax. You may change your initi al new hire HSA contributi on amount or subsequent annual open enrollment HSA contributi on amount at any ti me by going to www.cbizesc.com/matrixmedicalnetwork. You may arrange for an HSA savings account with any qualifi ed banking insti tuti on, but you will not have the advantage of pre-tax payroll deducti ons to fund your account, nor will you receive the employer contributi on.

In additi on, Matrix will contribute $400 per plan year for employee only coverage and $800 per year for employee plus dependent coverage. This amount is pro-rated per pay period over the course of the Plan Year based on electi on date of coverage. In order for you to receive this employer contributi on you must open a Healthcare Bank account through Discovery Benefi ts.

Contributi ons (both employee and employer) will be deposited into your account aft er each pay period within a reasonable period of ti me - typically between 7 to 10 business days aft er each pay date.

Healthcare Bank Makes it Easy to SaveHealthcare Bank, Member FDIC, is one of the nati on’s largest administrators of HSA’s. With Healthcare Bank, you get the experience and resources of a leading HSA bank, the ability to earn interest, access to a variety of investment opti ons, and the convenience of managing your healthcare banking online.

What Informati on will I Receive about my HSA from Healthcare Bank?Aft er Healthcare Bank has approved and processed your request to open a HSA, Healthcare Bank will send you a welcome packet, including your account number, and important account opti on informati on. This should arrive 3-5 days aft er your account has been opened. If you wish to view your account balance, you can register online. Registrati on informati on will be included in your welcome packet.

Access your Dollars with an HSA Debit CardWith Healthcare Bank, you will have a Health Savings Account MasterCard® prepaid debit card to easily and conveniently access your money:

• At any point-of-service locati on (such as a pharmacy or doctor’s offi ce) that accepts MasterCard• At any ATM displaying the MasterCard brand mark.

To pay a bill from a provider who accepts MasterCard, just write in your debit card number in the space provided on the provider’s billing statement.

Go online at your convenience to:• www.healthcarebank.com• Use online calculators to calculate future savings and contributi on amounts• View your account balance, monthly statement, and more• Pay bills• Check deposits or withdrawals• Set or reset phone or web password• Learn about investment opti ons and more

Opening, Funding and Using your HSA

13

UnitedHealthcare Programs and FeaturesVirtual Healthcare Visits• No driving!

• No crowded waiti ng rooms!

• See a doctor when you need a doctor – 24 hours a day/7 days a week – from the convenience of your home or offi ce!

• Lower cost than emergency room or urgent care provider services, and someti mes even less than visiti ng your PCP

• You will be able to see and speak with a doctor using real-ti me audio and video conferencing technology to obtain a diagnosis and any necessary prescripti ons for minor medical needs such as allergies, sinus infecti ons, urinary tract infecti ons, bronchiti s, seasonal fl u, cough/cold, sore throat, etc.

• Amwell and Doctor on Demand are the two providers of this service. Download their app to your smart device today so you are ready when you need it.

Sign up today through MyUHC.com. It’s easy! From your computer or mobile device, log into myuhc.com, register under “Virtual Visits” and request a visit. You can also down-load the UHC app “Health4Me” on your mobile device.

14

UnitedHealthcare Programs and Features (continued)Quit for Life Tobacco Cessati on Program

• According to the American Cancer Society®, tobacco use is the number one cause of preventable illness and death in the United States.

• One of the best ways to improve your health and reduce your healthcare costs is to disconti nue using tobacco products.

• Matrix is committ ed to helping our employees become tobacco-free and will support them as they take this important step to improve their overall health.

• Off ering UHC’s (in collaborati on with the American Cancer Society) Quit for Life Tobacco Cessati on Program

- Program will be available to enrolled members as of February 1, 2017

- No cost to enrolled employees

- Provides you coaching and resources

- Provides Nicoti ne Replacement Therapy

• Call 866-785-8454 to enroll

Tobacco Non User versus Tobacco User Employee Contributions

• Offering UHC’s (in collaboration with the American Cancer Society) Quit for Life Tobacco Cessation Program

‒ Program will be available to enrolled members as of February 1, 2017 ‒ No cost to enrolled employees ‒ Provides you coaching and resources ‒ Provides Nicotine Replacement Therapy

• In the interim, following are resources you can utilize:

‒ Deer Oaks Employee Assistance Program; call 888-993-7650 to obtain contact information for local community-based tobacco cessation programs

‒ National Smoke Free – interactive website that provides a variety of methods of support;

https://smokefree.gov/ American Lung Association;http://www.lung.org/our-initiatives/tobacco/cessation-and-

prevention/ VeryWell site;https://www.verywell.com/things-to-do-instead-of-smoking-2824746

‒ State specific Arizona– The Ash Line; https://ashline.org/; 1-800-556-6222 Florida - http://www.tobaccofreeflorida.com

35

14

15

Using myuhc.comThis UHC website provides tools that inform you so you can get the most out of your benefi ts. Aft er logging on to www.myuhc.com, your personalized home page will be displayed. Select a secti on you would like to visit. Drop down menus will let you reach any desti nati on on the site with one click:

• Get a personalized Health Assessment that will help you set goals and change health habits • Read valuable health informati on and obtain ti ps for staying healthy• Check your claims status and history• Review eligibility/benefi t informati on• Find an in-network physician or hospital• Print a temporary ID card and request a replacement ID card• Use Pharmacy Online to order and renew prescripti ons • Review hospital specialti es and quality measures using Hospital Comparison Tool• Explore various treatment costs with the Treatment Cost Esti mator• Compare the costs of diff erent plan opti ons using the Plan Comparison Calculator• Communicate one-on-one with a registered nurse using Live Nurse Chat• Research health conditi ons, symptoms and the latest treatment opti ons• This website also allows you access to unique programs that take a new approach to

wellness. These programs from UHC add value to your medical plans as you strive to stay bett er informed and healthier. Simply click the Health & Wellness tab and access all the various resources, tools and programs

Mobile access to myuhc.com works with most Blackberry devices,

Android and Apple phones.

DocGPS helps locate network doctors, clinics and hospitals,

anywhere, anytime.

Easy access to your medical plan information, claims status,

ID cards, etc.

Other Health & Wellness Programs• All programs listed below are at no charge to you or your enrolled dependents!• Rally - Shows you how to make simple changes to your daily routi ne, set smart goals and stay on target. You’ll get personalized

recommendati ons on how to move more, eat bett er and feel happier. Go to www.myuhc.com to get started.• Disease Management Programs - Focusing on Asthma, Chronic Obstructi ve Pulmonary Disease, Coronary Artery Disease,

Diabetes and Heart Failure. Call the customer service number on the back of your UHC ID card or go to [email protected].• Healthy Pregnancy Program - Get personalized help through pregnancy and delivery with Health Pregnancy. Call 800-411-7984

or www.healthy-pregnancy.com.• Nurse Line - An experienced team of registered nurses to help you make the right healthcare treatment locati on decisions. Call

the customer service number on the back of your UHC ID card.• Health Discount Program - Administered by HealthAllies to include discounts on fi tness, hearing aides, tobacco cessati on, Jenny

Craig, Curves, Fitbit, etc. Link to discounts through www.myuhc.com.

UnitedHealthcare Programs and Features (continued)

GAP ExceptionWhen there is no UHC provider in your area UHC has over 325,000 physicians and 3,000 hospitals nati onwide in their network. However, if you are residing in a regional area where there is not a UHC physician or hospital within a 30 mile radius, you may request a “network gap excepti on.”

Simply call the customer care phone number on the back of your UHC ID card and follow menu prompts to Care Coordinati on. A customer care representati ve in this department will take your informati on and you will be noti fi ed if you are approved to see a non-UHC physician or receive treatment at a non-UHC hospital or facility at the in-network benefi t level. Remember, you must get gap excepti on approval in advance for each ti me you require out of network approvals to be considered.

16

Things to Consider for Maximum Healthcare Cost SavingsChoosing the Right Health Setti ng• A Primary Care Physician (PCP) knows your history and can help you maintain your health with annual preventati ve wellness exams

and associated screenings in additi on to helping you manage any chronic conditi ons and guide you to specialists as needed. Be sure to select a PCP today to take control of your long term health.

• When you’re sick or hurt, and it’s not urgent, it’s usually best to go to your own primary care physician.• When you need care in the evening or on a weekend when your primary care physician may not be available, it’s important to

consider your best alternate health care setti ng for non life threatening or urgent situati ons:

- Virtual healthcare Visits

- Convenience Care Clinics (on site clinics found, for example, at Walgreens, CVS, and grocery stores

- Urgent Care Centers

• If the situati on is life threatening or urgent, then go to the closest Emergency Room• Stay in-network and your claims will be paid at the highest level and you will have the least out-of-pocket expense when you select

UHC in-network physicians and medical faciliti es for you (and your family’s) medical services. • The cost of medical care can vary widely and depends on where you receive care. Know the facts and spend your money wisely. If

you are not sure where to go, call the number on the back of your UHC medical ID Card to speak with NurseLine (a registered nurse) 24/7.

Here are the average costs for medical services in the various setti ngs:

If Enrolled in Advantage Plan (HDHP)Emergency Room visit = $1,351Urgent Care visit = $152Convenience Care Clinic visit = $78Virtual Visit = $45Call to NurseLine = No Cost

If Enrolled in the Classic PlanEmergency Room visit = $1,351Urgent Care visit = $50 copayConvenience Care Clinic visit = $78Virtual Visit = $45Call to NurseLine = No Cost

If Enrolled in Premium PlanEmergency Room visit = $100 copay (higher copay for 2 or more visits )Urgent Care visit = $50 copayConvenience Care Clinic visit = $20 copayVirtual Visit = $10 copayCall to NurseLine = No Cost

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Employee Assistance Program

EAP Contact Information

You may call Deer Oaks any time - 24 hours a day, 7 days a week at 888.993.7650reference company name:

Matrix Medical Network

Deer Oaks - Your EAP ProviderThe EAP benefi t is not only free to all employees, and their dependents, but it is also confi denti al and provides a wide variety of counseling, referral, consultati on services and on line tools and resources, which are designed to assist you and your family in resolving work/life issues in order to live happier, healthier and more balanced lives.

The EAP benefi t covers 6 confi denti al short-term counseling visits and is at no cost to employees and their families.

Deer Oaks EAP has considerable experti se and clinical knowledge possessed by its clinicians and numerous convenient locati ons. Deer Oaks clinicians are well versed in helping clients of all ages from young children up to the elderly.

The EAP can assist with many diff erent types of problems. Among these are stress, depression, anxiety, workplace diffi culti es, substance abuse, mari-tal problems, family or parenti ng confl icts, grief, violence and unhealthy lifestyles. The EAP can also provide additi onal assistance with, and tools & referrals for:

• Tobacco Cessati on Resources for local community-based programs• Childcare and Eldercare Resources with Referrals• Financial and legal issues• Free Interacti ve online simple will• Free ID Recovery Services• Reimbursed cab fare• Reti ree Assistance• Moving Resources/Checklist

Deer Oaks EAP is available when you need it, 24 hours a day, 365 days a year.

For additi onal informati on or a referral to a provider located nearest you please call the EAP toll-free at 1-888-993-7650. Online tools are available at: www.deeroakseap.com login & password: matrix.

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Your Dental Benefi ts - MetLife

This chart refl ects basic summary information only. Exact plan details should be confi rmed by MetLife or by referring to your Certifi cate of Coverage.

Matrix off ers three dental care plan opti ons to choose from - a Base PPO Plan, a Buy-Up PPO Plan and a Copay Plan. Carefully review the comparison chart below to determine which plan works best for you and your family.

What is a PPO Plan?A PPO Plan pays your dental provider directly or reimburses you for your qualifi ed dental expenses regardless of who provides the services. In-network denti sts have agreed to charge plan members a lower fee for service.

What is a Copay Plan?A Copay Plan is similar to a Health Maintenance Organizati on (HMO) in that there are no deducti bles or claim forms to fi le and in-network dental treatment is on a prepaid basis. These types of plans provide treatment and services based on copayments that apply when an in-network denti st performs work. You do not have to pay a certain amount (i.e., deducti ble) before benefi ts begin.

Please Note: Employees residing in Louisiana, Montana, and Texas may not enroll in the Copay plan due to state-specifi c Department of Insurance regulati ons. You will have a third PPO opti on to choose from. Please refer to the supplemental Dental Benefi ts insert for details on the three dental plans you have to choose from.

**MetLife does not issue dental Identi fi cati on cards.** You simply need to provide your Social Security number to your preferred denti st to receive benefi ts.

Benefit Highlights Copay Plan Base PPO Plan Buy-Up PPO Plan

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Annual Benefit Maximum $1,000 $1,000 $1,000 $1,000 $2,000 $2,000

Deductible (Indiv/Family) per calendar year None $50/150 $50/$150 $50/$150 $50/$150 $50/$150

Deductible Waived for Preventive N/A Yes Yes Yes Yes Yes

Preventive Services (% covered by the Plan, up to the annual benefit maximum)

See Schedule of Benefits

for Copay Detail 85% Plan covers at 100% 100% of reasonable

& customary Plan covers at

100% 100% of reasonable

& customary

Basic Services (% covered by the Plan after the annual deductible is satisfied, up to the annual benefit maximum)



& customary Plan covers at 80% 80% of reasonable & customary

Major Services (% covered by the Plan after the annual deductible is satisfied, up to the annual benefit maximum)



& customary Plan covers at 50% 50% of reasonable & customary

MetLife Dental Network PDP Plus PDP Plus PDP Plus

Member copays vary by state

Routine Exam, Cleaning $15 Preventive Preventive

X-Rays Bitewing, Full Mouth $5 - $10 Preventive Preventive

Periodental (Root planing & scaling) $90-$130 Basic Basic

Space Maintainers $120-$230 Preventive Preventive

Fillings $35-$55 Basic Basic

Oral Surgery $50-$80 Major Basic

Endodontics (Root Canal) $465-$635 Major Basic

Crowns $440-$640 Major Major

Inlays/Onlays $440-$640 Major Major

Bridges/Dentures $595-$830 Major Major

Orthodontia Services Overview (Adult and Child(ren) up to age 26)

Orthodontia Services 50% coinsurance up to lifetime maximum Not Covered 50% 50% of reasonable & customary

Orthodontia Benefit Lifetime Maximum $1,000/$1,000 Not Covered $2,500 $2,500

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The vision plan off ers you and your family a benefi t that covers all routi ne eye care, including eye exams and eyeglasses (lenses & frames) or contacts. The plan features in-network and out-of network benefi ts, with enhanced benefi ts in-network, and a nati onal panel of optometrists and ophthalmologists.

*You may purchase either glasses or contacts every 12 months.** Retail Allowance: Maximum amount paid toward the cost of vision materials. Amounts in excess of the retail allowance are the fi nancial responsibility of the parti cipant.This chart refl ects basic summary information only. Exact plan details should be confi rmed by VSP or by referring to your Certifi cate of Coverage.

Your Vision Benefi ts - VSP

Enhanced Vision

In-Network Out-of-Network

Eye Exams (Every 12 months) $10 copay Up to $45 allowance

Frames (Every 12 months) $175 allowance for most frames

$195 allowance for featured frames 20% savings when exceeding allowance

Up to $70 allowance

Prescription Lenses (Every 12 months)*

Single Vision $10 copay Up to $30 allowance**

Bifocal $10 copay Up to $50 allowance**

Trifocal $10 copay Up to $50 allowance**

Progressive $10 copay Up to $50 allowance**

Tints/Photochromic Lens (Transitions) Average savings of 20%-25% on other lens enhancements

Contact Lenses (Every 12 months)*

Conventional $175 allowance**; copay does not apply Up to $105 allowance**

Disposables $175 allowance**; copay does not apply Up to $105 allowance**

Elective Contact Lens Fitting and Exam Not to exceed $60 copay

Medically Necessary (Limitations and coordination with coverage may apply)

$20 copay

Laser Vision Correction (LASIK or PRK) Average 15% off the regular price or 5% off the

promotional price; discounts only available from contracted facilities

20

2017 Employee ContributionsIf you choose to enroll in the employee-paid benefi ts plans, Matrix will deduct your porti on of the costs twice a month, or 24 ti mes during the year. Because Matrix pays employees 26 ti mes a year, there will be two pay periods in which no benefi t deducti ons occur.

NOTE: For employee plus dependent coverage, if either you or your spouse/domesti c partner att est to being a tobacco user, tobacco user rates will apply.

2017 Medical Employee Contributions

Tobacco Non User Advantage Plan (HDHP) Classic Plan Premium Plan

Employee Only $28.61 $56.15 $77.05

Employee + Spouse/Domestic Partner $138.28 $235.12 $296.01

Employee + Child(ren) $123.98 $214.19 $271.98

Employee + Family $228.85 $380.61 $474.93

Vision Contributions (per pay period)

Enhanced Vision

Employee Only $5.00

Employee + Spouse/Domestic Partner $7.99

Employee + Child(ren) $8.16

Employee + Family $13.15

Dental Contributions (per pay period)

Base PPO Plan Buy-Up PPO Plan Copay Plan

Employee Only $9.64 $12.92 $6.40



Employee + Family $37.25 $52.81 $24.99

Tobacco User Advantage Plan (HDHP) Classic Plan Premium Plan

Employee Only $46.11 $73.65 $94.55



Employee + Family $263.17 $437.70 $546.17

20

21

There are some benefi t related expenses you know you will have to pay each year – medical and dental deducti bles and coinsurance; medical, prescripti on and/or vision copayments; day care for your child while you work. You normally pay these expenses with aft er tax income. However, Matrix Medical Network’s Flexible Spending Accounts let you use your pre-tax dollars to pay for these eligible healthcare and dependent care expenses.

Flexible Spending Accounts1. Healthcare FSA – For you and your dependents’ out of pocket qualifi ed health expenses2. Limited Purpose Healthcare FSA (with Health Savings Account) – Only dental and vision expenses are allowed unti l your medical plan deducti ble is met, then eligible medical expenses will be allowed3. Dependent Care FSA – For costs related to care of eligible dependents (child(ren) up to age 13 and dependent elders) while you (and your spouse) work

Annual MaximumsHealthcare: $2,600Limited Purpose Healthcare: $2,600Child Care: $5,000

Every dollar you put away into your FSA is one you shelter from taxes. Each Open Enrollment, you have an opportunity to decide whether you want to parti cipate in the FSA. You can sign up at that ti me for both types of accounts. Deducti ons will begin the fi rst pay period in which the plan year begins, or aft er eligibility and electi on of benefi t. Once you make your plan year contributi on electi on(s) you cannot change your contributi on amount unti l the next annual open enrollment period, unless you experience a qualifying event. An FSA debit card will be mailed to you. Log on to www.irs.gov for a complete list of eligible expenses, benefi t details, an explanati on of non-eligible expenses, and an FSA Savings Calculator.

Please note that FSA contributi ons are “use it or lose it.” This means that unused monies at the end of each plan year will be forfeited. Please be conservati ve and careful when determining the amount of money that you contribute to your FSA. Your Plan Year runs January 1, 2017 through December 31, 2017. You may submit receipts for reimbursement unti l March 31, 2018 for claims incurred during the Plan Year.

Please note, for new hires enrolling in the FSA aft er the beginning of the plan year, you will only be enrolled for a parti al plan year. For example, if you are eligible as of April 1, your FSA electi ons are only for the remainder of the plan year (December 31, 2017) so be thoughtf ul in making decisions on how much to contribute.

Typical Covered Health Expenses Included:• Copayments and deducti bles• Orthodonti a• Glasses,contact lenses and supplies

(such as saline soluti on and enzyme cleaner)• LASIK surgery

Typical Expenses NOT Included:• Medical or dental cosmeti c surgery or drugs*• Over the counter medicati ons without a physicians prescripti on• Exercise programs and equipment*

*Unless prescribed for treatment of an illness or injury

A Transportati on Reimbursement Incenti ve Program (TRIP) allows you to lower your commuti ng costs to and from your offi ce by using pre-tax dollars to pay for qualifi ed transportati on expenses, such as transit passes and parking. Contribute up to $255 monthly for parking expenses and $255 monthly for transit expenses.

Your Flexible Spending Account (FSA) Benefi ts - Discovery Benefi ts

• Smoking cessati on programs prescribed drugs

• Dental care• Hearing aids

Transportation Benefi ts

22

Life and Accidental Death & Dismemberment - Prudenti alBasic Life Insurance protects your family or other benefi ciaries in the event of your death. Accidental Death and Dismemberment (AD&D) provides an additi onal benefi t in the event of an accidental injury that results in the death or dismemberment of a covered person. This benefi t is 100% paid for by Matrix Medical Network.

Life Benefi t One ti mes your base annual salary, rounded up to next $1,000, up to $500,000 maximum

Accelerated Benefi t Up to 75% of benefi t if terminally ill with life expectancy of less than 12 months; remainder paid at death

Waiver of Premium Conti nuati on of benefi t if insured becomes totally disabled

Benefi t Age Reducti on Benefi ts reduce to 50% of the original amount at age 70

Supplemental Employee & Dependent Life Insurance - Prudenti alOpti onal Life and Dependent Life insurance pays benefi ts to your benefi ciaries if you die, or to you if a covered family member dies.

Employee Benefi t Increments of $10,000 to a maximum of $1,000,000

Employee Guarantee IssueIf purchased when fi rst eligible, the Guarantee Issue amount is three ti mes salary rounded to nearest $10,000 or $500,000, whichever is less. If you choose NOT to enroll when fi rst eligible, you will be required to submit evidence of insurability. There is NO annual open enrollment.

Spouse Benefi t Increments of $10,000 to a maximum of $200,000, but not to exceed 50% of the employee’s supplemental life coverage.

Spouse Guarantee Issue If purchased when fi rst eligible, Guarantee Issue is $50,000. If you choose not to enroll when fi rst eligible, you will be required to submit evidence of insurability.

Child(ren) Benefi t Increments of $5,000 to a maximum of $20,000

Child(ren) Guarantee Issue If purchased when fi rst eligible, the guarantee Issue is $20,000. If you choose not to enroll when fi rst eligible, you will be required to submit evidence of insurability.

Benefi t Age Reducti on Benefi ts reduce to 50% of the original amount at age 70

Premium Contributi ons Premiums are paid enti rely by employee

Portable Opti on to take with you upon terminati on of employment

Your Life & Supplemental Life Benefi ts

Benefi t Summary

Benefi t Summary

This chart refl ects basic summary informati on only. Please refer to your Certi fi cate of Coverage for exact plan details.

This chart refl ects basic summary informati on only. Please refer to your Certi fi cate of Coverage for exact plan details.

23

Short Term Disability (STD) - Prudenti alSTD provides benefi ts that are payable when you become disabled due to a non-work-related accident, sickness or pregnancy and are under the regular care of a medical provider. The benefi t amount, the day benefi ts begin, and the maximum period for which benefi ts are payable are chosen by the employer.

Your STD & LTD Benefi ts

This chart refl ects basic summary information only. Exact plan details should be confi rmed by Prudential or by referring to your Certifi cate of Coverage.

Long Term Disability (LTD) - Prudenti alLTD provides income if you cannot work due to a disability. Cancer, a back problem, an injury from a car accident, or any other condi-ti on that keeps you from being able to perform your job are examples of a disability. You do not have to be permanently disabled or unable to work at all to qualify for benefi ts.

This chart refl ects basic summary information only. Exact plan details should be confi rmed by Prudential or by referring to your Certifi cate of Coverage.

STD Benefits

Benefit – Option 1 60% of pre-disability base earnings $1,000 maximum weekly benefit


Elimination Period 7 days for injury, sickness or pregnancy

Max Paid Benefit Period 25 weeks (not including the one week elimination period)

LTD Benefits

Employer Paid Benefit 50% of pre-disability base earnings $10,000 maximum monthly benefit

Employee Buy-Up Benefit Up to 66.67% of pre-disability base earnings $15,000 maximum monthly benefit

Elimination Period 180 days

Max Paid Benefit Period Social Security Retirement Age

Benefit Summary Life Benefit One times your base annual salary, rounded up to next $1,000, up to $500,000 maximum

Accelerated Benefit Up to 75% of benefit if terminally ill with life expectancy of less than 12 months; remainder paid at death

Waiver of Premium Continuation of benefit if insured becomes totally disabled

Benefit Age Reduction Benefits reduce to 50% of the original at age 70

STD Benefits



Elimination Period 7 days for injury, sickness or pregnancy

Max Paid Benefit Period 25 weeks (not including the one week elimination period)

LTD Benefits

Employer Paid Benefit 50% of pre-disability base earnings $10,000 maximum monthly benefit

Employee Buy-Up Benefit Up to 66.67% of pre-disability base earnings $15,000 maximum monthly benefit

Elimination Period 180 days

Max Paid Benefit Period Social Security Retirement Age

Benefit Summary Life Benefit One times your base annual salary, rounded up to next $1,000, up to $500,000 maximum

Accelerated Benefit Up to 75% of benefit if terminally ill with life expectancy of less than 12 months; remainder paid at death

Waiver of Premium Continuation of benefit if insured becomes totally disabled

Benefit Age Reduction Benefits reduce to 50% of the original at age 70

24

There are ti mes in life when you (and if applicable, your spouse or eligible dependent children) may need the services of a qualifi ed att orney. MetLaw, the group legal plan available through Hyatt Legal Plans, makes things simple for you. You get the att orney you need at a cost that’s very aff ordable, with access by telephone or in-person for advice on an unlimited number of legal matt ers, and representati on for a wide variety of legal services.

When enrolled in this plan, you’ll have quick, easy access to a nati onwide network of over 13,000 att orneys who have an average of 25 years of experience in off ering a broad range of legal services. No matt er how many ti mes you use an in-network att orney over the course of the year for covered legal matt ers (for example, a simple will preparati on or power of att orney), all you pay is your payroll deducted monthly premium; there are no copayments or deducti bles. Complex wills/trusts may be handled diff erently with cost associated with preparati on.

MetLaw Legal Plan

*Some services not available in all states.**For Family Matt ers, diff erent terms and exclusions applyGroup legal plans and Family Matt ers provided by Hyatt Legal Plans, Inc., a MetLife company, Cleveland, Ohio. In certain states, group legal plans and Family Matt ers are provided through insurance coverage underwritt en by Metropolitan Property and Casualty Insurance Company and Affi liates, Warwick, RI.No service, including consultati ons, will be provided for: 1) employment-related matt ers, including company or statutory benefi ts; 2) matt ers involving the employer, MetLife and affi liates and plan att orneys; 3) matt ers in which there is a confl ict of interest between the employee and spouse or dependents in which case services are excluded for the spouse and dependents; 4) appeals and class acti ons; 5) farm and business matt ers, including rental issues when the parti cipant is the landlord 6) patent, trademark and copyright matt ers; 7) costs and fi nes; 8) frivolous or unethical matt ers; 9) matt ers for which an att orney-client relati onship exists prior to the parti cipant becoming eligible for plan benefi ts. For all other personal legal matt ers, an advice and consultati on benefi t is provided. Additi onal representati on is also included for certain matt ers. Please see your plan descripti on for details. MetLaw® and MetLife® are registered trademarks of Metropolitan Life Insurance Company, New York, NY. L1013345664[exp1214][All States]

Identity Theft ProtectionIdenti ty theft protecti on services from InfoArmor® help assess your risk, deter theft att empts, detect fraud, and manage the restora-ti on process if your identi ty is stolen. Your identi ty will be monitored to uncover fraud at its incepti on. You will be off ered an annual credit report, monthly credit scores, and monitoring of your TransUnion credit fi le.

InfoArmor® off ers privacy advocates who are certi fi ed and trained in identi ty restorati on. If they detect suspicious acti vity, a privacy advocate can act as a dedicated case manager on your behalf and resolve the issue.

Estate Planning Documents Financial Matters Real Estate Matters

• Simple and complex wills • Trusts (revocable and irrevocable • Powers of Attorney (healthcare, financial,

childcare) • Living Wills • Codicils

• Negotiations with creditors • Debt collection defense • Personal bankruptcy • Identity theft defense • Tax audit representation

(municipal, state, or federal)

• Sale, purchase, or refinancing of your primary residence

• Home equity loans • Tenant negotiations (Tenant only) • Eviction defense • Security defense assistance • Boundary / Title disputes • Property tax assessment

• Zoning applications Elder Law Matters Family Law Traffic and Criminal Matters

• Consultations and document review for issues related to your parents including Medicare, Medicaid, Prescription Plans, Nursing Home Agreements, leases, notes, deeds, wills, and power of attorney as these affect the participant

• Adoption • Uncontested Guardianship • Name change • Protection from domestic violence • Prenuptial agreement

• Defense of traffic tickets (excludes DUI)

• Driving privileges restoration (including DUI)

• Juvenile court proceedings

Defense of Civil Lawsuit Document Preparation Personal Property Protection • Administrative hearings • Civil litigation defense • Incompetency defense • School hearings

• Pet liabilities

• Affidavits • Deeds • Mortgages • Demand letters

• Notes

• Consultation and document review for personal property issues

• Assistance for disputes over goods and services

Immigration Assistance Consumer Protection **Family Matters™

• Review of immigration documents

• Preparation of affidavits and power of attorney

• Disputes over consumer goods and services

• Small claims assistance

• Separate plan for parents of participants for estate planning documents

• Available for an additional fee

• Easy enrollment; online or by phone

25

The voluntary benefi ts listed below, through Allstate Life Insurance, are available for you to elect and share these important features:

• Aff ordable• Complement your core benefi ts off ered by Matrix – Provides immediate, additi onal income for your initi al out-of-pocket expenses (i.e.

high deducti bles and coinsurance) • Portability – If you terminate your employment, you may conti nue your coverage with no increase in premiums• Benefi ts are paid directly to you, unless you specify otherwise• Coverage is available for your spouse or qualifi ed Domesti c Partner and children in most products• In the event of a claim, your benefi ts are paid regardless of any other insurance benefi ts you may be receiving or sick leave you may

have accumulated

Below are the various opti ons that are available for you to elect:

• Hospital Confi nement Insurance – Provides a lump sum benefi t for hospital confi nement and outpati ent surgery; helps off set deducti bles/coinsurance and costs not covered by major medical plans

• Criti cal Illness – Provides a lump sum benefi t you can use to pay the direct and indirect costs related to a covered criti cal illness, including cancer; helps off set deducti bles/coinsurance and costs not covered by major medical plans

• Accident Insurance – Provides a lump sum benefi t in the event of an unexpected injury; helps off set deducti bles/coinsurance and uncovered medical expenses

Other Voluntary Benefi ts

26

Legal NoticesMatrix Medical Network reserves the right to change, amend, or terminate any benefi ts plan at any ti me for any reason. Parti cipati on in a benefi t plan is not a promise or guarantee of future employment. Receipt of benefi ts documents does not consti tute eligibility.

This Benefi ts Guide, combined with these legal noti ces, provides an overview of the benefi ts available to you and your family. In the event of a discrepancy between the informati on presented in the Benefi ts Guide and offi cial plan documents, the offi cial plan documents will govern.

STATEMENT OF MATERIAL MODIFICATIONS (ERISA PLANS)This Benefi ts Guide consti tutes a summary of modifi cati ons to the employer’s group health plan. It is meant to supplement and/or replace certain informati on in the existi ng plan descripti ons. Please share these materials with your covered family members.

IMPORTANT NOTICE ABOUT CREDITABLE PRESCRIPTION DRUG COVERAGE AND MEDICAREIf you or your family members aren’t currently covered by Medicare and won’t become covered by Medicare during 2017, this noti ce doesn’t apply to you.

Please read this noti ce carefully and keep it where you can fi nd it. This noti ce has informati on about your current prescripti on drug coverage with Matrix Medical Network (referred to in the remainder of this noti ce as “Matrix”) and about your opti ons under Medicare’s prescripti on drug coverage. This informati on 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 off ering Medicare prescripti on drug coverage in your area. Informati on about where you can get help to make decisions about your prescripti on drug coverage is at the end of this noti ce.

There are two important things you need to know about your current coverage and Medicare’s prescripti on drug coverage: 1. Medicare prescripti on drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a

Medicare Prescripti on Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that off ers prescripti on drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also off er more coverage for a higher monthly premium.

2. Matrix has determined that the prescripti on drug coverages off ered under the: UnitedHealthcare (UHC) PPO $800 Deducti ble Plan; UHC PPO $1,250 Deducti ble Plan; UHC $1,500 HDHP Plan are, on average for all plan parti cipants, expected to pay out as much as standard Medicare prescripti on drug coverage pays and is therefore considered Creditable Coverage. Because your existi ng 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 fi rst become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescripti on 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 Matrix coverage will not be aff ected. If you do decide to join a Medicare drug plan and drop your current medical/Rx coverage off ered by Matrix through UnitedHealthcare, be aware that you and your dependents will be able to get this coverage back during annual open enrollment or in the event of a qualifying event.

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 Matrix and don’t join a Medicare drug plan within 63 conti nuous days aft er your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 conti nuous days or longer without creditable prescripti on drug coverage, your monthly premium may go up by at least 1% of the Medicare base benefi ciary 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 benefi ciary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescripti on drug coverage. In additi on, you may have to wait unti l the following October to join.

27

Legal Notices (Continued)For More Informati on About This Noti ce Or Your Current Prescripti on Drug Coverage… Contact your Regional HR Department for further informati on. NOTE: You’ll get this noti ce each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Matrix changes. You also may request a copy of this noti ce at any ti me.

For More Informati on About Your Opti ons Under Medicare Prescripti on Drug Coverage… More detailed informati on about Medicare plans that off er prescripti on 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 informati on about Medicare Prescripti on 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 prescripti on drug coverage is available. For informati on 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 noti ce. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this noti ce 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).

HIPAA SPECIAL ENROLLMENT NOTICENoti ce of special enrollment rights for health plan coverage

If you decline enrollment in a Matrix Medical Network health plan for you or your dependents (including your spouse) because of other health insurance or group health plan coverage, you or your dependents may be able to enroll in a Matrix Medical Network health plan without waiti ng unti l the next Open Enrollment period if you:

• Lose other health insurance or group health plan coverage. You must request enrollment within 31 days aft er the loss of other coverage.• Gain a new dependent as a result of marriage, birth, adopti on, or placement for adopti on. You must request health plan enrollment

within 31 days aft er the marriage, birth, adopti on, or placement for adopti on.• Lose Medicaid or Children’s Health Insurance Program (CHIP) coverage because you are no longer eligible. You must request medical

plan enrollment within 60 days aft er the loss of such coverage.

If you request a change due to a special enrollment event within the 31 day ti meframe, coverage will be eff ecti ve the date of birth, adopti on or placement for adopti on. For all other events, coverage will be eff ecti ve the fi rst of the month following your request for enrollment. In additi on, you may enroll in a Matrix Medical Network medical plan if you become eligible for a state premium assistance program under Medicaid or CHIP. You must request enrollment within 60 days aft er you gain eligibility for medical plan coverage. If you request this change, coverage will be eff ecti ve the fi rst of the month following your request for enrollment. Specifi c restricti ons may apply, depending on federal and state law.

Note: If your dependent becomes eligible for a special enrollment rights, you may add the dependent to your current coverage or change to another health plan. Any other currently covered dependents may also switch to the new plan in which you enroll.

WOMEN’S HEALTH AND CANCER RIGHTS ACT (WHCRA) NOTICEIf you have had or are going to have a mastectomy, you may be enti tled to certain benefi ts under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefi ts, coverage will be provided in a manner determined in consultati on with the att ending physician and the pati ent, for:

• All stages of reconstructi on of the breast on which the mastectomy was performed.• Surgery and reconstructi on of the other breast to produce a symmetrical appearance.• Prostheses.• Treatment of physical complicati ons of the mastectomy, including lymphedema.

28

Legal Notices (Continued)

These benefi ts will be provided subject to the same deducti bles and coinsurance applicable to other medical and surgical benefi ts provided under this plan.

NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT (NMHPA OR “NEWBORNS’ ACT”) NOTICEGroup health plans and health insurance issuers generally may not, under federal law, restrict benefi ts for any hospital length of stay in connecti on 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 secti on. However, federal law generally does not prohibit the mother’s or newborn’s att ending provider, aft er consulti ng 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 authorizati on from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

MICHELLE’S LAW NOTICEExtended dependent medical coverage during student medical leavesThe Matrix Medical Network plan, as applicable, may extend medical coverage for dependent children if they lose eligibility for coverage because of a medically necessary leave of absence from school. Coverage may conti nue for up to a year, unless your child’s eligibility would end earlier for another reason.

Extended coverage is available if a child’s leave of absence from school — or change in school enrollment status (for example, switching from full-ti me to part-ti me status) — starts while the child has a serious illness or injury, is medically necessary, and otherwise causes eligibility for student coverage under the plan to end. Writt en certi fi cati on from the child’s physician stati ng that the child suff ers from a serious illness or injury and the leave of absence is medically necessary may be required.

If your child will lose eligibility for coverage because of a medically necessary leave of absence from school and you want his or her coverage to be extended, contact your Matrix Medical Network’s HR Department.

29

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 informati on, 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 offi ce to fi nd 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 offi ce or dial 1-877-KIDS NOW or www.insurekidsnow.gov to fi nd 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 questi ons about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2016. Contact your State for more informati on on eligibility.


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

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2016. 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.hip.in.gov Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1-800-403-0864

COLORADO – Medicaid IOWA – Medicaid Medicaid Website: http://www.colorado.gov/hcpf Medicaid Customer Contact Center: 1-800-221-3943

Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562

Medicaid Website: Medicaid Customer Contact Center: 1

30

2

KANSAS – Medicaid 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: http://www.nyhealth.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: http://www.ncdhhs.gov/dma Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid Website: http://www.mass.gov/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/ma/ 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/hipp Phone: 1-800-692-7462

NEBRASKA – Medicaid RHODE ISLAND – Medicaid Website: http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/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: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900

Website: http://www.scdhhs.gov Phone: 1-888-549-0820

31


OMB Control Number 1210-0137 (expires 11/30/2016)

To see if any other states have added a premium assistance program since July 31, 2016, or for more informati on on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefi ts Security Administrati on Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov1-866-444-EBSA (3272) 1-877-267-2323, Menu Opti on 4, Ext. 61565

CONTINUATION OF BENEFITS (COBRA)Upon terminati on of employment for reasons other than gross misconduct, conti nuati on of an employee’s medical, dental, and vision coverage – and/or any insured dependent’s coverage - is available for up to 18 months under COBRA (Consolidated Omnibus Budget Reconciliati on Act), with the employee assuming all premium costs. If the employee is disabled, COBRA eligibility is increased to 29 months. Before an employee’s benefi ts coverage ends, the Human Resources department provides the terminati ng employee with personalized informati on concerning COBRA conti nuati on procedures. Conti nuati on of medical, dental and vision coverage is also available for “qualifi ed benefi ciaries” up to 36 months when one of the following qualifying events occurs:• Death of a covered employee;• Divorce or legal separati on;• Employee becomes eligible for Medicare;• Dependent child reaches maximum age allowed under group plan

“Qualifi ed benefi ciaries” are those individuals who were covered under the group plan on the day before the qualifying life event; this could include the employee’s spouse and dependent child(ren).

Please note: It is the responsibility of you, the employee, or qualifi ed benefi ciary to noti fy the Matrix Benefi ts Call Center of qualifying events, such as divorce, legal separati on or dependent child reaching the maximum allowable age to remain on your benefi t plans so that COBRA noti fi cati on can be sent.

HIPAA PRIVACY NOTICEPlease carefully review this noti ce. It describes how medical informati on about you may be used and disclosed and how you can get access to this informati on. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) imposes numerous requirements on the use and disclosure of individual health informati on by Matrix Medical Network health plans. This informati on, known as protected health informati on (PHI), includes almost all individually identi fi able health informati on held by a plan — whether received in writi ng, in an electronic medium, or as an oral communicati on. This noti ce describes the privacy practi ces of these plans: United Healthcare $350, $800 and $1,500 Plans. The plans covered by this noti ce may share health informati on with each other to carry out treatment, payment,

3

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

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP Website: Medicaid: http://health.utah.gov/medicaid CHIP: 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

To see if any other states have added a premium assistance program since July 31, 2016, 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

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

OMB Control Number 1210-0137 (expires 11/30/2016)

32

Legal Notices (Continued)or healthcare operati ons. These plans are collecti vely referred to as the Plan in this noti ce, unless specifi ed otherwise.

The Plan’s duti es with respect to health informati on about youThe Plan is required by law to maintain the privacy of your health informati on and to provide you with this noti ce of the Plan’s legal duti es and privacy practi ces with respect to your health informati on. If you parti cipate in an insured plan opti on, you will receive a noti ce directly from the Insurer. It’s important to note that these rules apply to the Plan, not Matrix Medical Network as an employer — that’s the way the HIPAA rules work. Diff erent policies may apply to other Matrix Medical Network programs or to data unrelated to the Plan.

How the Plan may use or disclose your health informati onThe privacy rules generally allow the use and disclosure of your health informati on without your permission (known as an authorizati on) for purposes of healthcare treatment, payment acti viti es, and healthcare operati ons. Here are some examples of what that might entail:

• Treatment includes providing, coordinati ng, or managing healthcare by one or more healthcare providers or doctors. Treatment can also include coordinati on or management of care between a provider and a third party, and consultati on and referrals between providers. For example, the Plan may share your health informati on with physicians who are treati ng you.

• Payment includes acti viti es by this Plan, other plans, or providers to obtain premiums, make coverage determinati ons, and provide reimbursement for healthcare. This can include determining eligibility, reviewing services for medical necessity or appropriateness, engaging in uti lizati on management acti viti es, claims management, and billing; as well as performing “behind the scenes” plan functi ons, such as risk adjustment, collecti on, or reinsurance. For example, the Plan may share informati on about your coverage or the expenses you have incurred with another health plan to coordinate payment of benefi ts.

• Healthcare operati ons include acti viti es by this Plan (and, in limited circumstances, by other plans or providers), such as wellness and risk assessment programs, quality assessment and improvement acti viti es, customer service, and internal grievance resoluti on.

• Healthcare operati ons also include evaluati ng vendors; engaging in credenti aling, training, and accreditati on acti viti es; performing underwriti ng or premium rati ng; arranging for medical review and audit acti viti es; and conducti ng business planning and development. For example, the Plan may use informati on about your claims to audit the third parti es that approve payment for Plan benefi ts.

The amount of health informati on used, disclosed or requested will be limited and, when needed, restricted to the minimum necessary to accomplish the intended purposes, as defi ned under the HIPAA rules. If the Plan uses or discloses PHI for underwriti ng purposes, the Plan will not use or disclose PHI that is your geneti c informati on for such purposes.

How the Plan may share your health informati on with Matrix Medical NetworkThe Plan, or its health insurer or HMO, may disclose your health informati on without your writt en authorizati on to Matrix Medical Network for plan administrati on purposes. Matrix Medical Network may need your health informati on to administer benefi ts under the Plan. Matrix Medical Network agrees not to use or disclose your health informati on other than as permitt ed or required by the Plan documents and by law. Human Resources and other support staff may have access to your health informati on for plan administrati on functi ons.

Here’s how additi onal informati on may be shared between the Plan and Matrix Medical Network, as allowed under the HIPAA rules:• The Plan, or its insurer or HMO, may disclose “summary health informati on” to Matrix Medical Network, if requested, for purposes of

obtaining premium bids to provide coverage under the Plan or for modifying, amending, or terminati ng the Plan. Summary health informati on is informati on that summarizes parti cipants’ claims informati on, from which names and other identi fying informati on have been removed.

• The Plan, or its insurer or HMO, may disclose to Matrix Medical Network informati on on whether an individual is parti cipati ng in the Plan or has enrolled or dis-enrolled in an insurance opti on or HMO off ered by the Plan.

In additi on, you should know that Matrix Medical Network cannot and will not use health informati on obtained from the Plan for any employment-related acti ons. However, health informati on collected by Matrix Medical Network from other sources — for example, under the Family and Medical Leave Act, Americans with Disabiliti es Act, or workers’ compensati on programs — is not protected under HIPAA (although this type of informati on may be protected under other federal or state laws).

Other allowable uses or disclosures of your health informati onIn certain cases, your health informati on can be disclosed without authorizati on to a family member, close friend, or other person you identi fy who is involved in your care or payment for your care. Informati on about your locati on, general conditi on, or death may be provided to a similar person (or to a public or private enti ty authorized to assist in disaster relief eff orts). You’ll generally be given the chance to agree or object to these disclosures (although excepti ons may be made — for example, if you’re not present or if you’re incapacitated). In additi on, your health informati on may be disclosed without authorizati on to your legal representati ve. The Plan also is allowed to use or disclose your health informati on without your writt en authorizati on for the following acti viti es:

33


Workers’ compensation Disclosures to workers’ compensation or similar legal programs that provide benefits for work-related injuries or illness without regard to fault, as authorized by and necessary to comply with the laws

Necessary to prevent serious threat to health or safety

Disclosures made in the good-faith belief that releasing your health information is necessary to prevent or lessen a serious and imminent threat to public or personal health or safety, If made to someone reasonably able to prevent or lessen the threat (or to the target of the threat); includes disclosures to help law enforcement officials identify or apprehend an individual who has admitted participation in a violent crime that the Plan reasonably believes may have caused serious physical harm to a victim, or where it appears the individual has escaped from prison or from lawful custody

Public health activities

Disclosures authorized by law to persons who may be at risk of contracting or spreading a disease or condition; disclosures to public health authorities to prevent or control disease or report child abuse or neglect; and disclosures to the Food and Drug Administration to collect or report adverse events or product defects

Victims of abuse, neglect, or domestic violence

Disclosures to government authorities, including social services or protected services agencies authorized by law to receive reports of abuse, neglect, or domestic violence, as required by law or if you agree or the Plan believes that disclosure is necessary to prevent serious harm to you or potential victims (you’ll be notified of the Plan’s disclosure if informing you won’t put you at further risk)

Judicial and administrative proceedings

Disclosures in response to a court or administrative order, subpoena, discovery request, or other lawful process (the plan may be required to notify you of the request or receive satisfactory assurance from the party seeking your health information that efforts were made to notify you or to obtain a qualified protective order concerning the information)

Law enforcement purposes

Disclosures to law enforcement officials required by law or legal process, or to identify a suspect, fugitive, witness, or missing person; disclosures about a crime victim if you agree or if disclosure is necessary for immediate law enforcement activity; disclosures about a death that may have resulted from criminal conduct; and disclosures to provide evidence of criminal conduct on the plan’s premises

Decedents Disclosures to a coroner or medical examiner to identify the deceased or determine cause of death; and to funeral directors to carry out their duties

Organ, eye, or tissue donation Disclosures to organ procurement organizations or other entities to facilitate organ, eye, or tissue donation and transplantation after death

Research purposes Disclosures subject to approval by institutional or private privacy review boards, subject to certain assurances and representations by researchers about the necessity of using your health information and the treatment of the information during a research project

Health oversight activities

Disclosures to health agencies for activities authorized by law (audits, inspections, investigations, or licensing actions) for oversight of the health care system, government benefits programs for which health information is relevant to beneficiary eligibility, and compliance with regulatory programs or civil rights laws

Specialized government functions

Disclosures about individuals who are armed forces personnel or foreign military personnel under appropriate military command; disclosures to authorized federal officials for national security or intelligence activities; and disclosures to correctional facilities or custodial law enforcement officials about inmates

HHS investigations Disclosures of your health information to the Department of Health and Human Services to investigate or determine the Plan’s compliance with the HIPAA privacy rule

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Legal Notices (Continued) The Plan will noti fy you if it becomes aware that there has been a loss of your health informati on in a manner that could compro-mise the privacy of your health informati on.The Plan is not required to agree to a requested restricti on. If the Plan does agree, a restricti on may later be terminated by your writt en request, by agreement between you and the Plan (including an oral agreement), or unilaterally by the Plan for health informati on created or received aft er you’re noti fi ed that the Plan has removed the restricti ons. The Plan may also disclose health informati on about you if you need emergency treatment, even if the Plan has agreed to a restricti on.

An enti ty covered by these HIPAA rules (such as your healthcare provider) or its business associate must comply with your request that health informati on regarding a specifi c healthcare item or service not be disclosed to the Plan for purposes of payment or healthcare operati ons if you have paid out of pocket and in full for the item or service.

Right to receive confi denti al communicati ons of your health informati onIf you think that disclosure of your health informati on by the usual means could endanger you in some way, the Plan will accommodate reasonable requests to receive communicati ons of health informati on from the Plan by alternati ve means or at alternati ve locati ons.

If you want to exercise this right, your request to the Plan must be in writi ng and you must include a statement that disclosure of all or part of the informati on could endanger you.

Right to inspect and copy your health informati onWith certain excepti ons, you have the right to inspect or obtain a copy of your health informati on in a “designated record set.” This may include medical and billing records maintained for a healthcare provider; enrollment, payment, claims adjudicati on, and case or medical management record systems maintained by a plan; or a group of records the Plan uses to make decisions about individuals. However, you do not have a right to inspect or obtain copies of psychotherapy notes or informati on compiled for civil, criminal, or administrati ve proceedings. The Plan may deny your right to access, although in certain circumstances, you may request a review of the denial. If you want to exercise this right, your request to the Plan must be in writi ng. Within 30 days of receipt of your request (60 days if the health informati on is not accessible on site), the Plan will provide you with one of these responses:

• The access or copies you requested.• A writt en denial that explains why your request was denied and any rights you may have to have the denial reviewed or fi le a

complaint.• A writt en statement that the ti me period for reviewing your request will be extended for no more than 30 more days, along with the

reasons for the delay and the date by which the Plan expects to address your request.

You may also request your health informati on be sent to another enti ty or person, so long as that request is clear, conspicuous, and specifi c. The Plan may provide you with a summary or explanati on of the informati on instead of access to or copies of your health informati on, if you agree in advance and pay any applicable fees. The Plan also may charge reasonable fees for copies or postage. If the Plan doesn’t maintain the health informati on but knows where it is maintained, you will be informed where to direct your request.

If the Plan keeps your records in an electronic format, you may request an electronic copy of your health informati on in a form and format readily producible by the Plan. You may also request that such electronic health informati on be sent to another enti ty or person, so long as that request is clear, conspicuous, and specifi c. Any charge that is assessed to you for these copies must be reasonable and based on the Plan’s cost.

Right to amend your health informati on that is inaccurate or incompleteWith certain excepti ons, you have a right to request that the Plan amend your health informati on in a designated record set. The Plan may deny your request for a number of reasons. For example, your request may be denied if the health informati on is accurate and complete, was not created by the Plan (unless the person or enti ty that created the informati on is no longer available), is not part of the designated record set, or is not available for inspecti on (e.g., psychotherapy notes or informati on compiled for civil, criminal, or administrati ve proceedings).

If you want to exercise this right, your request to the Plan must be in writi ng, and you must include a statement to support the requested amendment. Within 60 days of receipt of your request, the Plan will take one of these acti ons:

• Make the amendment as requested• Provide a writt en denial that explains why your request was denied and any rights you may have to disagree or fi le a complaint

35


• Provide a writt en statement that the ti me period for reviewing your request will be extended for no more than 30 more days, along with the reasons for the delay and the date by which the Plan expects to address your request

Right to receive an accounti ng of disclosures of your health informati onYou have the right to a list of certain disclosures of your health informati on the Plan has made. This is oft en referred to as an “accounti ng of disclosures.” You generally may receive this accounti ng if the disclosure is required by law, in connecti on with public health acti viti es, or in similar situati ons listed in the table earlier in this noti ce, unless otherwise indicated below.

You may receive informati on on disclosures of your health informati on for up to six years before the date of your request. You do not have a right to receive an accounti ng of any disclosures made in any of these circumstances:

• For treatment, payment, or healthcare operati ons• To you about your own health informati on• Incidental to other permitt ed or required disclosures• Where authorizati on was provided• To family members or friends involved in your care (where disclosure is permitt ed without authorizati on)• For nati onal security or intelligence purposes or to correcti onal insti tuti ons or law enforcement offi cials in certain circumstances• As part of a “limited data set” (health informati on that excludes certain identi fying informati on)

In additi on, your right to an accounti ng of disclosures to a health oversight agency or law enforcement offi cial may be suspended at the request of the agency or offi cial.

If you want to exercise this right, your request to the Plan must be in writi ng. Within 60 days of the request, the Plan will provide you with the list of disclosures or a writt en statement that the ti me period for providing this list will be extended for no more than 30 more days, along with the reasons for the delay and the date by which the Plan expects to address your request. You may make one request in any 12-month period at no cost to you, but the Plan may charge a fee for subsequent requests. You’ll be noti fi ed of the fee in advance and have the opportunity to change or revoke your request.

Right to obtain a paper copy of this noti ce from the Plan upon requestYou have the right to obtain a paper copy of this privacy noti ce upon request. Even individuals who agreed to receive this noti ce electronically may request a paper copy at any ti me.Your individual rightsYou have the following rights with respect to your health informati on the Plan maintains. These rights are subject to certain limitati ons, as discussed below. This secti on of the noti ce describes how you may exercise each individual right.

Right to request restricti ons on certain uses and disclosures of your health informati on and the Plan’s right to refuseYou have the right to ask the Plan to restrict the use and disclosure of your health informati on for treatment, payment, or healthcare operati ons, except for uses or disclosures required by law. You have the right to ask the Plan to restrict the use and disclosure of your health informati on to family members, close friends, or other persons you identi fy as being involved in your care or payment for your care. You also have the right to ask the Plan to restrict use and disclosure of health informati on to noti fy those persons of your locati on, general conditi on, or death — or to coordinate those eff orts with enti ti es assisti ng in disaster relief eff orts. If you want to exercise this right, your request to the Plan must be in writi ng.

Except as described in this noti ce, other uses and disclosures will be made only with your writt en authorizati on. For example, in most cases, the Plan will obtain your authorizati on before it communicates with you about products or programs if the Plan is being paid to make those communicati ons. If we keep psychotherapy notes in our records, we will obtain your authorizati on in some cases before we release those records. The Plan will never sell your health informati on unless you have authorized us to do so. You may re-voke your authorizati on as allowed under the HIPAA rules. However, you can’t revoke your authorizati on with respect to disclosures the Plan has already made. You will be noti fi ed of any unauthorized access, use, or disclosure of your unsecured health informati on as required by law.

Changes to the informati on in this noti ceThe Plan must abide by the terms of the privacy noti ce currently in eff ect. This noti ce takes eff ect on January 1, 2016. However, the Plan reserves the right to change the terms of its privacy policies, as described in this noti ce, at any ti me and to make new provisions eff ecti ve

36

Legal Notices (Continued)for all health informati on that the Plan maintains. This includes health informati on that was previously created or received, not just health informati on created or received aft er the policy is changed. If changes are made to the Plan’s privacy policies described in this noti ce, you will be provided with a revised privacy noti ce via e-mail.

ComplaintsIf you believe your privacy rights have been violated or your Plan has not followed its legal obligati ons under HIPAA, you may complain to the Plan and to the Secretary of Health and Human Services. You won’t be retaliated against for fi ling a complaint. To fi le a complaint, contact a member of your Human Resource Department.

ContactFor more informati on on the Plan’s privacy policies or your rights under HIPAA, contact your Matrix Medical Network HR Department.

New Health Insurance Marketplace Coverage Options and Your Health CoverageForm Approved OMB No. 1210-0149 (expires 1-31-2017)

PART A: GENERAL INFORMATIONWhen key parts of the healthcare law take eff ect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate opti ons for you and your family, this noti ce provides some basic informati on about the new Marketplace and employment based health coverage off ered by your employer.

What is the Health Insurance Marketplace? The Marketplace is designed to help you fi nd health insurance that meets your needs and fi ts your budget. The Marketplace off ers “one-stop shopping” to fi nd and compare private health insurance opti ons. 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 starti ng 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 off er coverage, or off ers 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 Aff ect Eligibility for Premium Savings through the Marketplace?Yes. If you have an off er 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 reducti on in certain cost-sharing if your employer does not off er coverage to you at all or does not off er 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 Aff ordable Care Act, you may be eligible for a tax credit (An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefi t costs covered by the plan is no less than 60 percent of such costs).

Note: If you purchase a health plan through the Marketplace instead of accepti ng health coverage off ered by your employer, then you may lose the employer contributi on (if any) to the employer-off ered coverage. Also, this employer contributi on -as well as your employee contributi on to employer-off ered coverage- is oft en excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an aft er-tax basis.

How Can I Get More Informati on?For more informati on about your coverage off ered by your employer, please check your summary plan descripti on or contact your Matrix Medical Network HR Department.

The Marketplace can help you evaluate your coverage opti ons, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more informati on, including an online applicati on for health insurance coverage and contact informati on for a Health Insurance Marketplace in your area.

PART B: INFORMATION ABOUT HEALTH COVERAGE OFFERED BY YOUR EMPLOYERThis secti on contains informati on about any health coverage off ered by your employer. If you decide to complete an applicati on for coverage in the Marketplace, you will be asked to provide this informati on. This informati on is numbered to correspond to the Marketplace applicati on.

37

Legal Notices (Continued)Here is some basic informati on about health coverage off ered by this employer:• As your employer, we off er a health plan to:• Some employees. Eligible employees are: Full ti me employees working 30 hours or more per week

• With respect to dependents:• We do off er coverage. Eligible dependents are: Legally married spouse, same or opposite sex domesti c partner, and/or

dependent children up to age 26

• This coverage meets the minimum value standard, and the cost of this coverage to you is intended to be aff ordable, based on employee wages.

** Even if your employer intends your coverage to be aff ordable, you may sti ll 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 sti ll qualify for a premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here’s the employer informati on you’ll enter when you visit HealthCare.gov to fi nd out if you can get a tax credit to lower your monthly premiums.

The informati on below corresponds to the Marketplace Employer Coverage Tool. Completi ng this secti on is opti onal for employers, but will help ensure employees understand their coverage choices.

* An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefi t costs covered by the plan is no less than 60 percent of such costs (Secti on 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

3. Employer name Community Care Health Network d/b/a Matrix Medical Network 4. Employer Identification Number (EIN) 06-1599981

5. Employer address 9201 E Mountain View, Ste 220 6. Employer phone number 877-564-3627

7. City Scottsdale 8. State AZ 9. ZIP code 85258

10. Who can we contact about employee health coverage at this job? Human Resources

11. Phone number (if different from above) 12. Email address [email protected]

13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?

Yes (Continue)

13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue)

No (STOP and return this form to employee))

14. Does the employer offer a health plan that meets the minimum value standard*?

Yes (Go to question 15) No (STOP and return this form to employee)

15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn’t receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan? $

b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly

If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and return form to employee.

16. What change will the employer make for the new plan year?

☐ Employer won’t offer health coverage

☐ Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)

a. How much will the employee have to pay in premiums for that plan? $


3. Employer name Community Care Health Network d/b/a Matrix Medical Network 4. Employer Identification Number (EIN) 06-1599981

5. Employer address 9201 E Mountain View, Ste 220 6. Employer phone number 877-564-3627

7. City Scottsdale 8. State AZ 9. ZIP code 85258

10. Who can we contact about employee health coverage at this job? Human Resources

11. Phone number (if different from above) 12. Email address [email protected]

13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?

Yes (Continue)

13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue)

No (STOP and return this form to employee))

14. Does the employer offer a health plan that meets the minimum value standard*?

Yes (Go to question 15) No (STOP and return this form to employee)

15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn’t receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan? $


If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and return form to employee.

16. What change will the employer make for the new plan year?

☐ Employer won’t offer health coverage

☐ Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)

a. How much will the employee have to pay in premiums for that plan? $


383838

About this Booklet. This booklet highlights important features of Matrix Medical Network’s benefi ts for it’s employees. While eff orts have been made to ensure the accuracy of the informati on presented, in the event of any discrepancies your actual coverage and benefi ts will be determined by the legal plan documents and the contracts that govern these plans. Benefi t plans may be changed for any reason, to the extent allowed by law. Your parti cipati on in these benefi ts is not a contract of employment and does not guarantee future employment.

CBIZ Benefi ts & Insurance Services1765 East Skyline DriveTucson, AZ 85718

Final 11/11//16