2018.CVHP.Benefit.Guide.Final

2018

Benefit and Live Well



TABLE OF CONTENTS

Eligibility ................................................................................................................................... 3
Qualifying Events........................................................................................................................ 4
Cost of Coverage......................................................................................................................... 5
How to Enroll?............................................................................................................................ 6
Medical Plans ............................................................................................................................ 7
Medical EPO .............................................................................................................................. 8
Medical PPO ............................................................................................................................ 10
Pharmacy (Rx) Plans................................................................................................................. 12
Dental ..................................................................................................................................... 13
Vision...................................................................................................................................... 14
Flexible Spending Accounts (FSA’s) ........................................................................................... 15
Life Insurance .......................................................................................................................... 16
Voluntary Worksite Benefits ....................................................................................................... 17
Additional Benefits ................................................................................................................... 18
Key Terms ............................................................................................................................... 20
Required Federal Notices .......................................................................................................... 22
For Assistance.......................................................................................................................... 28
Notes ...................................................................................................................................... 29

Medicare Part D Notice: If you (and/or your dependents) have Medicare or will become
eligible for Medicare in the next 12 months, a federal law gives you more choices about your
prescription drug coverage. Please see the Annual Notices on pages 23-24 for more details.

1

Benefit and Live Well.

At Citrus Valley Health Partners (CVHP), we believe that you, our employees, are our most important asset. Helping
you and your families achieve and maintain good health—physical, emotional and financial—is the reason Citrus
Valley Health Partners (CVHP) offers you a comprehensive benefits program. We are providing you with this overview
to help you understand the benefits that are available to you and how to best use them. Please review it carefully
and ensure you understand the benefit options that are available to you and your covered dependents. A list of plan
contacts is provided at the back of this summary, should you have any questions.
For more detailed information, please refer to your plan benefit booklets or summary plan descriptions (SPDs). The
plan benefit booklets determine how all benefits are paid.

The benefits in this summary are effective:
January 1, 2018 - December 31, 2018

2

Eligibility SPOUSAL SURCHARGE

WHO IS ELIGIBLE? If you are covering your spouse/domestic partner in a
Citrus Valley Health Partners Medical plan (under the
Benefit eligible employees working 48 hours or more Employee + Spouse or Employee + Family tier), CVHP
per pay period are eligible for the benefits outlined in will be assessing a spousal surcharge of $25 per
this overview. paycheck ($54.17 per month). The surcharge will
only apply if your spouse/domestic partner has access
WHAT IS THE EFFECTIVE DATE OF to other group sponsored coverage.
COVERAGE?
WHAT IS THE DEFINITION OF
Coverage begins on the 1st of month following 30 DOMESTIC PARTNER?
days of employment, provided you have completed
the online enrollment process and have provided any Domestic partner is defined as a person of the same
applicable documentation to Human Resources. or opposite sex with whom you have entered into a
Failure to enroll prior to the deadline date may result domestic partnership and reside together in the same
in no coverage for the plan year. principal residence where both of you are 18 years or
older and have not married nor have had another
CAN I ENROLL MY DEPENDENTS? domestic partner within the past 6 months.

You can enroll your spouse, domestic partner and WHEN CAN I MAKE CHANGES TO
children up to the age of 26 regardless of student or MY BENEFIT ELECTIONS?
marital status. Children over the age of 26 may be
eligible if they are incapacitated due to a disability Newly acquired dependents may be added to the plan
and primarily dependent on you for support. Children during the year by submitting the information to HR
include natural born children, stepchildren, children and providing verification documents within 31 days
placed under a “qualified medical child support of their eligibility. If you do not add dependents
order,” adopted children or children placed for within the 31-day period and do not qualify for a
adoption. “special enrollment”, they will not be eligible to
enroll until the next “open enrollment” period.

3

Qualifying Events

Qualifying events include:
• Change in legal marital status – including marriage, divorce, legal separation, annulment and death of a
spouse

• Change in number of dependents – including birth, adoption, placement for adoption or death of a
dependent child

• Change in employment status that affects benefit eligibility – including the start or termination of
employment by you, your spouse or your dependent child

• Change in work schedule – including an increase or decrease in hours of employment by you, your spouse,
or your dependent child, including a switch between part-time and full-time employment that affects
eligibility for benefits

• Change in a child’s dependent status – either newly satisfying the requirements for dependent child
status or ceasing to satisfy them

• Change in place of residence or worksite – including a change that affects the accessibility of network
providers

• Change in your health coverage or your spouse’s coverage attributable to your spouse’s employment

• Change in an individual’s eligibility for Medicare or Medicaid

• A court order resulting from a divorce, legal separation, annulment, or change in legal custody
(including a Qualified Medical Child Support Order) requiring coverage for your child

• An event that is a “special enrollment” under the Health Insurance Portability and Accountability
Act (HIPAA) – including acquisition of a new dependent by marriage, birth or adoption or loss of
coverage under another health insurance plan

• An event that is allowed under the Children’s Health Insurance Program (CHIP) Reauthorization Act-
under provisions of the Act -, employees have 60 days after the following events to request enrollment:

 Employee or dependent loses eligibility for Medicaid (known as Medi-Cal in CA) or CHIP (known
as Healthy Families in CA)

 Employee or dependent becomes eligible to participate in a premium assistance program under
Medicaid or CHIP

Two rules apply to making changes to your benefits during the year:
• Any change you make must be consistent with the change in status, AND
• You must notify Human Resources and submit supporting documentation within 31 days of the date the
qualifying event

4

Cost of Coverage

Below you will find the new bi-weekly payroll deductions that will become effective January 1, 2018 and will
remain in effect through December 31, 2018.

MEDICAL Your Cost DENTAL Your Cost
$20.58 $2.67
EPO $96.07 DeltaCare USA HMO
Employee Only $82.34 Employee Only $7.18
Employee + $137.24 Employee + Spouse/Domestic
Spouse/Domestic Partner Partner $6.43
Employee + Child(ren) Your Cost Employee + Child(ren) $9.53
Employee + Family $65.89 Employee + Family Your Cost
PPO $203.47 Delta Dental PPO $11.81
Employee Only $174.41 Employee Only
Employee + $290.66 Employee + Spouse/Domestic $27.47
Spouse/Domestic Partner Partner
Employee + Child(ren) Your Cost Employee + Child(ren) $23.54
Employee + Family $0.00 Employee + Family $35.19
$2.89 Delta Dental PPO Buy-Up Your Cost
VISION $3.05 Employee Only $23.07
$6.09 Employee + Spouse/Domestic
VSP Vision Partner $51.12
Employee Only Employee + Child(ren)
Employee + Employee + Family $43.82
Spouse/Domestic Partner $68.99
Employee + Child(ren)
Employee + Family

5

How to Enroll?

Step 1:
Go to https://www.workterra.net and log in:

• Username: First two letter of your last name, the first two letters of your first name (all lower case letters),
and the last four digits of your Social Security Number.

• Password: First two letters of your last name, the first two letters of your first name (all lower case letters),
2 digit month and 2 digit birth date. Once you login, you will be prompted to change your password. This
will be your new password going forward.

• Company Name: CVHP
Step 2:
Once you log in, please read and accept the employee usage agreement. Then you will have the opportunity to:

• Find more information about your benefits options
• Review your demographics
• Review and update dependent information
• Add/Drop dependents from benefits coverage
• Review current benefit elections and select new options
• Enroll in a Flexible Spending Account
• Designate beneficiary information for life and AD&D insurance coverage.
After each update or selection, be sure to elect coverage and click the “Enroll” button.

Step 3:
Confirm your benefits! Your confirmation statement is a summary of your benefit selections. Review this statement
carefully to verify everything is correct. If everything is correct, print a copy for your records and then click “Finish”
to complete the enrollment process.

Note: Throughout the year, you can go online to https://www.workterra.net to do the following:

• View your confirmation statement (which verifies your coverage)
• Change your beneficiaries for your life and AD&D plans
• Change your password
• Download forms and plan summaries
Remember: In order to ensure the accuracy of enrolled dependent information, CVHP requires that you provide
documentation of dependent status for all dependents that you wish to enroll in the CVHP Medical, Dental and/or
Vision Plans. As dependent coverage is an important part of your benefits package, we want to ensure that only
eligible dependents are provided coverage under the benefits program.

Your dependents will not be enrolled if the required documentation is not received prior to your effective
date for benefits.

To help you further understand the documentation that is needed, please review the Dependent Eligibility Matrix
and Questions and Answers about Dependent Eligibility Verification. (The matrix is available through the Workterra
website under forms library and the CVHP benefits website.)

Please provide a copy of the confirmation statement along with the appropriate documentation to Human
Resources. The office is located at 140 W. College St. 2nd Floor, Covina, CA 91723 or via fax at (626) 858-8506.
Please submit copies only as your documentation will not be returned to you.

6

Medical Plans

Medical coverage provides you with benefits that help keep you healthy, such as preventive care screenings and
access to urgent care. It also provides important financial protection if you have a serious medical condition.
Citrus Valley Health Partners (CVHP) gives you a choice between two medical plans administered through
HealthNow Administrative Services (HNAS). HNAS is the medical benefit administrator for Citrus Valley Health
Partners.
You can reach the CVHP dedicated service team toll-free at (855) 323-1132. Representatives are available Monday
through Friday 8am to 7pm, nationally. After these hours, our interactive voice response system is available allowing
you to access claim status and eligibility information.
You can also go online to www.myhnas.com to:

• Access plan information, including claim status
• Access a list of Tier 1 and Tier 2 Providers
• Understand how claims are paid via the Explanation of Benefits (EOB)
• Request an additional ID card and/or print a temporary ID card.
• Access My Health, a free online resource to help you and your family live healthier (Select Health

Management Solutions and from the drop down menu, click My Health to access this benefit)
To initially log on to the website, you will need to enter your date of birth, gender, first name, and your social
security number or member ID number (found on your new ID card).
You will receive your Plan ID cards at your home address on file with Human Resources. The ID cards can be used
to access coverage for medical and prescription drug benefits. You will need to provide a copy of your medical card
to all of your medical and pharmacy providers for all services.

7

Medical EPO

When covered under the EPO plan, you must use the services of a participating provider. No specialist referral is
required. Certain medical services will require prior authorization. To receive the maximum benefit, use
Tier 1- CVHP providers.

CVHP Medical EPO Plan

Network Tier 1 Tier 2
CVHP Providers
Annual Deductible Blue Shield of CA
$0 Individual Participating Providers
Annual Out-of-Pocket Max $0 Family
$750 Individual
Lifetime Max $1,000 Individual $1,500 Family
Office Visit $2,000 Family
Primary Provider Unlimited $2,500 Individual
Specialist $5,000 Family
Telehealth/Telepsych
Preventive Services Unlimited
Chiropractic Care
Lab and X-ray $10 copay $25 copay
$20 copay $60 copay
Home Health Services $15 copay
Inpatient Hospitalization No Charge No Charge
Outpatient Surgery Not Available $25 copay
Urgent Care Complex imaging: 20% after deductible;
Emergency Room No Charge All Other: $60 copay
20% after deductible
Ambulance No Charge 20% after deductible
Mental Health / Substance Abuse No Charge 20% after deductible
Inpatient Admission No Charge $25 copay
Hospital Charges Not Available $150 copay
Outpatient Services $150 copay (copay waived if admitted)
(copay waived if admitted) 20% after deductible
Not Available

No Charge 20% after deductible
No Charge 20% after deductible
$10 copay
$25 copay

* Plan Deductibles, Plan Copayments and Pharmacy (Rx) Copayments accumulate toward the Annual Out-of-Pocket Maximum.

8

Medical (Prescription Drugs) EPO - Continued

Below is the prescription drug plan that is offered with our CVHP Medical EPO plan.

CVHP Medical EPO Plan

Network Tier 1 Tier 2
CVHP Providers
Annual Out-of-Pocket Limit Blue Shield of CA Participating
$1,000 Individual Providers
Pharmacy $2,000 Family
Generic $2,500 Individual
Preferred Brand (Combined with Medical) $5,000 Family
Non-preferred Brand
Specialty Drugs (Combined with Medical)
Supply Limit
Mail Order $10 copay $20 copay
Generic $25 copay $45 copay
Preferred Brand $55 copay $120 copay
Non-preferred Brand 20% up to $100 20% up to $150
Supply Limit
30 days 30 days
CVS Walk-In Only
$40 copay
$20 copay $90 copay
$50 copay $240 copay
$110 copay
90 days
90 days

9

Medical PPO

The PPO plan allows you and your dependents to seek needed medical care from any Hospital, Physician or other
provider you wish. To receive the maximum benefit, use Tier 1- CVHP providers.

CVHP Medical PPO Plan

Network Tier 1 Tier 2 Tier 3
CVHP Providers Non-Participating
Annual Deductible Blue Shield of CA
$0 Individual Participating Providers
Annual Out-of-Pocket Max $0 Family Providers
$600 Individual
Lifetime Max $1,000 Individual $300 Individual $1,200 Family
Office Visit $2,000 Family $600 Family $8,000 Individual
Primary Provider Unlimited $14,000 Family
Specialist $6,000 Individual
Telehealth/Telepsych $12,000 Family Unlimited
Preventive Services
Chiropractic Care Unlimited
Lab and X-ray
Home Health Services $10 copay $20 copay 40% after deductible
Inpatient Hospitalization $20 copay $35 copay 40% after deductible
Outpatient Surgery $15 copay Not covered
Urgent Care No charge No charge Not covered
Emergency Room Not available $20 copay Not covered
Ambulance No charge 20% after deductible 40% after deductible
Mental Health / Substance Abuse No charge 20% after deductible 40% after deductible
Inpatient Admission No charge 20% after deductible Not covered
Hospital Charges No charge 20% after deductible 50% after deductible
Outpatient Services 40% after deductible

Not available 20% after deductible 40% after deductible

$100 copay (copay waived if admitted)

Not available 20% after deductible 20% after deductible

No charge 20% after deductible 50% after deductible
No charge 20% after deductible 50% after deductible
$10 copay 40% after deductible
$20 copay

*Plan Deductibles, Plan Copayments and Pharmacy (Rx) Copayments accumulate toward the Annual Out-of-Pocket Maximum.

10

Medical (Prescription Drugs) PPO – Continued

Below is the prescription drug plan that is offered with our CVHP Medical PPO plan.

CVHP Medical PPO Plan

Network Tier 1 Tier 2 Tier 3
CVHP Providers Non-Participating
Annual Out-of-Pocket Limit Blue Shield of CA
$1,000 Individual Participating Providers
Pharmacy $2,000 Family Providers
Generic $8,000 Individual
Preferred Brand (Combined with Medical) $6,000 Individual $14,000 Family
Non-preferred Brand $12,000 Family (Combined with Medical)
Specialty Drugs (Combined with Medical)
Supply Limit
Mail Order $10 copay $20 copay Not covered
Generic $25 copay $45 copay Not covered
Preferred Brand $55 copay $120 copay Not covered
Non-preferred Brand 20% up to $100 20% up to $150 Not covered
Supply Limit Not applicable
30 days 30 days
CVS Walk-In Only Not covered
$40 copay Not covered
$20 copay $90 copay Not covered
$50 copay $240 copay Not applicable
$110 copay
90 days
90 days

11

Pharmacy (Rx) Plans

Prescription drug coverage provides a benefit that is important to your overall health, whether you need a
prescription for a short-term health issue, such as bronchitis or an ongoing condition, such as high blood pressure.
If you enroll in medical coverage, you will automatically receive coverage for prescription drugs.
Ventegra is the administrator for your prescription drugs.
Things to know:

• Use your health insurance card sent to you by HNAS when you pick up your prescriptions.

• Your health insurance card is accepted at a wide network of chains and independent pharmacies, as well
as a mail order pharmacy that offers convenient delivery of medications directly to your home or office.

We have partnered with three local CVS pharmacies, one near each CVHP Hospital, to offer Tier 1 pharmacy
benefits. These benefits include reduced co-pays, the ability to order a 90-day supply of medications for the cost
of two monthly co-pays, extended hours and locations conveniently located near each CVHP campus.

Tier 1 Pharmacy Providers

CVS Pharmacy (near Queen of the CVS Pharmacy (near Inter-Community CVS Pharmacy (near Foothill
Valley Hospital) Hospital) Presbyterian Hospital)
727 South Glendora Avenue 206 North Azusa Ave 130 North Grand Ave
West Covina, CA 91790 Covina, CA 91722 Glendora, CA 91741
(626) 337-7284 (626) 331-9907 (626) 963-0385
M-F 8AM to 9PM, Sat 9AM to 6PM, M-F 8AM to 9PM, Sat 9AM to 6PM, M-F 8AM to 9PM, Sat 9AM to 6PM,
Sun 10 AM to 6PM Sun 10 AM to 6PM Sun 10 AM to 6PM

You also have the option of using another pharmacy, other than the three CVS locations listed above. This will be
considered a Tier 2 Pharmacy Provider.

Ventegra, has over 63,000 contracted retail pharmacies nationwide. In addition to a mail- order service pharmacy.

Please review the Medical Plan Highlights for the EPO & PPO plans to note the difference in copays for Tier 1
Pharmacy Provider and Tier 2 Pharmacy Provider.

Drugsource, Inc. is the mail order pharmacy used for Citrus Valley Health Partners’ claims. Mail order service is
recommended for long-term medication. Drugsource, Inc. mail service delivers up to a 90-day supply directly to
your home or office, 24/7 pharmacy support and prescription tracking and ordering online. You can contact the
DrugSource, Inc. customer service team at (800) 854-8764. How to order mail service prescriptions through
Drugsource:

• Call (800) 854-8764

Visit www.drugsourceinc.com. Additional information on how to create a patient profile can be found on the CVHP
Benefits page.

12

Dental

Regular visits to your dentists can protect more than your smile; they can help protect your health. Recent studies
have linked gum disease to damage elsewhere in the body and dentists are able to screen for oral symptoms of
many other diseases including cancer, diabetes, and heart disease.

Citrus Valley Health Partners (CVHP) offers three options: a DHMO plan, a PPO plan, and a PPO Buy-Up plan.

Employees may enroll in the Dental Health Maintenance Organization and choose a dentist from the DeltaCare USA
network. The DHMO plan provides you with a list of qualified DeltaCare USA dentists who will deliver you the same
services, but at a set of pre-negotiated rates. To locate a dentist please visit www.deltadentalins.com and click
on “Find a Dentist”, then click on DeltaCare USA.

The Dental PPO Plan provides you the ability to visit any dentists in the Delta Dental network making your costs
significantly reduced by obtaining your dental care from the Preferred Providers (in-network dentists) over the Non
Preferred Providers (out-of-network providers). To locate a network dentist please visit www.deltadentalins.com

DeltaCare Delta Dental Delta Dental
USA DHMO DPPO DPPO Buy-Up

In-Network In-Network Out-Of-Network In-Network Out-Of-Network

Calendar Year Deductible

Individual $0 $0 $50 $0 $50

Family $0 $0 $100 $0 $100

Annual Plan Maximum Unlimited $1,500 $2,000*

Diagnostic and Preventive $0-$25 copay1 100% 100% 100% 100%

Basic Services $0-$90 copay1 20% 20% 20% 20%
Fillings

Root Canals $0-$155 copay1 20% 20% 20% 20%

Periodontics $0-$250 copay1 20% 20% 20% 20%

Major Services $0-$175 copay1 50% 50% 50% 50%

Orthodontic Services $1,600 copay2 Not applicable 50%
$1,800 copay2 50%
Orthodontia $1,500
Children
Adults

Lifetime Maximum

* Diagnostic & Preventive Services do not count toward the Buy-Up PPO Plan’s annual maximum
1 Copays varies by service; see contract for fee schedule.
2 See contract for fee schedule, Start-Up Fee $350.

13

Vision

Routine vision exams are important, not only for correcting vision but because they can detect other serious health
conditions.

The VSP Vision plan provides participants with access to a large network of vision care providers. To locate a
network provider visit www.vsp.com. If you decide not to see a VSP doctor, the Out-Of-Network copay will apply.
Your VSP benefits are a tremendous part of your overall benefits package. There are no ID cards necessary for this
plan.

VSP Choice Network

In-Network Out-Of-Network

Examination $10 copay Up to $45
Benefit 1 x every 12 months In-network limitations apply
Frequency $10 copay $10 copay
Materials
Eyeglass Lenses No Charge of basic lens (materials copay applies) Up to $30
Single Vision Lens No Charge of basic lens (materials copay applies) Up to $50
Bifocal Lens No Charge of basic lens (materials copay applies) Up to $65
Trifocal Lens 1 x every 24 months In-network limitations apply
Frequency
Frames Up to $150 plan pays (20% discount over allowance) Up to $70
Benefit 1 x every 24 months In-network limitations apply
Frequency
Contacts (Elective) Up to $150 (copay waived; instead of eyeglasses) Up to $105
Benefit 1 x every 24 months 1 x every 24 months
Frequency

14

Flexible Spending Accounts (FSA’s)

A Flexible Spending Account (FSA) lets you set aside money How FSA’s Work
before its taxed-through payroll deductions. The money can be
used for eligible healthcare and dependent day care expenses  PLAN - You estimate how much your health care
you and your family expect to have over the next year. The main
benefit of using an FSA is that you reduce your taxable income, and/ or dependent care expenses might be for the
which means you have more money to spend. You must re-enroll 2018 calendar year (or portion thereof depending on
in this program each year. Employee Benefit Specialists (EBS) your coverage effective date). Then you decide how
administers this program. much you want to put into your account(s), subject
to the plan limit.
THE “USE IT OR LOSE IT” RULE:
 CONTRIBUTE - The amount you set aside will
This rule status that if you contribute your pre-tax dollars to an
FSA and do not use all of the dollars you deposit, you will lose automatically be deducted from your paychecks in
the remaining balance in the account at the end of the Grace equal amounts throughout the year.
Period. The FSA plans have an added feature (Grace Period)
that allows you to continue to incur new claims up to March 15,  COLLECT - As you incur your eligible expenses,
2018, with any remaining funds from your 2017 elected
amount. It is essential to plan ahead before deciding to the amount you owe can be reimbursed by
contribute to the two FSA plans. completing a claim form and submitting it with the
required documentation to EBS. Claims can be
HEALTH CARE FSA submitted online, by mail or FAX, deadline is March
31, 2018. Reimbursement checks are issued by
For 2018, you may contribute up to $2,600 in pre-tax dollars EBS via direct deposit (if elected for FSA) or by
to cover eligible health care expenses. The entire amount you check.
set aside is available to you on your coverage effective date.
This plan offers a benefit debit card for your convenience. • FSA Debit Card - You can also pay for eligible
expenses using your FSA Debit Card. If you use
The Health Care FSA allows you to pay for a variety of health your FSA Debit Card, you may be asked to submit
care expenses incurred by you, your spouse, and your children your receipt to EBS as proof of an eligible
up to age 26. Some examples of the expenses you could pay expense, so be sure to keep all your receipts.
with your Health Care FSA:
Please note that you’re Health Care and Dependent
• Co-pays • Dental Treatment Care FSA elections may be subject to change based
• Coinsurance • Eye Exams on the results of Non-Discrimination Testing.
• Deductibles • Eye Glasses
• Prescriptions • Hearing Aids • Lasik Surgery
• Psychologist fees
• Chiropractor and Acupuncture
• Orthodontia

DEPENDENT CARE FSA

For 2018, you may contribute up to $5,000 in pre-tax dollars to cover eligible dependent care expenses. If you
and your spouse file separate tax returns, your maximum contribution is $2,500. The entire amount you set
aside is not available right away - funds are available as they are deducted from your paycheck.

Eligible dependent care expenses are those that enable an individual or married couple to remain gainfully
employed or look for work. If married, your spouse must be working, looking for work, or be a full-time student.
Some examples of eligible dependent care expenses:

• Care of a dependent child under the age of 13 by babysitters, nannies, nursery schools, pre-school, daycare
centers or summer day camp

• Care for any member of your household who is physically or mentally incapable of caring for him/herself and
qualifies as a Federal tax dependent

15

Life Insurance

If you have loved ones who depend on your income Employee Up to the lesser of 3 X your
for support, having life and accidental death Voluntary salary or $500,000
insurance can help protect your family's financial Life Amount
security. $5,000 or $10,000
Spouse Voluntary
BASIC LIFE AND AD&D Life Amount $1,000 or $5,000 for
each child
Basic Life Insurance pays your beneficiary a lump Child(ren)
sum if you die. AD&D provides another layer of Voluntary Up to 10x your salary –
benefits to either you or your beneficiary if you suffer Life Amount Minimum $25,000
from loss of a limb, speech, sight, or hearing, or if Maximum $500,000
you die in an accident. The cost of coverage is paid Employee
in full by the company and all eligible employees will Voluntary AD&D*
be automatically enrolled. Coverage is provided by
CIGNA. *Voluntary AD&D available for family when voluntary
life is elected.
Basic Life Amount 1 X covered annual
Basic AD&D Amount earnings up to a The plan will pay dismemberment benefits for any of
maximum of $800,000 the following losses:

$3,000 • Both Hands
• Both Feet
Guarantee Issue: There is a Guarantee Issue (GI) • Sight of Both Eyes
amount of $650,000. Evidence of Insurance (EOI) is • One Hand and One Foot
required for amounts over $650,000 to a maximum • One Hand and Sight of One Eye
of $800,000. • One Hand
• One Foot
Taxes: Due to IRS regulations, a life insurance • Sight of One Eye
benefit of $50,000 or more is considered a taxable
benefit. You will see the value of the benefit included Loss of sight means total and irrevocable loss of sight.
in your taxable income on your paycheck and W-2. Loss of hand or foot means loss by severance at or
above the wrist and ankle. The total payment for all
VOLUNTARY LIFE AND AD&D losses due to any one accident will not be more than
your full amount of AD&D insurance.
Voluntary Life Insurance allows you to purchase
additional life insurance to protect your family's Evidence of Insurability (EOI): Elections over 2
financial security. Coverage is provided by CIGNA. times your salary or $250,000 will require the
completion of an EOI form which involves providing
You are able to purchase Voluntary Life with or the insurance company with additional information
without purchasing the AD&D benefit. about your health. If you elect spouse coverage for
the first time at Open Enrollment or increase spouse
coverage at Open Enrollment, EOI will be required.
EOI form is available through CVHP Intranet,
Workterra or through Human Resources.

Beneficiary Reminder: Make sure that you have
named a beneficiary for your life insurance benefit.
It's important to know that many states require that a
spouse be named as the beneficiary, unless they sign
a waiver.

16

Voluntary Worksite Benefits

Here are some other valuable supplemental programs that you are eligible to participate in:

UNIVERSAL LIFE INSURANCE with CANCER INSURANCE
LONG TERM CARE
If you or a covered family member face a cancer
The Universal Life policy cost does not increase as diagnosis this program can help offset the
you age. Over time, the policy will accrue cash value out-of-pocket medical and indirect expenses related
that you can access. You can buy Universal Life to cancer. This program offers, individual,
coverage for yourself, your spouse, and your children. one-parent, or two-parent coverage options. Benefits
Coverage available for you, your spouse and your are paid directly to you in addition to major medical
dependent children and grandchildren. insurance. First occurrence benefit, pays lump sum
upon cancer diagnosis.
CRITICAL ILLNESS INSURANCE
ACCIDENT INSURANCE
This benefit provides a lump-sum, tax-free benefit
upon diagnosis of a covered illness (Heart Attack, Accident Insurance is designed to help you pay for
Stroke, Cancer, etc.). You can cover yourself and your unexpected costs that result from an accidental
family members if needed. Unum Group provides injury. Accident Insurance includes benefits for a
coverage for this program. wide range of common injuries such as fractures,
dislocations, burns, emergency room or urgent care
HOSPITALIZATION INSURANCE visits and physical therapy.

When an accident or illness results in an inpatient If you or a covered family member suffer from an
hospital stay, the costs can add up. If you or a covered accident, this plan will pay specific benefit amounts.
family member have a covered inpatient hospital stay, The amount of money you receive depends on the
this plan will pay you a lump-sum, tax-free benefit. type and severity of your injury and can used any way
you choose. Coverage is available for you, your spouse
and your eligible children.

ID THEFT PROTECTION

Identity theft is one of the fastest-growing crimes in
the United States. This program provides additional
financial security for you and your family and features
24-hour phone access to identify theft recovery
counselors.

LEGAL ASSISTANCE PROGRAM

Enrollment in the Legal Assistance Program includes
consultation on a variety of common legal matters
and simple will preparation. This program provides
website access to user-friendly online resources

17

Additional Benefits LONG-TERM SICK (LTS)

Here are more benefits that are available at CVHP: LTS can be used starting on the 8th consecutive day
of illness/accident or the 4th day of worker’s
CVHP RETIREMENT PLAN compensation. You accrue LTS, up to 2.0 hours per
pay period, based on regular hours paid. LTS pay is
You may choose to set up and account with Lincoln integrated with California state disability or workers’
Financial to save for your retirement by making compensation, and provides you with income during
convenient tax-deferred contributions through regular a period of significant illness.
payroll deductions. A Roth account where you make
after tax deductions is also available. You can direct PAID TIME OFF (PTO)
your contributions to a wide choice of investments.
You accrue paid time off benefits based on your
When you contribute to the CVHP Retirement Plan, length of employment and the hours you are paid
CVHP makes matching contributions each pay period each pay period (excluding Long-Term Sick (LTS) and
if you meet the eligibility requirements. The match in-House Registry). Paid time off can be used for
varies depending on your years of service, and is vacations, holidays and personal sick time.
100% vested after 5 years’ service of 1,000 hours in
each year. Time of Accrual Factor Maximum
Employment Accrual Per
529 COLLEGE SAVINGS PLAN 0.0334 per Pay Period
0-90 days hour
You can contribute to a 529 College Savings Plan, 90 days – 1 0.00
through payroll deductions, to save for your child’s 0.0850 per
education. To open and account: year hour 6.80
1-4 years
• Visit www.corporate.collegeboundfund.com 0.0887 per 7.10
• Select “Company” as your ID, type and enter 5-9 years hour
8.60
the following: 10+ years 0.1076 per
hour 10.20
Corporate User ID: CVHP
Corporate Password: COLLEGE 0.1275 per
hour
• Create an individual User ID and password.
This will allow you to log in to the site upon BEREAVEMENT
future visits.
In the event of the death of a designated family
For questions about the CorporateCollegeBoundfund member, you will receive pay for bereavement time if
program, contact a Client Services Representative at you are previously scheduled to work – if you are a
(800) 227-2900 or call Human Resources for more full-time 8 hour employee, you will receive up to 32
information. hours pay – if you are a full-time 12 hour employee,
you will receive up to 36 hours pay. Pay is prorated
TIME OFF for part-time employees.

CVHP provides several programs for when you need
some time away from work.

18

Additional Benefits - Continued

WORKERS’ COMPENSATION EMPLOYEE ASSISTANCE PROGRAM
(EAP)
You receive payment for work-related illnesses,
accidents or conditions, beginning the 1st day of You and your family members have access to
hospitalization or 4th consecutive day of absence. professional and confidential assistance for dealing
with financial difficulties, marital/family problems,
STATE DISABILITY legal concerns, substance abuse, work related issues,
etc. CVHP pays the full cost of the EAP program. We
Through the State of California, you receive payment strongly encourage you to utilize this benefit resource
for an absence due to non-work related illness or before utilizing your EPO or PPO medical plan. For
accident. Benefits begin on the 8th consecutive day further information contact:
of illness or accident. You must apply for benefits if
you are eligible. • The Employee Assistance Program:
(800) 266-0510
SHORT TERM DISABILITY
INSURANCE • Your supervisor
• Human Resources
Short Term Disability insurance protects your most
valuable asset, your income, if you are unable to work EDUCATION REIMBURSEMENT
due to an illness or off the job injury. You can receive
up to 30% of your pre-tax income to help If you take courses directly related to your present
complement California State Disability. For more position or advancement in the health care field,
information about this policy contact Mutual of tuition, registration fees and other related fees may
Omaha at (800) 877-5176. be partially reimbursed by CVHP once you meet the
eligibility requirements. Reimbursement is 100% of
the costs to the following maximum amounts:

• Full-time employees - $3,000 per year
• Part-time Regular employees - $1,500 per year

Prior approval is required.

19

Key Terms

MEDICAL/GENERAL TERMS Family Deductible - The maximum dollar amount any
one family will pay out in individual deductibles in a
Allowable Charge - The most that an in-network year.
provider can charge you for an office visit or service.
Healthcare Flexible Spending Account – The Flexible
Balance Billing - Non-network providers are allowed Spending Account (HFSA) enables you to pay for
to charge you more than the plan's allowable charge. out-of-pocket health care expenses with tax – free
This is called Balance Billing. money. Eligible expenses include health care
expenses for you and your eligible family members
Coinsurance - The cost share between you and the that are not reimbursed through any other means. At
insurance company. Coinsurance is always a Open Enrollment (or at the time when your first
percentage totaling 100%. For example, if the plan become eligible), you elect an amount to contribute
pays 70%, you are responsible for paying the to the HCFSA. Your contributions are made through
remaining 30% of the cost. payroll deductions on a pretax basis. Eligible
expenses are reimbursed from your account during
Copay - The fee you pay to a provider at the time of the plan year. You generally cannot use funds in your
service. HCFSA to pay for expenses for a domestic partner or
children of a domestic partner.
Deductible - The amount you have to pay out-of-
pocket for expenses before the insurance company Individual Deductible - The dollar amount a member
will cover any benefit costs for the year (except for must pay each year before the plan will pay benefits
preventive care and other services where the for covered services.
deductible is waived).
In-Network - Services received from providers
Dependent Care Flexible Spending Account – The (doctors, hospitals, etc.) who are a part of your health
Dependent Care Flexible Spending Account (DCFSA) plan's network. In-network services generally cost you
enables you to pay for day care expenses with tax-free less than out-of-network services.
money. Eligible day care expenses are for your child
(ren) age 12 or under or for another dependent not Out-of-Network - Services received from providers
capable of self-care. At Open Enrollment (or at the (doctors, hospitals, etc.) who are not a part of your
time when your first become eligible), you elect an health plan's network. Out-of-network services
amount to contribute to the DCFSA. Your generally cost you more than in-network services.
contributions are made through payroll deductions on With some plans, such as HMOs and EPOs, out-of-
a pretax basis. Eligible expenses are reimbursed from network services are not covered.
your account during the plan year. Any funds
remaining in your account at the end of the plan year Out-of-Pocket - Healthcare costs you pay using your
will be forfeited. own money, whether from your bank account, credit
card, Health Reimbursement Account (HRA), Health
Exclusive Provider Organization – An EPO is a Savings Account (HSA) or Flexible Spending Account
managed care organization similar to a Preferred (FSA).
Provider Organization. Members must receive their
care from affiliated providers. Services rendered Out-of-Pocket Maximum – The most you would pay
outside of the network will be the full responsibility out-of-pocket for covered services in a year. Once you
of the member, similar to an HMO. reach your out-of-pocket maximum, the plan covers
100% of eligible expenses.
Explanation of Benefits (EOB) - The statement you
receive from the insurance carrier that explains how
much the provider billed, how much the plan paid (if
any) and how much you owe (if any). In general, you
should not pay a bill from your provider until you have
received and reviewed your EOB (except for copays).

20

Key Terms - Continued Preferred Brand Drug - A brand name drug that the
plan has selected for its preferred drug list. Preferred
Preferred Provider Organization – A PPO or Preferred drugs are generally chosen based on a combination of
Provider Organization is a group system of health care clinical effectiveness and cost.
organized by an insurance company. Physicians,
health care providers of all types, hospitals and Specialty Pharmacy - Provides special drugs for
clinics sign contracts with the PPO system to provide complex conditions such as multiple sclerosis, cancer
care to its insured people. These medical providers and HIV/AIDS.
accept the PPO’s fee schedule and guidelines for its
managed medical care. This arrangement helps Step Therapy - The practice of starting to treat a
maximize your benefits as well as lowers your overall medical condition with the most cost effective and
out-of-pocket expenses. safest drug therapy and progressing to other more
costly or risky therapy, only if necessary.
Preventive Care – A routine exam, usually yearly, that
may include a physical exam, immunizations and DENTAL TERMS
tests for certain health conditions.
Basic Services - Generally include coverage for
Tier 1 – Tier 1 is classified as CVHP Providers fillings and oral surgery.
(physicians and hospital). Seeking services under this
tier provides you with the best option to reduce your Diagnostic and Preventive Services - Generally
out-of-pocket medical expense. include routine cleanings, oral exams, x-rays,
sealants and fluoride treatments. Most plans limit
PRESCRIPTION DRUG TERMS preventive exams and cleanings to two times a year.

Brand Name Drug - A drug sold under its trademarked Endodontics - Commonly known as root canal
name. A generic version of the drug may be available. therapy.

Generic Drug – A drug that has the same active Implants - An artificial tooth root that is surgically
ingredients as a brand name drug, but is sold under placed into your jaw to hold a replacement tooth or
a different name. Generics only become available bridge. Many dental plans do not cover implants.
after the patent expires on a brand name drug. For
example, Tylenol is a brand name pain reliever Major Services - Generally include restorative dental
commonly sold under its generic name, work such as crowns, bridges, dentures, inlays and
Acetaminophen. onlays.

Dispense as Written (DAW) - A prescription that does Orthodontia - Some dental plans offer Orthodontia
not allow for substitution of an equivalent generic or services for children (and sometimes adults too) to
similar brand drug. treat alignment of the teeth. Orthodontia services are
typically limited to a lifetime maximum.
Maintenance Medications - Medications taken on a
regular basis for an ongoing condition such as high Periodontics - Diagnosis and treatment of gum
cholesterol, high blood pressure, asthma, etc. Oral disease.
contraceptives are also considered a maintenance
medication. Pre-Treatment Estimate - An estimate of how much
the plan will pay for treatment. A pre-treatment
Non-Preferred Brand Drug - A brand name drug for estimate is not a guarantee of payment.
which alternatives are available from either the plan's
preferred brand drug or generic drug list. There is
generally a higher copayment for a non-preferred
brand drug.

21

Required Federal Notices

AVAILABILITY OF PRIVACY PRACTICES WOMEN’S HEALTH AND CANCER RIGHTS
NOTICE ACT

We maintain the HIPAA Notice of Privacy Practices for If you have had or are going to have a mastectomy, you may
CITRUS VALLEY HEALTH PARTNERS (CVHP) describing be entitled to certain benefits under the Women’s Health
how health information about you may be used and and Cancer Rights Act of 1998 (WHCRA). For individuals
disclosed. You may obtain a copy of the Notice of Privacy receiving mastectomy-related benefits, coverage will be
Practices by contacting Human Resources provided in a manner determined in consultation with the
attending physician and the patient, for:
HIPAA NOTICE OF SPECIAL
ENROLLMENT RIGHTS • All stages of reconstruction of the breast on which the
mastectomy was performed;
If you decline enrollment in CITRUS VALLEY HEALTH
PARTNERS health plan for you or your dependents • Surgery and reconstruction of the other breast to
(including your spouse) because of other health insurance produce a symmetrical appearance;
or group health plan coverage, you or your dependents may
be able to enroll in CITRUS VALLEY HEALTH PARTNERS • Prostheses; and
health plan without waiting for the next open enrollment
period if you: • Treatment of physical complications of the
mastectomy, including lymphedema.
• Lose other health insurance or group health plan
coverage. You must request enrollment within 30 These benefits will be provided subject to the same
days after the loss of other coverage. deductibles and coinsurance applicable to other medical
and surgical benefits provided under this plan. If you would
• Gain a new dependent as a result of marriage, birth, like more information on WHCRA benefits, call your plan
adoption, or placement for adoption. You must administrator.
request health plan enrollment within 30 days after
the marriage, birth, adoption, or placement for NEWBORNS’ AND MOTHERS’ HEALTH
adoption. PROTECTION ACT NOTICE

• Lose Medicaid or Children’s Health Insurance Group health plans and health insurance issuers generally
Program (CHIP) coverage because you are no longer may not, under Federal law, restrict benefits for any
eligible. You must request medical plan enrollment hospital length of stay in connection with childbirth for the
within 60 days after the loss of such coverage. mother or newborn child to less than 48 hours following a
vaginal delivery, or less than 96 hours following a cesarean
If you request a change due to a special enrollment event section. However, Federal law generally does not prohibit
within the 30 day timeframe, coverage will be effective the the mother’s or newborn’s attending provider, after
date of birth, adoption or placement for adoption. For all consulting with the mother, from discharging the mother or
other events, coverage will be effective the first of the her newborn earlier than 48 hours (or 96 hours as
month following your request for enrollment. In addition, applicable). In any case, plans and issuers may not, under
you may enroll in CITRUS VALLEY HEALTH PARTNERS Federal law, require that a provider obtain authorization
health plan if you become eligible for a state premium from the plan or the insurance issuer for prescribing a
assistance program under Medicaid or CHIP. You must length of stay not in excess of 48 hours (or 96 hours). If
request enrollment within 60 days after you gain eligibility you would like more information on maternity benefits, call
for medical plan coverage. If you request this change, your plan administrator.
coverage will be effective the first of the month following
your request for enrollment. Specific restrictions 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.

22

AVAILABILITY OF SUMMARY 2. CITRUS VALLEY HEALTH PARTNERS has determined
INFORMATION that the prescription drug coverage offered by the CVHP
is, on average for all plan participants, expected to pay
As an employee, the health benefits provided by CITRUS out as much as standard Medicare prescription drug
VALLEY HEALTH PARTNERS (CVHP) represent a coverage pays and is therefore considered Creditable
significant component of your compensation package. They Coverage. Because your existing coverage is Creditable
also provide important protection for you and your family in Coverage, you can keep this coverage and not pay a higher
the case of illness or injury. premium (a penalty) if you later decide to join a Medicare
drug plan.
CITRUS VALLEY HEALTH PARTNERS (CVHP) offers
a variety of benefit plans to eligible employees. The federal When Can You Join A Medicare Drug Plan?
health care reform law requires that eligible members of an
employer plan receive a Summary of Benefits and Coverage You can join a Medicare drug plan when you first become
(SBC) for any medical and pharmacy plans available. The eligible for Medicare and each year from October 15th to
SBC is intended to provide important plan information to December 7th.
individuals, such as common benefit scenarios and
definitions for frequently used terms. The SBC is intended However, if you lose your current creditable prescription
to serve as an easy-to-read, informative summary of drug coverage, through no fault of your own, you will also
benefits available under a plan. SBCs and any revisions or be eligible for a two (2) month Special Enrollment Period
amendments of the plans offered by CITRUS VALLEY (SEP) to join a Medicare drug plan.
HEALTH PARTNERS (CVHP) are available on our online
enrollment system, WORKTERRA, or by contacting your What Happens To Your Current Coverage If You Decide
Human Resources Department. to Join A Medicare Drug Plan?

MEDICARE PART D If you decide to join a Medicare drug plan, your CITRUS
VALLEY HEALTH PARTNERS coverage will not be affected.
Important Notice from CITRUS VALLEY HEALTH See below for more information about what happens to your
PARTNERS (CVHP) About Your Prescription Drug current coverage if you join a Medicare drug plan.
Coverage and Medicare Important Note for Retiree Plans: Certain retiree plans
will terminate RX coverage when an individual enrolls in
Please read this notice carefully and keep it where you can Medicare Part D and individuals might not be able to re-
find it. This notice has information about your current enroll in that coverage. If completing this Notice for a
prescription drug coverage with CITRUS VALLEY HEALTH retiree plan, review the plan provisions before completing
PARTNERS and about your options under Medicare’s this form and modify this section as needed.
prescription drug coverage. This information can help you
decide whether or not you want to join a Medicare drug Since the existing prescription drug coverage under CVHP
plan. If you are considering joining, you should compare is creditable (e.g., as good as Medicare coverage), you can
your current coverage, including which drugs are covered at retain your existing prescription drug coverage and choose
what cost, with the coverage and costs of the plans offering not to enroll in a Part D plan; or you can enroll in a Part D
Medicare prescription drug coverage in your area. plan as a supplement to, or in lieu of, your existing
Information about where you can get help to make prescription drug coverage.
decisions about your prescription drug coverage is at the
end of this notice. If you do decide to join a Medicare drug plan and drop your
CITRUS VALLEY HEALTH PARTNERS prescription drug
There are two important things you need to know about your coverage, be aware that you and your dependents can only
current coverage and Medicare’s prescription drug get this coverage back at open enrollment or if you
coverage: experience an event that gives rise to a HIPAA Special
Enrollment Right.
1. Medicare prescription drug coverage became available
in 2006 to everyone with Medicare. You can get this
coverage if you join a Medicare Prescription Drug Plan or
join a Medicare Advantage Plan (like an HMO or PPO) that
offers prescription drug coverage. All Medicare drug plans
provide at least a standard level of coverage set by
Medicare. Some plans may also offer more coverage for a
higher monthly premium.

23

When Will You Pay A Higher Premium (Penalty) To Join For more information about Medicare prescription drug
A Medicare Drug Plan? coverage:

You should also know that if you drop or lose your current • Visit medicare.gov
coverage with CITRUS VALLEY HEALTH PARTNERS and
don’t join a Medicare drug plan within 63 continuous days • Call your State Health Insurance Assistance Program
after your current coverage ends, you may pay a higher (see the inside back cover of your copy of the
premium (a penalty) to join a Medicare drug plan later. “Medicare & You” handbook for their telephone
number) for personalized help
If you go 63 continuous days or longer without creditable
prescription drug coverage, your monthly premium may go • Call 800-MEDICARE (800-633-4227). TTY users
up by at least 1% of the Medicare base beneficiary should call 877-486-2048.
premium per month for every month that you did not have
that coverage. For example, if you go nineteen months If you have limited income and resources, extra help paying
without creditable coverage, your premium may for Medicare prescription drug coverage is available. For
consistently be at least 19% higher than the Medicare base information about this extra help, visit Social Security on
beneficiary premium. You may have to pay this higher the web at socialsecurity.gov, or call them at 800-772-
premium (a penalty) as long as you have Medicare 1213 (TTY 800-325-0778).
prescription drug coverage. In addition, you may have to
wait until the following October to join. Date: October 2017

For More Information About This Notice Or Your Name of Entity/Sender: CITRUS VALLEY HEALTH
Current Prescription Drug Coverage… PARTNERS

Contact the office listed below for further information. Contact-Position/Office: Human Resources
NOTE: You’ll get this notice each year. You will also get it
before the next period you can join a Medicare drug plan, Address: 140 W. College St. Covina, CA 91723
and if this coverage through CITRUS VALLEY HEALTH
PARTNERS changes. You also may request a copy of this Phone Number: 626-858-8515
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.

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare
drug plans, you may be required to provide a copy of this notice when you join to show whether
or not you have maintained creditable coverage and, therefore, whether or not you are required
to pay a higher premium (a penalty).

24

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 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 August 10, 2017. Contact your State for more information on eligibility –

ALABAMA – Medicaid IOWA – Medicaid
Website: http://www.myalhipp.com Website: http://www.dhs.state.ia.us/hipp/
Phone: 1-855-692-5447 Phone: 1-888-346-9562

ALASKA – Medicaid KANSAS – Medicaid
The AK Health Insurance Premium Payment Program Website: http://www.kdheks.gov/hcf/
Website: http://myakhipp.com/ Phone: 1-785-296-3512
Phone: 1-866-251-4861
Email: [email protected] KENTUCKY – Medicaid
Medicaid Eligibility: Website: http://chfs.ky.gov/dms/default.htm
http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx Phone: 1-800-635-2570

ARKANSAS – Medicaid LOUISIANA – Medicaid
Website: http://myarhipp.com/ Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331
Phone: 1-855-MyARHIPP (855-692-7447) Phone: 1-888-695-2447

COLORADO – Medicaid MAINE – Medicaid
Medicaid Website: http://www.colorado.gov/hcpf Website: http://www.maine.gov/dhhs/ofi/public-
Medicaid Customer Contact Center: 1-800-221-3943 assistance/index.html
Phone: 1-800-442-6003
FLORIDA – Medicaid TTY: Maine relay 711
Website: http://flmedicaidtplrecovery.com/hipp/
Phone: 1-877-357-3268 MASSACHUSETTS – Medicaid and CHIP
Website: http://www.mass.gov/MassHealth
GEORGIA – Medicaid Phone: 1-800-462-1120
Website: http://dch.georgia.gov/medicaid
Click on Health Insurance Premium Payment (HIPP) MINNESOTA – Medicaid
Phone: 404-656-4507 Website: http://mn.gov/dhs/ma/
Phone: 1-800-657-3739
INDIANA – Medicaid
Healthy Indiana Plan for low-income adults 19-64 MISSOURI – Medicaid
Website: http://www.hip.in.gov Website:
Phone: 1-877-438-4479 http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
All other Medicaid Phone: 573-751-2005
Website: http://www.indianamedicaid.com
Phone 1-800-403-0864

25

MONTANA – Medicaid RHODE ISLAND – Medicaid
Website: Website: http://www.eohhs.ri.gov/
http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 401-462-5300
Phone: 1-800-694-3084
SOUTH CAROLINA – Medicaid
NEBRASKA – Medicaid Website: http://www.scdhhs.gov
Website: Phone: 1-888-549-0820
http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/
Pages/accessnebraska_index.aspx SOUTH DAKOTA - Medicaid
Phone: 1-855-632-7633 Website: http://dss.sd.gov
Phone: 1-888-828-0059
NEVADA – Medicaid
Medicaid Website: http://dwss.nv.gov/ TEXAS – Medicaid
Medicaid Phone: 1-800-992-0900 Website: https://www.gethipptexas.com/
Phone: 1-800-440-0493
NEW HAMPSHIRE – Medicaid
Website: UTAH – Medicaid and CHIP
http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Website Medicaid: http://health.utah.gov/medicaid
Phone: 603-271-5218 Website CHIP: http://health.utah.gov/chip
Phone: 1-877-543-7669
NEW JERSEY – Medicaid and CHIP
Medicaid Website: http://www.state.nj.us/humanservices/ VERMONT– Medicaid
dmahs/clients/medicaid/ Website: http://www.greenmountaincare.org/
Medicaid Phone: 609-631-2392 Phone: 1-800-250-8427
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710 VIRGINIA – Medicaid and CHIP
Medicaid Website:
NEW YORK – Medicaid http://www.coverva.org/programs_premium_assistance.cfm
Website: http://www.nyhealth.gov/health_care/medicaid/ Medicaid Phone: 1-800-432-5924
Phone: 1-800-541-2831 CHIP Website:
http://www.coverva.org/programs_premium_assistance.cfm
NORTH CAROLINA – Medicaid CHIP Phone: 1-855-242-8282
Website: http://www.ncdhhs.gov/dma
Phone: 919-855-4100 WASHINGTON – Medicaid
Website:
NORTH DAKOTA – Medicaid http://www.hca.wa.gov/medicaid/premiumpymt/pages/index.as
Website: px
http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-562-3022 ext. 15473
Phone: 1-844-854-4825
WEST VIRGINIA – Medicaid
OKLAHOMA – Medicaid and CHIP Website:
Website: http://www.insureoklahoma.org http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/
Phone: 1-888-365-3742 default.aspx
Phone: 1-877-598-5820, HMS Third Party Liability
OREGON – Medicaid
Website: http://www.oregonhealthykids.gov WISCONSIN – Medicaid and CHIP
http://www.hijossaludablesoregon.gov Website:
Phone: 1-800-699-9075 https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf
Phone: 1-800-362-3002
PENNSYLVANIA – Medicaid
Website: http://www.dhs.pa.gov/hipp WYOMING – Medicaid
Phone: 1-800-692-7462 Website: https://wyequalitycare.acs-inc.com/
Phone: 307-777-7531

To see if any other states have added a premium assistance program since January 31, 2017, or for more information on
special enrollment rights, contact either:

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

OMB Control Number 1210-0137 (expires 12/31/2019)

26

Notice Informing Individuals About Nondiscrimination and Accessibility
Requirements and Nondiscrimination Statement:

Discrimination is Against the Law

Citrus Valley Health Partners complies with applicable Federal civil rights laws and does not discriminate on the basis of race,
color, national origin, age, disability, or sex. Citrus Valley Health Partners does not exclude people or treat them differently
because of race, color, national origin, age, disability, or sex.

Citrus Valley Health Partners:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages

If you need these services, contact Ryan Burke. If you believe that Citrus Valley Health Partners has failed to provide these
services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance
with: Ryan Burke 140 W College St, 2nd Floor, Covina, CA 91722, Telephone Number-626-858-8538, Fax Number-626-858-
8506 or by email at [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing
a grievance, Ryan Burke is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights,
electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or
by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 1-800-537-7697 (TDD)

Complaint forms are available at https://www.hhs.gov/ocr.

Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-301-5522.
Chinese
Vietnamese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1 – 855-301-5522
Korean CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-301-5522.
Tagalog
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-855-301-5522번으로 전화해 주십시오.
Russian PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad.
Arabic Tumawag sa 1-855-301-5522.
French Creole ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-301-5522.
(Haitian Creole) .(xxx-xxx-xxxx-1 :‫ )رﻗﻢ ھﺎﺗﻒ اﻟﺼﻢ واﻟﺒﻜﻢ‬5522-301-855-1 ‫ اﺗﺼﻞ ﺑﺮﻗﻢ‬.‫ ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن‬،‫ إذا ﻛﻨﺖ ﺗﺘﺤﺪث اذﻛﺮ اﻟﻠﻐﺔ‬:‫ﻣﻠﺤﻮظﺔ‬
French ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-855-301-5522.

Polish ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-855-301-
Portuguese 5522.
Italian UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-855-301-5522.
ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-855-301-5522.
Japanese ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il
numero 1-855-301-5522.
German 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-855-301-5522 まで、お電話にてご連絡くだ
さい。
Persian (Farsi) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer:
1-855-301-5522.
.‫ ﺗﻤﺎس ﺑﮕﯿﺮﯾﺪ‬5522-301-855-1 ‫ ﺑﺎ‬.‫ ﺗﺴﮭﯿﻼت زﺑﺎﻧﯽ ﺑﺼﻮرت راﯾﮕﺎن ﺑﺮای ﺷﻤﺎ ﻓﺮاھﻢ ﻣﯽ ﺑﺎﺷﺪ‬،‫ اﮔﺮ ﺑﮫ زﺑﺎن ﻓﺎرﺳﯽ ﮔﻔﺘﮕﻮ ﻣﯽ ﮐﻨﯿﺪ‬:‫ﺗﻮﺟﮫ‬

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For Assistance

Plan Type Healthnow Plan Phone Number Website
Medical Admininstrative EPO (855) 323-1132 www.myhnas.com
Services (HNAS) PPO
Pharmacy
Ventegra Rx (877) 867-0943 www.ventegra.com

Drugsource Mail Order Rx (800) 854-8764 www.drugsourceinc.com

Dental Delta Dental Dental HMO (800) 422-4234 www.deltadentalins.com
Dental PPO and Buy-Up PPO

Vision VSP Vision Service Plan (800) 877-7195 www.vsp.com

Life/AD&D CIGNA Basic Life/AD&D (800) 362-4462 www.cigna.com
Voluntary Life

Voluntary AD&D

Flexible Employee Benefit Health Care FSA (888) 327-2770 www.ebsbenefits.com
Spending Specialist (EBS) Dependent Care FSA
Account

Additional Lincoln Financial Group Retirement Plan (800) 234-3500 www.lfg.com
Benefits

Mutual of Omaha Voluntary Short Term Disability (800) 877-5176 www.mutualofomaha.com

Vol Universal Life with LTC

Supplemental Critical Illness Insurance
Benefits Hospital Indemnity Insurance (800) 621-0067 www.farmingtonco.com
Farmington

Voluntary Cancer Insurance

Voluntary ID Theft Insurance

28

Notes

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10/24/2017
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