table of contents & contact information · preventive services (periodic oral exam, cleanings...

Table Of Contents & Contact InformationTable Of Contents & Contact Information

USI BENEFIT RESOURCE CENTER (BRC):

Provider Name Benefit Resource CenterProvider Phone Number 855-874-0835Provider e-mail Address [email protected]

MEDICAL:

Provider Name CignaProvider Phone Number 1-866-494-2111Provider Web Address www.mycigna.com

DENTAL:

Provider Name United HealthCareProvider Phone Number 1-877-816-3596Provider Web Address www.myuhc.com

VISION:

Provider Name United HealthCareProvider Phone Number 1-800-638-3120Provider Web Address www.myuhcvision.com

HEALTH SAVINGS ACCOUNT (HSA):

Provider Name HSA BankProvider Phone Number 1-866-494-2111Provider Web Address WWW.mycigna.com

BASIC LIFE & ACCIDENTAL DEATH & DISMEMBERMENT: Provider Name United HealthCareProvider Phone Number 1-888-299-2070Provider Web Address www.myuhc.com

VOLUNTARY LIFE:


SHORT TERM AND LONG TERM DISABILITY:


ACCIDENT AND CRITICAL ILLNESS

DISCLOSURE NOTICES:

3

6

15

16

18

21

25

26

31

Refer to this list when you need to contact one of your benefit vendors. For general information contact Human Resources.

27

Benefit Resource Center ServicesBenefit Resource Center Services 3

Your Benefits Plan

Bill Ussery Motors offers a variety of benefits allowing

you the opportunity to customize a benefits package that

meets your personal needs.

In the following pages, you’ll learn more about the

benefits offered. You’ll also see how choosing the right

combination of benefits can help protect you and your

family’s health and finances – and your family’s future.

Benefit Who pays the cost?

Medical Insurance Shared cost between

employer and employee.

Vision and Dental You pay entire cost

Basic Life and Accidental

Death & Dismemberment

Insurance

Employer pays cost

Voluntary Life Insurance You pay entire cost

Short Term Disability

Employer pays cost if

employee enrolled in

Medical

Long Term Disability

Employer pays cost if

employee enrolled in

Medical

Accident*

Critical Illness*

You pay entire cost

You pay entire cost

Eligibility

All Regular full-time employees are eligible to join the benefits plan on the 1st of the month following 60 days of active employment.. “Regular Full-Time Employees” must be regularly scheduled and working at least 30 hours per week.

You may also elect enroll your dependents in the Benefits Plan at the time of enrollment.

Eligible dependents include:

> Your Spouse (unless you are divorced) and

domestic partner*.

> Your married or unmarried natural children, step-

children living with you, legally adopted children and

any other children for whom you have legal

guardianship, who are:

► Under 26 years of age for medical, dental and

vision;

► A dependent who is older than 26 years of age, but

less than 30 years of age may be eligible for

medical benefits. To be eligible, a Dependent must:

► Be Unmarried and not have dependents of his

or her own; AND

► Be a Resident of Florida or a Student; AND

► Not have coverage of their own, or covered

under any other plan; AND

► Not entitled to benefits under

Medicare/Medicaid

**Domestic Partnership: must show proof of cohabitation for a

minimum of 12 (Twelve) months.**

When Can You Enroll?

You can sign up for Benefits at any of the following

times:

� After completing initial eligibility period;

� During the annual open enrollment period;

� Within 30 days of a qualified family-status change.

If you do not enroll at one of the above times, you must

wait for the next annual open enrollment period.

**See Page 5, “Making Changes” for additional information.**

*For information on the worksite benefits, go to the on-line benefits portal http://www.explainmybenefits.com/bumgbenefits/

Benefit InformationBenefit Information

Choosing Your Benefits

You must actively choose any benefit that you pay for, orshare in the cost with Bill Ussery Motors.

Your part of the cost is automatically taken out of your paycheck. There are two ways that the money can be taken out:

> Before your taxes are calculated – medical, dental, and vision

> After your taxes are calculated – voluntary life, accident, and critical illness.

Why do I pay for benefits with before-tax money?

There is a definite advantage to paying for some benefits with before-tax money:

Taking the money out before your taxes are calculated lowers the amount of your pay that is taxable. Therefore, you pay less in taxes.

Making Changes

Generally, you can only change your benefit choices during the annual benefits enrollment period. However, you may be able to change your benefit choices at anytime if you have a change in status including:

> Your marriage

> Your divorce or legal separation

> Birth or adoption of an eligible child

> Death of your spouse or covered child

> Change in your spouse’s work status that affects his or her benefits

> Change in your work status that affects your benefits

> Change in residence or work site that affects your eligibility for coverage

> Change in your child’s eligibility for benefits

> Receiving Qualified Medical Child Support Order (QMCSO)

If you do not notify Human Resources within 30 days of a family status change, you will have to wait until the next annual enrollment period to make benefit changes unless you have another family status change.

When Coverage Ends

Coverage for all benefits end on the date of termination of employment.

Key Benefit Terms

COBRA – A Federal law that allows workers and dependents who lose their medical, dental, or vision coverage to continue any of these coverages for a specified length of time by electing and paying for continuation benefits.Coinsurance – The percentage of the medical or dental charge that you pay after the deductible has been met.Copayment – A flat fee that you pay for medical services, regardless of the actual amount charged by your doctor or another provider. This generally applies to physicians’ office visits and prescription drugs.Deductible – The amount you pay toward medical and dental expenses each calendar year before the plan begins paying benefits.Out of Pocket Maximum – The maximum amount you will pay in coinsurance during the calendar year

Pre-Existing Conditions Limitations Notice

Effective 1/1/2014, in accordance with The Patient Protection and Affordable Care Act, there is no longer any pre-existing conditions limitations for newly covered employees or dependents or current employees or dependents covered by the medical plans.

Benefit InformationBenefit Information

Frequently Asked Questions About Your Medical Plan

Q. What should I do if I have a problem getting a claim paid?

A. Start by contacting the carrier’s member services to determine the nature of the problem. If the issue is the way the doctor or other service provider has billed the claim, then contact your doctor or Claims Advocate at the Benefit Resource Center. If the insurance company has an eligibility issue, contact Human Resources for assistance.

Q. What is the difference between brand formulary, brand non-formulary, and generic drugs?

A. Brand formulary is a prescription drug that is listed on the formulary (i.e., a list of prescription drugs covered by the plan). These drugs are protected by a patent issued to the original innovator or marketer. Brand non-formulary drugs are patent protected but are not listed. A generic equivalent drug can become available when the patent protection runs out, and is deemed equal in therapeutic power to the brand name originals.

Q. When should I go the Urgent Care vs. Emergency Room?

A. For non-life threatening injury/illness after normal doctor’s office hours or when unable to schedule an appointment for immediate care.

Medical InsuranceMedical Insurance

Bill Ussery Motors offers two medical plans with Cigna. To find a network provider go to www.Cigna.com

In-Network Cigna

Plan Name OAP HDHP w/ H.S.A OAP Plan IN

Calendar Year Deductible

Individual $2,000 $4,000

Family $4,000 + $8,000

Maximum Out-of-Pocket

Individual $4,000 $6,350

Family $4,000 $12,700

Coinsurance

80% 100%

Lifetime Maximum

Unlimited

Preventive Care

100%

Office Visits

No PCP Required / Open Access

Primary Care Doctor 20% after CYD $25 copay

Specialist 20% after CYD $45 copay

Facility

In-Patient Hospital 20% after CYD 0% after CYD

Out-Patient Surgery 20% after CYD 0% after CYD

Emergency Room 20% after CYD $300 copay

Urgent Care 20% after CYD $25 copay

Complex Imaging 20% after CYD $300 copay

Prescription Benefits

CYD applies then copays

Retail (30 days) $10 / $35 / $60 $20 / $40 / $70

Mail Order (90 days) $30 / $105 / $180 $60 / $120 / $210

Out-of-Network

Deductible (Ind/Fam) $3,500 / $7,000

N/COut-of-Pocket (Ind/Fam) $4,500 / $9,000

Coinsurance 60%

Bi-Weekly Rates OAP HDHP w/ H.S.A.* OAP Plan IN

Employee Only $58.13 $149.08

Employee + Spouse $400.36 $569.80

Employee + Child(ren) $310.51 $459.34

Family $589.15 $801.89

*Health Savings Account may be added only when electing High Deductible Plan Option.

+ Please note: The Deductible is non-embedded. Which means that if an employee has Family coverage, the Family deductible has to

be met before benefits are payable.

6

This document reflects highlights of Bill Ussery Motor’s benefits program. It is not intended to provide complete plan description. In the event of any contradictions or disputes as to the

terms contained in this material and the legal plan documents, the legal plan document will govern.”

Dental InsuranceDental Insurance

Bill Ussery Motors offers two dental plans through United Healthcare. The Low DPPO and High DPPO plans allow you to use in-network or out-of-network benefits. If out-of-network dentists are used, you will be responsible to pay the difference between UHC’s allowed amount and what the dentist may charge. To find a network provider go to www.myuhc.com

In-Network United Healthcare

Plan name Low DPPO High DPPO

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

Deductible

Individual / Family $50 / $150 $75 / 225 $50 / $150 $50 / $150

Waived for Preventive

Yes No Yes No

Annual Maximum

$1,000 $2,000 $1,000

Orthodontia

N/C 50%

Lifetime Benefit

N/A $1,000 children age 19

Preventive Services (Periodic Oral Exam, Cleanings & X-Rays)

100% 100% 100% 100%

Basic Services (Fillings, Perio/Endo, Oral Surgery)

90% 80% 100% 80%

Major Services (Crown, Bridges & Dentures)

60% 50% 60% 50%

Out-of-Network Reimbursement

Maximum Allowed Contract 90th

Waiting Period for Services

None

Dependent Children Age

Age 26

Bi-Weekly Rates Low DPPO High DPPO w/Ortho

Employee Only $16.48 $21.05

Employee + Spouse $33.18 $42.29

Employee + Child (ren) $39.48 $53.90

Family $56.18 $75.15

15



Dental Network: Low DPPO – National Options PPO 20High DPPO – National Options PPO 30

Vision InsuranceVision Insurance

Bill Ussery Motors offers a vision plan through United Healthcare. This vision plan provides coverage both in and out of network. The chart below provides a brief overview of the plan. To find a network provider go to www.myuhcvision.com

16

United Healthcare Vision

In-Network Out-of-Network

Exam

$10 copay Up to $40

Materials

$25 copay

Frames Up to $45Single Vision Lenses Up to $40Lined Bifocal Lenses Up to $60

Contact Lenses

Elective $130 Up to $105

Medically Necessary $25 copay Up to $210

Benefit Frequency

Exam Once every 12 monthsLenses Once every 12 monthsFrames Once every 24 months

Dependent Children Age

Age 26

Bi-Weekly Rates Vision

Employee Only $2.68

Employee + Spouse $4.51

Employee + Child (ren) $4.60

Family $7.28



Shop eyeglasses and sunglasses at warbyparker.com or find a location near you.You’ll need your Member ID.

Find it on your ID card or at myuhcvision.com. You’ll need it to check and apply benefits.

Can’t find it? Call Warby Parker at 855-550-0743 to have your benefits verified without it.

Check myuhcvision.com to:

• Confirm whether you havea benefit for eyeglasses.

• Learn what your copay is.

• Find out what your planmay cover after your copay.

Need to contact Warby Parker?

Call 855-550-0743 or email [email protected].

Questions about your benefits?

Call 1-800-638-3120.

MT-1168376.0 3/18 ©2018 United HealthCare Services, Inc. 18-7354

Please note that Warby Parker does not sell contact lenses. Select Warby Parker locations offer eye exams. See warbyparker.com for details.

UnitedHealthcare vision coverage provided by or through UnitedHealthcare Insurance Company, located in Hartford, Connecticut, UnitedHealthcare Insurance Company of New York, located in Islandia, New York, or their affiliates. Administrative services provided by Spectera, Inc., United HealthCare Services, Inc. or their affiliates.

Facebook.com/UnitedHealthcare Twitter.com/UHC Instagram.com/UnitedHealthcare YouTube.com/UnitedHealthcare

Head to Warby Parker for eyeglasses and sunglasses (both single-vision and

progressive) starting at just $95

That means that you’re eligible for a huge range of Warby Parker frames for just the cost of your copay. Lenses are included!

Warby Parker’s frames are designed in-house and crafted from top-tier materials. Their eyeglasses come with scratch-resistant,

smudge-resistant, and anti-reflective treatments at zero additional cost. And for every pair purchased, a pair is distributed to

someone in need.

warbyparker.com/united

UnitedHealthcare Vision Members: Use your vision benefits at Warby Parker!You and anyone else covered on your plan can now shop for glasses at Warby Parker online and at their retail locations nationwide! It’s part of your UnitedHealthcare vision network.

Health Savings Accounts (HSA) Health Savings Accounts (HSA)

Health Savings AccountsA health savings account (HSA) is an account funded to help you save for future medical expenses not covered by your insurance plan, including the deductible, coinsurance and even vision and dental expenses. You must be enrolled in a HSA compatible health plan to be eligible, and there are certain advantages to putting money into these accounts, including favorable tax treatment and the ability to roll unused funds over from year to year.

Who Can Have an HSA?Any adult can contribute to an HSA if you:

· Have coverage under an HSA-qualified, high-deductible health plan (HDHP)· Have no other first-dollar medical coverage (other types of insurance, including specific injury or

accident, disability, dental care, vision care, or long-term care insurance are permitted)· Are not enrolled in Medicare or Tricare· Cannot be claimed as a dependent on someone else’s tax return

Contributions to your HSA can be made by you, your employer or both. However, the total contributions are limited annually. If you make a contribution, you can deduct the contributions (even if you do not itemize deductions) when completing your federal income tax return.Contributions 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.

HDHPsYou must have coverage under the Cigna HDHP to open and contribute to an HSA.

HSA ContributionsYou can make a contribution to your HSA each year that you are eligible. Contributions from all sources can be no more than:

Individuals ages 55 and older can also make additional “catch-up” contributions. The maximum annual catch-up contribution is $1,000.

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· Self-only coverage: $3,550 in 2020 and $3,600 in 2021· Family coverage: $7,100 in 2020 and $7,200 in 2021

HSA Plan Usage Frequently Asked QuestionsHSA Plan Usage Frequently Asked Questions

How do I manage my HSA?

Your Health Savings Account (HSA) is your account; the HSA dollars are your dollars. Since you are the account holder or HSA beneficiary, you manage your HSA account. You may choose when to use your HSA dollars or when not to use your HSA dollars. HSA dollars pay for any eligible expense. Most commonly, the HSA account holder will use HSA dollars to pay the out-of-pocket expenses (i.e., deductible and coinsurance) associated with their high deductible plan.

What expenses are eligible for reimbursement from my HSA?

HSA dollars may be used for qualified medical expenses incurred by the account holder and his or her spouse and dependents. Qualified medical expenses are outlined within IRS Section 213(d). In summary the IRS Section 213(d) states that “the expense has to be primarily for the prevention or alleviation of a physical or mental defect or illness”. In addition to qualified medical expenses, the following insurance premiums may be reimbursed from an HSA:

· COBRA premiums· Health insurance premiums while receiving unemployment Benefits· Any health insurance premiums paid, other than for a

Medicare supplemental policy, by individuals ages 65 and over

Are dental and vision care qualified medical expenses under

an HSA?

Yes, as long as these are deductible under the current rules. For example, cosmetic procedures, like cosmetic dentistry, would not be considered qualified medical expenses.

What expenses are NOT eligible for reimbursement from my

HSA?

The following expenses may not be reimbursed from an HSA:· Premiums for Medicare supplemental policies· Expenses covered by another insurance plan· Expenses incurred prior to the date the HSA was established· Over-the-counter drugs purchased without a prescription (except insulin)

What happens when my HSA funds run out?

You may be financially responsible for any eligible medical expenses that fall within the coverage gap.

Can I use my HSA dollars for non-eligible expenses?

Money withdrawn from an HSA account to reimburse non-eligible medical expenses is taxable income to the account holder and subject to a 20 percent tax penalty - unless over age 65, disabled or upon death of the account holder.

When can I start using my HSA dollars?

You can use your HSA dollars immediately following your HSA account activation and once contributions have been made.

How do I pay my physician or network facility at time of

service with my HSA dollars?

You may request that the network provider submit your claim to your health plan. You should make sure that your provider has your most up-to-date insurance information. Once the medical claim has been processed, if applicable, out-of-pocket expenses will be billed. At this time you may choose to use your HSA Debit card to pay for any out-of-pocket expenses, or you may choose to pay with your own money and receive reimbursement at a later date. You should always ask that your medical claim be submitted to the health plan before you seek reimbursement from your HSA. This procedure will ensure that provider discounts are applied. Also, remember to keep all medical receipts and Explanation of Benefits (EOBs) for tax purposes.

What if I have HSA dollars left in my account at year-end?

The money is yours to keep. It will continue to be available for you and your health care costs next year.

What happens to my HSA dollars if I leave Bill Ussery

Motors?

The funds are yours to keep. You may elect one of the following options:

· Leave your funds in your current HSA account· Transfer your funds to an HSA with your new employer· Transfer your funds to another qualifying account within 60 days

Can I use the money in my account to pay for my

dependents’ medical expenses?

You can use the money in your account to pay for medical expenses for yourself, your spouse or your dependent children. You can pay for the unreimbursed expenses of your spouse and dependent children even if they are not covered by your HDHP.

Can couples establish a “joint” account and both make

contributions to the account, including “catch-up”

contributions?

“Joint” HSA accounts are not permitted. Each spouse should consider establishing an account in their own name. This allows you both to make catch-up contributions when each spouse is 55 or older.

Can I shift my IRA funds to my HSA?

Owners of individual retirement accounts that are enrolled in a high-deductible health plan can shift IRA funds to an HSA without facing a tax penalty. The IRS allows a one-time transfer that does not exceed your maximum HSA contribution limit.

Can I borrow against the money in my HSA?

No. You may not borrow against it or pledge the funds in it. For more information on prohibited activities see Section 4975 of the Internal Revenue Code.

Bill Ussery Motors is always looking to protect its employees pockets when it can.

Take a look at the various pharmacy discounts available to you simply for being a consumer. You do not need to be a member of the medical plan in order to participate in any of these programs. For more information please visit the websites below.

$4 PrescriptionsChoose from hundreds of generic drugsand over–the–counter medications

FREE antibiotics

Get up to a 14-day supply of the following generic oral antibiotics free: •Amoxicillin•Ampicillin•Sulfamethoxazole/Trimethoprim (SMZ-TMP)•Ciprofloxacin (excluding Ciprofloxacin XR)•Penicillin VK

•FREE Metformin•FREE Lisinopril•FREE Amlodipine

Many consumers have yet to take advantage of the low prices for prescription drugs offered by many retailers. For example, some American consumers still pay an average of $50 a month for the generic drug, Pravastatin to lower cholesterol. But you can buy a 30-day supply for $4 at Target or Walmart and pay even less per dose for a 90-day supply.

GoodRx gathers current prices and discounts to help you find the lowest cost pharmacy for your prescriptions. The average GoodRx customer saves $276 a year on their prescriptions. GoodRx is 100% free. No personal information required. Visit their website at www.goodrx.com or download their app.

Getting more from your Health Care DollarsGetting more from your Health Care Dollars



Basic Life and AD&D InsuranceBasic Life and AD&D Insurance

Bill Ussery Motors provides Basic Life and AD&D life insurance to all active full time employees. The chart below provides an overview of the plan.

Note: Please see your Benefits Representative for a Beneficiary Designation Form.

The only time you can enroll in guaranteed issue voluntary life insurance, is at the date you first become eligible to enroll. If you do not enroll then and later decide that you would like to enroll, you will be required to complete a medical questionnaire and go through medical underwriting. The insurance carrier reserves the right to decline coverage based on medical information obtained on the medical questionnaire.

21

Employer Paid United Healthcare

Basic Life and Accidental Death & Dismemberment

Full-time Employees $25,000

Full-time Directors, Managers 100% of salary to max of $250,000

Full-time CEO, CFO, COO, GM, President, Owner 200% of salary to max of $500,000

Vice President $250,000

Definition of Earnings

W2-Earnings

Benefit Reductions

@ Age 65 65%

@ Age 70 40%

@ Age 75 25%

Accelerated Death Benefit

If you are diagnosed as terminally ill you may receive payment of a portion of your Life Insurance. The

remaining amount of your Life Insurance would be paid to your beneficiary when you die.

Waiver of Premium if disabled

Yes

Conversion

Included

Portability

Included



Will and trust preparationCreating a will and trust may help give you more control over future events and allows the family to follow your wishes. Your life insurance plan includes online will and trust services to help you:

• Create and prepare a will — registration required.• Locate nearby attorneys, search legal forms, find helpful

articles by legal experts and more.• Access financial planning help and helpful cost calculators.

About your life insurance plan.Your life insurance plan is a term life policy that will pay a cash benefit directly to your designated beneficiaries if you should pass away. Your beneficiary can use the money to help cover costs like funeral expenses, mortgage, and education.

For your specific plan details, including the length (term) of your policy, please see your certificate of coverage.

24/7 support for you and your beneficiaries.Your plan includes many resources and personal support services to help you prepare and to help your loved ones cope. These services are available 24/7 and at no additional cost.

Prepare your will today.Go to liveandworkwell.com.

1. Enter access code: LIFEBENSVS.

2. Select Financial & Legal tab.

3. Select Estate Planning or Retirement Planning.

The decision to get life insurance can sometimes be tough, but it’s a good feeling to know you’ve provided financial and emotional support for your loved ones in case of your unexpected death.

Use this guide to learn about the many services you get with your plan and how you and your loved ones can access them.

For personal andconfidential assistance,call 1-866-302-4480, TTY 711. Translators are available.

Get help anonymouslyat liveandworkwell.com Use access code: LIFEBENSVS. This secure, online resource can help you locate providers, community and grief support resources and learn about timely and important life topics.

Maintaining your privacy and confidentiality is of utmost importance. All records, referrals and evaluations are kept private in accordance with federal and state laws.

Beneficiary Companion The Beneficiary Companion Program provides 24/7 guidance for your beneficiary on closing your estate and protecting your identity.

Guidance services:Help is available anytime to obtain death certificate copies and to notify:

Social Media Shut-Down: It can be a time-consuming process to close your social media accounts. Help is available to:• Discontinue access to your social media accounts (e.g., Facebook, Instagram, Twitter, LinkedIn, Google

properties, etc.).• Assist with memorialization of specific accounts to preserve your digital profile for friends and family.

Fraud resolution:Identity theft is a growing risk. Expert help is available to help protect it -- and lend a hand if it is stolen. Services include:

• A credit report review.• Suppression of the credit report or freezing/closing the account. • Full-service resolution assistance, including affidavit assistance, credit bureau, and fraud department

notification, help to file a police report and creditor follow up.

Steps to filing a claim.1. Notify the employer about the

death of the covered person.

2. Access the claim packet at myuhc.com® (log in not required).

3. Select Popular Forms.

4. Select Disability, Life and Supplemental Insurance Claim Forms.

If you need assistance, please call our claim service team at 1-888-299-2070, 8 a.m. to 6 p.m. ET.

Beneficiary services After a death, there’s so much to deal with that it can be overwhelming. It’s nice to know your beneficiary will have a team of professionals — included in your plan — ready to help provide emotional, financial and legal guidance. All services are confidential, and specialists are available 24/7.

Grief support:• Unlimited phone access to masters-level specialists, 24/7.• Up to 2 referrals for face-to-face grief counseling sessions,¹ with

access to a national network of 144,000+ clinicians.2

Financial and legal support:• One 30- to 60-minute financial consultation with a credentialed

financial professional who can discuss estate taxes and other financial matters.

• One 30-minute legal consultation. As a beneficiary, you can retain an attorney for ongoing services at a discounted rate.3

Wealth management account:• Option to open a bank account from Optum Bank® for help

managing the money. Visit optumbank.com to learn more. • An account automatically opens for payments of $5,000 or more.

Request the guidebook. Get assistance or request your complimentary guidebook by calling toll-free 1-866-643-4241.

• Social Security Administration• Credit reporting agencies• Credit card companies/ financial institutions

• Third-party vendors• Government agencies

Travel assistanceIf you or your beneficiaries travel 100 miles or more away from home or outside the country, call 1-800-527-0218 to access these travel assistance services 24 hours a day, anywhere in the world. Just a few of the services UnitedHealthcare Global travel provides:

Travel assistance services:• Emergency travel arrangements.• Assistance in replacing lost or stolen

travel documents.• Emergency translation services.

All trademarks are the property of their respective owners.

UnitedHealthcare Life and Disability products are provided by UnitedHealthcare Insurance Company and certain products in California by Unimerica Life Insurance Company. Life and Disability products are provided on policy forms LASD-POL (05/03) et al. and UHCLD-POL 2/2008 et al., in Texas on forms LASD-POL-TX(05/03) and UHCLD-POL 2/2008-TX and in Virginia on LASD-POL(05/03) and UHCLD-POL 2/2008. The policies have exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Some products are not available in all states. UnitedHealthcare Insurance Company is located in Hartford, CT and Unimerica Life Insurance Company is located in Milwaukee, WI.

Noninsurance services are offered only on specific lines of coverage and are not insurance. These services may be modified or terminated at any time, may not be available in all states and may vary depending on state laws and regulations. Will and Trust and Beneficiary Services are offered through Optum. Optum is an affiliate of UnitedHealthcare. Travel Assistance services are provided by UnitedHealthcare Global Assistance. Beneficiary Companion is provided by Generali Global Assistance, LLC, a service provider not affiliated with UnitedHealthcare. UnitedHealthcare is not responsible or liable for care, services, or advice given by the provider or vendor of these services.

1 Optum internal network analysis, February 2019. 1 There is no charge for referrals or for seeing a clinician within our network for up to 3 visits per issue.2 Due to the potential for a conflict of interest, legal consultation will not be provided on issues that may involve legal action against UnitedHealthcare, its affiliates or any entity through which the caller is receiving

services directly or indirectly.

The company does not discriminate on the basis of race, color, national origin, sex, age, or disability in health programs and activities. We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the member toll-free phone number listed on your ID card. ATENCION: Si habla espańol (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al numero de telefono gratuito que aparece en su tarjeta de identificación. 請注意：如果您說中文 (Chinese)，我們免費為您提供語言協助服務. 請撥打會員卡所列的免付費會員電話號碼.

8349887.1 4/19 ©2019 United HealthCare Services, Inc. 19-11955-C Facebook.com/UnitedHealthcare Twitter.com/UHC Instagram.com/UnitedHealthcare YouTube.com/UnitedHealthcare

Medical assistance services:• Worldwide medical and dental referrals.• Relay of insurance and medical information. • Assistance in replacing corrective lenses and

medical devices and much more.

Get travel help anytime and on the go.Log in to UHCGlobal.com to print your Global Assistance ID card, get up-to-date travel alerts, travel tips and much more.

Create your account:1. Select Member Log-in.2. Select Visit Global Intelligence Center.3. Select Create User and enter the ID number 358231.

Client Name:

UHC Global ID#:

GLOBALASSISTANCE

Notice to Physicians/Hospitals: Call immediately for benefits verification and procedures. Call 24 hours a day(multilingual). If you do not have access to a phone, email for assistance: [email protected]

If the condition is an emergency, you should immediately call local emergency services or go to the

nearest physician or hospital without delay. Then contact the 24-hour Emergency Response Center. If you have a travel problem, simply call or email for assistance. Carrier charges may

be incurred. The Emergency Response Center can obtain a call back number to minimize telecom charges to you.

A multilingual case manager will ask for your name, your organization’s name, the number shown on the front of your ID card, and a description of the situation.

We will immediately begin assisting you.

UnitedHealthcare Global Emergency Response Center

United States +1.410.453.6330

1.800.527.0218 (toll free within U.S. & Canada)[email protected]

24 hours a day, 7 days a week, 365 days a year

Client Name: UnitedHealthcareUHC Global ID: 358231

Voluntary LifeVoluntary Life

Bill Ussery Motors provides Voluntary life insurance to all active full time employees. The chart below provides an overview of the plan.

Note: Please see your Benefits Representative for a Beneficiary Designation Form.

The only time you can enroll in guaranteed issue voluntary life insurance, is at the date you first

become eligible to enroll. If you do not enroll then and later decide that you would like to enroll, you

will be required to complete a medical questionnaire and go through medical underwriting. The

insurance carrier reserves the right to decline coverage based on medical information obtained on

the medical questionnaire.

Voluntary Life Insurance

Rates vary based on age and amount of insurance elected. Rates will be shown on the on-line enrollment system.*Please refer to United Healthcare cost sheet for bi-weekly deductions.

25

Employee Paid United Healthcare

Voluntary Life

Employee

$10,000 to $500,000 in $10,000 increments

Spouse

$10,000 to $250,000 in $10,0000 increments, not to exceed 100% of employee's amount

Children

14 days to age 26, $10,000 not to exceed employee's amount

Guarantee Issue Limits

Employee $180,000

Spouse $30,000

Children $10,000

Waiver of Premium if Disabled

Yes

Portability

Yes

Conversion

Yes

Benefit Reductions-of original amount

@ Age 65 35%

@ Age 70 60%

@ Age 75 75%



Disability InsuranceDisability Insurance

Bill Ussery Motors provides all active full time employees Short Term and Long Term Disability coverage through a group plan, if the employee is enrolled in the Medical Plan. In the event you become disabled from a non work-related injury or sickness, disability benefits are provided as a source of income. You are not eligible to receive short-term disability benefits if you are receiving workers’ compensation benefits.

26

Long Term Disability United Healthcare

Employer Paid benefit only for Employees Electing Cigna Medical

Class: Other Employee Exec/Management


W2 - Earnings

Contributory/Non-Contributory

Non-Contributory Non-Contributory

Benefit Percentage

60% to $6,000 60% to $15,000

Own Occupation Period

24 months To age 65 Own occupation

Elimination Period

90 days 90 days

Benefit Duration

Social Security Normal Retirement Age

Social Security Normal Retirement Age

Pre-existing Conditions

3/12

Short Term Disability United Healthcare

Employer Paid benefit only for Employees Electing Cigna Medical


W-2 Earnings

Contributory/Non-Contributory

Non-Contributory

Benefit Percentage

60% to $1,500

Benefit Period

11 weeks

Pre-existing Conditions

N/A

Benefits Begin

Accident 15th day

Illness 15th day



Don’t let a serious illness add financial stress.Help protect your finances and your family.Almost everyone knows someone who has had cancer, a heart attack or a stroke and has seen the financial impact. Critical Illness Protection Plan from UnitedHealthcare is designed to help ensure that, should you be diagnosed with a covered critical illness, you’ll have financial support to help you continue to pay your daily living expenses.

What’s covered?1

Conditions and coverage may vary depending on where you live or what your employer is offering:

• Benign brain tumor.

• Cancer — Invasive.

• Cancer — Non-invasive (partial benefit).

• Chronic renal failure.

• Coma.

• Coronary artery disease (partial benefit).

• Heart attack.

• Heart failure.

• Major organ failure.

• Permanent paralysis.

• Ruptured aneurysm.

• Stroke.

How does it work?The UnitedHealthcare Critical Illness Protection Plan sends a lump- sum payment directly to you after your diagnosis so you can help stay on top of your bills.

While a traditional health plan is necessary, there are costs it may not cover. This is where Critical Illness Protection Plan can help, enabling you to use the lump-sum payment to help pay expenses such as:

• Mortgage or rent payments.

• Groceries.

• Child care during treatment.

• Out-of-pocket health plan costs (deductibles, coinsurance, etc.).

• Prescriptions.

• Transportation to and from therapy and specialist appointments.

For a COMPLETE LIST of covered conditions and benefit payment amounts, see your official plan documents. Your plan may include more covered conditions which are listed on the back page.

Heart disease, stroke and cancer are among the leading critical illnesses in the U.S. Americans suffer 1.5 million heart attacks and strokes each year.2 About 1.6 million new cancer cases are expected to be diagnosed in the U.S. this year.3

Many employees are not prepared for high, unexpected costs. Almost 2 in 3 American workers say they have less than $1,000 on hand to pay the out-of-pocket expenses of unexpected, serious illness or emergency.4

1 All benefits are payable at 100 percent unless otherwise noted as a partial benefit.2 American Heart Association. Disease and Stroke Statistics 2017 Update. A Report From the American Heart Association;

Mar. 2017. Web.3 American Cancer Society. Cancer Facts & Figures 2017. Atlanta: American Cancer Society; 2017. Web.4 Weschler, Pat. “63% of Americans Can’t Cover Unexpected Expenses.” Fortune. 63% of Americans Can’t Cover Unexpected

Expenses. Time Inc., 06 Jan. 2016. Web.

Financial Protection Critical Illness Protection Plan

MT-1158245.0 10/17 ©2017 United HealthCare Services, Inc. 17-6195

Lump-sum payments are 100 percent of the coverage amount unless otherwise noted as a partial benefit. Subject to medical verifications and conditions as defined in the policy.

THIS IS A LIMITED BENEFIT POLICY.This information does not replace your official health plan documents. Please see your official health plan documents for all coverage details, which includes limitations and exclusions. The policies have exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. UnitedHealthcare Critical Illness product is provided by UnitedHealthcare Insurance Company. Critical Illness coverage is NOT considered “minimum essential coverage” under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor. The policies have exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Some products are not available in all states. UnitedHealthcare Insurance Company is located in Hartford, CT.

Facebook.com/UnitedHealthcare Twitter.com/UHC Instagram.com/UnitedHealthcare YouTube.com/UnitedHealthcare

The company does not discriminate on the basis of race, color, national origin, sex, age, or disability in health programs and activities.We provide free services to help you communicate with us, such as letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the member toll-free phone number listed on your ID card. ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación.請注意：如果您說中文 (Chinese)，我們免費為您提供語言協助服務。請撥打會員卡所列的免付費會員電話號碼。

Enroll Today. Consider the financial protection you’ll gain by enrolling in the UnitedHealthcare Critical Illness Protection Plan.

Additional Covered Conditions.Conditions and coverage may vary depending on where you live or what your employer is offering.

• Advanced Alzheimer’s.

• Advanced Multiple Sclerosis.

• Advanced Parkinson’s.

• Amyotrophic Lateral Sclerosis (ALS).

• Complete Blindness.

• Complete Loss of Hearing.

Child-only Conditions.• Cerebral Palsy.

• Cleft Lip/Palate.

• Cystic Fibrosis.

• Down Syndrome.

• Muscular Dystrophy.

• Spina Bifida.

Benefits will be 25 percent of employee coverage. Child-only coverage is included with employee coverage. One covered condition per child. Coverage is from birth to age 26.

For a COMPLETE LIST of covered conditions and benefit payment amounts, see your official plan documents.

The Newborns’ and Mothers’ Health

Protection Act of 1996

The Newborns’ and Mothers’ Health Protection Act of 1996 prohibits group and

individual health insurance policies from restricting benefits for any hospital length of

stay for the mother or newborn child in connection with childbirth; (1) following a

normal vaginal delivery, to less than 48 hours, and (2) following a cesarean section, to

less then 96 hours. Health insurance policies may not require that a provider obtain

authorization from the health insurance plan or the issuer for prescribing any such

length of stay. Regardless of these standards an attending health care provider may,

in consultation with the mother, discharge the mother or newborn child prior to the

expiration of such minimum length of stay.

Further, a health insurer or health maintenance organization may not:

1. Deny to the mother or newborn child eligibility, or continued eligibility, to enroll

or to renew coverage under the terms of the plan, solely to avoid providing

such length of stay coverage;

2. Provide monetary payments or rebates to mothers to encourage such mothers

to accept less than the minimum coverage;

3. Provide monetary incentives to an attending medical provider to induce such

provider to provide care inconsistent with such length of stay coverage;

4. Require a mother to give birth in a hospital; or

5. Restrict benefits for any portion of a period within a hospital length of stay

described in this notice.

These benefits are subject to the plan’s regular deductible and co-pay. For further

details, refer to your Summary Plan Description. Keep this notice for your records and

call Human Resources for more information.

Women’s Health and Cancer Rights

Act of 1998

The Women’s Health and Cancer Rights Act of 1998 requires Bill Ussery Motors to

notify you, as a participant or beneficiary of the Bill Ussery Motors Health and Welfare

Plan, of your rights related to benefits provided through the plan in connection with a

mastectomy. You, as a participant or beneficiary, have rights to coverage to be

provided in a manner determined in consultation with your attending physician for:

1. All stages of reconstruction of the breast on which the mastectomy was

performed;

2. Surgery and reconstruction of the other breast to produce a symmetrical

appearance; and

3. Prostheses and treatment of physical compilations of the mastectomy,

including lymphedema.

These benefits are subject to the plan’s regular deductible and co-pay. For further

details, refer to your Summary Plan Description. Keep this notice for your records and

call Human Resources for more information.

Michelle’s Law

The law allows for continued coverage for dependent children who are covered under

your group health plan as a student if they lose their student status because of a

medically necessary leave of absence from school. This law applies to medically

necessary leaves of absence that begin on or after January 1, 2010

If your child is no longer a student, as defined in your Certificate of Coverage, because

he or she is on a medically necessary leave of absence, your child may continue to be

covered under the plan for up to one year from the beginning of the leave of absence.

This continued coverage applies if your child was (1) covered under the plan and (2)

enrolled as at student at a post-secondary educational institution (includes colleges,

universities, some trade schools and certain other post-secondary institutions).

Your employer will require a written certification from the child’s physician that states

that the child is suffering from a serious illness or injury and that the leave of absence

is medically necessary.

Required Annual Employee

Disclosure Notices

Required Annual Employee

Disclosure Notices

Patient Protection:

If the Group Health Plan generally requires the designation of a primary care provider

who participates in the network and who is available to accept you or your family

members. For children, your may designate a pediatrician as the primary care

provider.

You do not need prior authorization from the carrier or from any other person

(including a primary care provider) in order to obtain access to obstetrical or

gynecological care from a health care professional in the network who specializes in

obstetrics or gynecology. The health care professionals, however, may be required to

comply with certain procedures, including obtaining prior authorization for certain

services, following a pre-approved treatment plan or procedures for making referrals.

For a list of participating health care professionals who specialize in obstetrics or

gynecology, or for information on how to select a primary care provider, and for a list of

the participating primary care providers, contact the Plan Administrator or refer to the

carrier website.

It is your responsibility to ensure that the information provided on your application is

accurate and complete. Any omissions or incorrect statements made by you on your

application may invalidate your coverage. The carrier has the right to rescind coverage

on the basis of fraud or misrepresentation.

31

Statement of ERISA Rights

As a participant in the Plan you are entitled to certain rights and protections under the

Employee Retirement Income Security Act of 1974 (“ERISA”). ERISA provides that all

participants shall be entitled to:

Receive Information about Your Plan and Benefits

• Examine, without charge, at the Plan Administrator’s office and at other

specified locations, the Plan and Plan documents, including the insurance

contract and copies of all documents filed by the Plan with the U.S. Department

of Labor, if any, such as annual reports and Plan descriptions.

• Obtain copies of the Plan documents and other Plan information upon written

request to the Plan Administrator. The Plan Administrator may make a

reasonable charge for the copies.

• Receive a summary of the Plan’s annual financial report, if required to be

furnished under ERISA. The Plan Administrator is required by law to furnish

each participant with a copy of this summary annual report, if any.

Continue Group Health Plan Coverage

If applicable, you may continue health care coverage for yourself, spouse or

dependents if there is a loss of coverage under the plan as a result of a qualifying

event. You and your dependents may have to pay for such coverage. Review the

summary plan description and the documents governing the Plan for the rules on

COBRA continuation of coverage rights.

Prudent Actions by Plan Fiduciaries

In addition to creating rights for participants, ERISA imposes duties upon the people

who are responsible for operation of the Plan. These people, called “fiduciaries” of the

Plan, have a duty to operate the Plan prudently and in the interest of you and other

Plan participants.

No one, including the Company or any other person, may fire you or discriminate

against you in any way to prevent you from obtaining welfare benefits or exercising

your rights under ERISA.

Required Annual Employee Disclosure

Notices - Continued


Notices - Continued

Enforce your Rights

If your claim for a welfare benefit is denied in whole or in part, you must receive a

written explanation of the reason for the denial. You have a right to have the Plan

review and reconsider your claim.

Under ERISA, there are steps you can take to enforce these rights. For instance, if you

request materials from the Plan Administrator and do not receive them within 30 days,

you may file suit in federal court. In such a case, the court may require the Plan

Administrator to provide the materials and pay you up to $110 a day until you receive

the materials, unless the materials were not sent due to reasons beyond the control of

the Plan Administrator. If you have a claim for benefits which is denied or ignored, in

whole or in part, and you have exhausted the available claims procedures under the

Plan, you may file suit in a state or federal court. If it should happen that Plan

fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting

your rights, you may seek assistance from the U.S. Department of Labor, or you may

file suit in a federal court. The court will decide who should pay court costs and legal

fees. If you are successful, the court may order the person you have sued to pay these

costs and fees. If you lose (for example, if the court finds your claim is frivolous) the

court may order you to pay these costs and fees.

Assistance with your Questions

If you have any questions about your Plan, this statement, or your rights under ERISA,

you should contact the nearest office of the Employee Benefits and Security

Administration, U.S. Department of Labor, listed in your telephone directory or the

Division of Technical Assistance and Inquiries, Employee Benefits and Security

Administration, U.S. Department of Labor, 200 Constitution Avenue N.W.,

Washington, D.C. 20210.

Section 111

Effective January 1, 2009 group health plans are required by Federal government to

comply with Section 111 of the Medicare, Medicaid, and SCHIP Extensions of 2007’s

new Medicare Secondary Payer regulations. The mandate is designed to assist in

establishing financial liability of claims assignments. In other words, it will help

establish who pays first. The mandate requires group health plans to collect additional

information, more specifically Social Security numbers for all enrollees, including

dependents 6 months of age or older. Please be prepared to provide this information

on your benefits enrollment form when enrolling into benefits.

I. No access to protected health information (PHI) except for

summary health information for limited purpose and enrollment /

dis-enrollment information.

Neither the group health plan nor the plan sponsor (or any member of

the plan sponsor’s workforce) shall create or receive protected health

information (PHI) as defined in 45 C.F.R. §160.103 except for (1)

summary health information for purpose of (a) obtaining premium bids

or (b) modifying, amending, or terminating the group health plan, and

(2) enrollment and dis-enrollment information.

II. Insurer for group health plan will provide privacy notice

The insurer for the group health plan will provide the group health

plan’s notice of privacy practices and will satisfy the other requirements

under HIPAA related to the group health plan’s PHI. The notice of

privacy practices will notify participants of the potential disclosure of

summary health information and enrollment / dis-enrollment

information to the group health plan and the plan sponsor.

III. No intimidating or retaliatory acts

The group health plan shall not intimidate, threaten, coerce,

discriminate against, or take other retaliatory action against individuals

for exercising their rights , filing a complaint, participating in an

investigation, or opposing any improper practice under HIPAAA.

IV. No Waiver

The group health plan shall not require an individual to waive his or her

privacy rights under HIPAA as a condition of treatment, payment,

enrollment or eligibility. If such an action should occur by one of the

plan sponsor’s employees, the action shall not be attributed to the

group health plan.

HIPAA Privacy Policy for Fully-Insured

Plans with no Access to PHI

The group health plan is a fully-insured group health plansponsored by the “Plan Sponsor”. The group health plan and theplan sponsor intend to comply with the requirements of 45 C.F.R.§164.530 (k) so that the group health plan is not subject to mostof HIPAA’s privacy requirements.


Notices - Continued


Notices - Continued

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).

Notice of Special Enrollment Rights

If you are declining enrollment for yourself or your dependents (including your spouse)

because of other health insurance or group health plan coverage, you may be able to

enroll yourself and your dependents in this plan if you or your dependents lose

eligibility for that other coverage (or if the employer stops contributing toward your or

your dependents’ other coverage). However, you must request enrollment within 30

days after your or your dependents’ other coverage ends (or after the employer stops

contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or

placement for adoption, you may be able to enroll yourself and your dependents.

However, you must request enrollment within 30 days after the marriage, birth,

adoption, or placement for adoption.

Further, if you decline enrollment for yourself or eligible dependents (including your

spouse) while Medicaid coverage or coverage under a State CHIP program is in effect,

you may be able to enroll yourself and your dependents in this plan if:

coverage is lost under Medicaid or a State CHIP program; or

you or your dependents become eligible for a premium assistance subsidy from the

State.

In either case, you must request enrollment within 30 days from the loss of coverage

or the date you become eligible for premium assistance.

To request special enrollment or obtain more information, contact person listed at the

end of this summary.


Notices - Continued


Notices - ContinuedIf you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states

is current as of January 31, 2015. Contact your State for more information on eligibility –

ALABAMA – Medicaid GEORGIA – Medicaid

Website: www.myalhipp.comPhone: 1-855-692-5447

Website: http://dch.georgia.gov/- Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP)Phone: 1-800-869-1150

ALASKA – Medicaid INDIANA – Medicaid

Website: http://health.hss.state.ak.us/dpa/programs/medicaid/Phone (Outside of Anchorage): 1-888-318-8890Phone (Anchorage): 907-269-6529

Website: http://www.in.gov/fssaPhone: 1-800-889-9949

COLORADO – Medicaid IOWA – Medicaid

Medicaid Website: http://www.colorado.gov/hcpfMedicaid Customer Contact Center: 1-800-221-3943

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

FLORIDA – Medicaid KANSAS – Medicaid

Website: https://www.flmedicaidtplrecovery.com/Phone: 1-877-357-3268

Website: http://www.kdheks.gov/hcf/Phone: 1-800-792-4884

KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid

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

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdfPhone: 603-271-5218

LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP

Website: http://www.lahipp.dhh.louisiana.govPhone: 1-888-695-2447

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

MAINE – Medicaid NEW YORK – Medicaid

Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.htmlPhone: 1-800-977-6740TTY 1-800-977-6741

Website: http://www.nyhealth.gov/health_care/medicaid/Phone: 1-800-541-2831

MASSACHUSETTS – Medicaid and CHIP NORTH CAROLINA – Medicaid

Website: http://www.mass.gov/MassHealthPhone: 1-800-462-1120

Website: http://www.ncdhhs.gov/dmaPhone: 919-855-4100

MINNESOTA – Medicaid NORTH DAKOTA – Medicaid

Website: http://www.dhs.state.mn.us/id_006254Click on Health Care, then Medical Assistance

Phone: 1-800-657-3739

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/Phone: 1-800-755-2604

MISSOURI – Medicaid OKLAHOMA – Medicaid and CHIP

Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htmPhone: 573-751-2005

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

MONTANA – Medicaid OREGON – Medicaid

Website: http://medicaid.mt.gov/memberPhone: 1-800-694-3084

Website: http://www.oregonhealthykids.govhttp://www.hijossaludablesoregon.gov

Phone: 1-800-699-9075NEBRASKA – Medicaid PENNSYLVANIA – Medicaid

Website: www.ACCESSNebraska.ne.govPhone: 1-855-632-7633

Website: http://www.dpw.state.pa.us/hippPhone: 1-800-692-7462

NEVADA – Medicaid RHODE ISLAND – Medicaid

Medicaid Website: http://dwss.nv.gov/Medicaid Phone: 1-800-992-0900

Website: www.ohhs.ri.govPhone: 401-462-5300

SOUTH CAROLINA – Medicaid VIRGINIA – Medicaid and CHIP

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

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

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid

Website: http://dss.sd.govPhone: 1-888-828-0059

Website: http://www.hca.wa.gov/medicaid/premiumpymt/pages/ index.aspxPhone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid WEST VIRGINIA – Medicaid

Website: https://www.gethipptexas.com/Phone: 1-800-440-0493

Website: www.dhhr.wv.gov/bms/ Phone: 1-877-598-5820, HMS Third Party Liability

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP

Website: Medicaid: http://health.utah.gov/medicaidCHIP: http://health.utah.gov/chipPhone: 1-866-435-7414

Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htmPhone: 1-800-362-3002

VERMONT– Medicaid WYOMING – Medicaid

Website: http://www.greenmountaincare.org/Phone: 1-800-250-8427

Website: http://health.wyo.gov/healthcarefin/equalitycarePhone: 307-777-7531

To see if any other states have added a premium assistance program since January 31, 2015, or for more information on special enrollment rights, contact either:US Department of LaborEmployee Benefits Security Administrationwww.dol.gov/ebsa

1-866-444-EBSA (3272)|

US Department of Health and Human ServicesCenters for Medicare & Medicaid Serviceswww.cms.hhs.gov

1-877-267-2323, Menu Option 4, Ext 61565

Required Annual Employee Disclosure Notices - Continued

Medicare Part D

This notice applies to employees and covered dependents who are eligible for

Medicare Part D.

Please read this notice carefully and keep it where you can find it. This notice has

information about your current prescription drug coverage with Cigna and about your

options under Medicare’s prescription drug Plan. If you are considering joining, you

should compare your current coverage including which drugs are covered at what cost,

with the coverage and costs of the plans offering Medicare prescription drug coverage

in your area. Information about where you can get help to make decisions about your

prescription drug coverage is at the end of this notice.

1. Medicare prescription drug coverage became available in 2006 to everyone

with Medicare through Medicare prescription drug plans and Medicare

Advantage Plan (like an HMO or PPO) that offer prescription drug coverage.

All Medicare prescription drug plans provide at least a standard level of

coverage set by Medicare. Some plans may also offer more coverage for a

higher monthly premium.

2. Cigna has determined that the prescription drug overage offered by the

Welfare Plan for Employees of Bill Ussery Motors under the Cigna option are,

on average for all plan participants, expected to pay out as much as the

standard Medicare prescription drug coverage pays and is therefore

considered Creditable Coverage. Because your existing coverage is

Creditable Coverage, you can keep this coverage and not pay a higher

premium (a penalty) if you later decide to join a Medicare drug plan.

You should also know that if you drop or lose your coverage with Cigna and don’t

enroll in Medicare prescription drug coverage after your current coverage ends, you

may pay more (a penalty) to enroll in Medicare prescription drug coverage later.

___________________________________________________________

When can you join a Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and

each year from October to December .

However, if you lose your current creditable prescription drug coverage, through no

fault of your own, you will also be eligible for a two (2) month Special Enrollment

Period (SEP) to join a Medicare drug plan.

What happens to your current coverage if you decide to join a Medicare Drug

Plan?

If you decide to join a Medicare drug plan, your current Cigna coverage will not be

affected. You can keep this coverage if you elect part D and this plan will coordinate

with Part D coverage.

If you decide to join a Medicare drug plan and drop your current Cigna coverage, be

aware that you and your dependents will be able to get this coverage back.

When will you pay a higher premium (penalty) to join a Medicare drug Plan?

You should also know that if you drop or lose your current coverage with Cigna and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage,

your monthly premium may go up at least 1% of the Medicare base beneficiary

premium per month for every month that you did not have that coverage. For example,

if you go nineteen months without creditable coverage, your premium may consistently

be at least 19% higher than the Medicare base beneficiary premium. You may have to

pay this higher premium (a penalty) as long as you have Medicare prescription drug

coverage. In addition, you may have to wait until the following October to join.

For more information about this notice or your current prescription drug

coverage…

Contact our office for further information (see contact information below). NOTE:

You’ll get this notice each year. You will also get it before the next period you can join

a Medicare drug plan, and if this coverage through Cigna changes. You also may

request a copy of this notice at any time.

For more information about your options under Medicare prescription drug

coverage…

More detailed information about Medicare plans that offer prescription drug coverage

is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail

every year from Medicare. You may also be contacted directly by Medicare drug

plans. For more information about Medicare prescription drug coverage:

> Visit www.medicare.gov

> Call your State Health Insurance Assistance Program (see your copy of the

Medicare & You handbook for their telephone number) for personalized help,

> Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-

2048.

If you have limited income and resources, extra help paying for Medicare prescription

drug coverage is available. For information about this extra help, visit Social Security

on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-

325-0778).

Remember: Keep this notice. If you enroll in one of the new plans approved by

Medicare which offer prescription drug coverage, you may be required to

provide a copy of this notice when you join to show that you are not required to

pay a higher premium amount.

Date: 2020-2021

Name of Entity/Sender: Bill Ussery Motors

Contact--Position/Office: Ann Popplewell, Director of Human Resources

Address: 300 Almeira Ave

Coral Gables, Fl 33134

Phone Number: 786-413-1376


Notices - Continued


Notices - Continued

EMB Enroll Instructions

1. Go to http://www.explainmybenefits.com/bumgbenefits

▪ Enter Username: (Example: Tim Johnson SSN 1234 = tjohnso1234)

➢ 1st Initial of First Name and

➢ 1st Six Characters of your Last Name and

➢ Last 4 of SSN

▪ Enter Password: ussery#1

2. Click on “Get Started” to begin Enrolling in Benefits, or “Continue Enrollment” if returning.

3. Personal Information screen: Verify information on this screen for accuracy (name, SSN, address, birthdate, marital status),

then click “Next: Review My Family” (bottom right). If Personal Information cannot be edited on the screen, please

contact your benefits administrator. (TIP: To return to prior screen, click ”< Back” icon, bottom left).

4. Dependent Information screen: Verify/Edit/Remove/Add Current Family Members, then click “Next: Shop For

Benefits”. (TIP: If box is highlighted in RED, you must complete information marked required).

5. Current Benefit Elections screen: Start with “Medical” coverage by clicking on the “Shop Plans”, or “Change

Plan” icon.

▪ The benefit description will display at the top of each screen. Click “+ View More” (top middle) for coverage videos and

general information.

▪ Select a Plan: Click on “View Plan” to view plan specific details, family members covered, and payroll

deduction amounts. (TIP: To return to prior screen to view other plans, click “< To Available Plans” or “< To Benefits”, top left).

▪ To choose the benefit, click “Update Cart”, or “ Decline … Benefits” to Waive the coverage. (TIP: The

Shopping Cart (top right) will display the Per Pay Period total each time you select a benefit/click “Update Cart”).

▪ For Health Savings Account: Choose a Contribution amount (or leave at $0.00 if waiving), then click

“Enrolled”.

▪ The next benefit will automatically display at the top of each screen. Proceed with each Enrollment by choosing “View

Plan”, then “Update Cart”, or “ Decline … Benefits” until an election has been made for

all benefits offered. (Ex: Dental, Vision)

▪ For Employer Paid benefits: Click “Enrolled”, or select coverage amount (if offered), then “Update Cart”.(TIP: To add a Beneficiary, click “+Add Beneficiary”, then enter Beneficiary Name/Relationship, and Allocation amount, which must equal 100. Next, click “Confirm”, then “SAVE”).

▪ Once all benefits have been made, you will automatically be directed to the Benefit Elections screen. To

complete enrollment for the benefits chosen, scroll down to bottom of screen and click “Review and

Checkout”. Next, scroll down to bottom of screen again and click “Checkout”.

▪ After checking out, you will be presented with the Enrollment Confirmation to Download, Email, or Print.

The information in this Benefits Summary is presented for illustrative purposes and is based on information provided by

the employer. The text contained in this Summary was taken from various summary plan descriptions and benefit

information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible.

In case of discrepancy between the Benefits Summary and the actual plan documents, the actual plan documents will

prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you

have any questions about this summary, contact Human Resources.

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