Benefit Summary for the Employees of

Effective Date:

September 1, 2018 to August 31, 2019

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Your Benefits Plan Vantage Radiology and Diagnostic Services is pleased to offer a comprehensive benefits program to our valued employees. In the following pages, you will learn more about the benefits Vantage Radiology and Diagnostic Services offers. You will also see how choosing the right combination of benefits can help protect you and your family’s health, finances and future.

Benefit Carrier

Medical/Vision Insurance Regence

BlueShield

HSA Administrator Health Equity

Dental Insurance Guardian

Group Life and AD&D Insurance Unum

Voluntary Life and AD&D Insurance

Unum

Disability Insurance Unum

Employee Assistance Program Unum

Eligibility Full-Time employees are eligible for benefits after completion of the waiting period. Children are eligible for benefits up to age 26 regardless of dependent, student or marital status.1 Spouses and domestic partners (same and opposite gender) are eligible for benefits.

1 For Voluntary life insurance children are eligible up to age 19 without status restrictions, and to age 26 if full-time student.

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 the above times, you must wait for the next annual open enrollment period.

Making Changes Generally, you can only change your benefit elections during the annual benefits enrollment period. However, you may be able to change some of your benefit elections upon the occurrence of certain change in status events, provided you properly notify your Employer. These changes in status events may include:

• Marriage

• 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 have a family status change, you must timely notify Human Resources and complete the necessary forms. For more information refer to your benefits booklet.

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Medical / Vision Plans

Vantage Radiology and Diagnostic Services, offers a choice between four medical plans through Regence BlueShield. You can choose the HSA Health plan 3.0, the Innova PPO, Regence Classic Mulitcare or Regence Classic UW Medicine plan.

*deductible waived ** certain chronic disease generics $4 retail copay ($10 mail order) ***deductible waived for certain preventive drugs & immunizations at participating pharmacies

Contact Lenses are in lieu of all other frames and lenses benefits. When you receive contact lenses, you will not be eligible for any frames and/or lenses until the next calendar year.

Benefit Description QHDHP / HSA 3.0 PPO Plan Regence Classic Multicare &

UW Medicine

Preventive Care 100% (dw)* 100% (dw) 100% (dw)

Office Visit (Primary/Specialist) You pay 20% Preferred:$30 copay (dw)

Participating: $45 copay (dw) Preferred Provider: $30 copay (dw)

Calendar Year Deductible*

(Individual/Family) $1,500 / $3,000 aggregate $1,000 / $3,000 $1,000 / $3,000

Calendar Year Out-of-Pocket Max

(Individual/Family)

$5,000 / $10,000 aggregate

($5,000 per individual) $3,500 / $7,000 $3,500 / $7,000

Annual HSA Contribution $1,400 N/A N/A

Hospital Services You pay 20% You pay 10% You pay 20%

Emergency Room You pay 20% $100 copay,(waived if admitted)

then you pay 10%

$100 copay, (waived if admitted) then

you pay 20%

Mental Health/Substance Abuse You pay 20% InPt: you pay 10% OutPt: $30 copay

InPt: you pay 20% OutPt: $30 copay

Lab X-ray / (MRI/CT Scans)

You pay 20% $0-400: no charge, thereafter you

pay 10% You pay 20%

Retail Prescription Drugs 30 days

Generic: 20% Preferred Brand: 20% Non-Preferred: 20%

Specialty: same as above

Generic: $10 copay Preferred Brand:$35 copay Non-Preferred: $75 copay Specialty: same as above

Generic: ** $10 copay

Preferred Brand: $35 copay Non-Preferred: $75 copay Specialty: same as above

Mail Order Prescriptions 90 days

Generic: 20% Preferred Brand: 20% Non-Preferred: 20%

3 X copay for 90 day supply (Specialty not available for mail-

order)

3 X copay for 90 day supply (Specialty not available for mail-

order)

Vision Services – VSP Network – www.VSP.com

Vision Exam 1 Routine Vision Exam PCY

1 Routine Vision Exam PCY

1 Routine Vision Exam PCY

Vision Hardware1

Frames or elective contacts limited to $150 from VSP Doctors Lenses (Single Vision, Bi-focal, trifocal, Progressive or elective

contacts)

Frames or elective contacts limited to $150 from VSP Doctors Lenses (Single Vision, Bi-focal, trifocal, Progressive or elective

contacts)

Frames or elective contacts limited to $150 from VSP Doctors

Lenses (Single Vision, Bi-focal, trifocal, Progressive or elective

contacts)

OUT OF NETWORK CARE:

Calendar Year Deductible Most Services

$1,500/$3,000 aggregate Plan pays 60% of allowed

expenses

$1,000/$3,000 70% of allowed expenses

$1,000/$3,000 60% of allowed expenses

Out of Pocket Maximum $5,000/$10,000 $3,500/7,000 $3,500/$7,000

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OUT OF AREA BENEFITS

The BlueCard Program enables access to providers across the country and around the world. When traveling outside the Regence service area, you can take advantage of lower rates the local Blue Plan has negotiated with providers in the area. For covered services, you should not be responsible for any amount above these negotiated rates and will only pay applicable out-of-pocket expenses, as stated in your plan documents when using a BlueCard Provider.

Please go to www.bcbs.com or call 800-810-BLUE (2583) to find providers in the area.

MANDATORY GENERIC SUBSITUTION (INNOVA PPO & REGENCE CLASSIC PLANS ONLY)

If an equivalent generic medication is available and you choose to fill a prescription order with a brand name medication, even if the prescribing provider specifies that the brand name medication must be dispensed as written, you will be responsible for paying the difference in cost plus the applicable copay. The difference is calculated at the time of purchase based upon the difference in price between the equivalent generic medication and the applicable brand name medication, in addition to the co-pays (as applicable).

Regence BlueShield – Regence Classic Networks – Multicare & UW Medicine Networks Regence Classic is an accountable care product that encourages patient-provider collaboration, emphasizes prevention, and facilitates coordination of treatments. When you enroll in Regence Classic, you and your dependents will choose which network (Multicare Health Systems or UW Medicine) you wish to utilize. Care outside the network you elect will be out-of-network.

Regence Classic would be best if you… Regence PPO/HDHP would be best if you…

• Trust your regular doctor to recommend specialists

• Want to work with your providers to make decisions about your care

• Are looking for value and accountability

• Travel frequently

• Have covered dependents who don’t live with you

• Value broad access and willing to pay for it

For more information about the Regence Classic plans, please see the Regence benefit highlight sheets in your benefit package.

Health Savings Account (HSA)

When you are enrolled in a Qualified High Deductible Health Plan and you meet the eligibility requirements, the IRS allows you to open and contribute to a Health Savings Account (HSA).

What is an HSA Account? An HSA is a tax-favored bank account that you own for the purpose of paying current or future eligible health care expenses for you and/or your eligible dependents. The HSA is yours to keep, even if you change jobs or medical plans. There is no “use it or lose it” rule; your balance carries over year to year. Plus, you get extra tax advantages with an HSA because:

• You contributions to your HSA (to the IRS annual maximum amount) are tax deductible

• Interest in your account grows tax-free

• You don’t pay income taxes on withdrawals used to pay for eligible health expenses. (If you withdraw funds for non-eligible expenses, taxes and penalties apply) and;

• You also have a choice of investment options which earn competitive interest rates so your unused funds grow over time.

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Are You Eligible to Open a Health Savings Account (HSA)? Although everyone is able to enroll in the Qualified High Deductible Health Plan, not everyone is eligible to open and contribute to an HSA. If you do not meet these requirements, you cannot contribute to a Health Savings Account. To be eligible to contribute to an HSA, or to receive the contribution from Vantage Radiology, as of the first of any given month you:

• must be enrolled in a Qualified High Deductible Health Plan (QHDHP)

• must not be covered by another non-QHDHP health plan, such as a spouse’s Traditional PPO plan, that provides any benefits covered by your health plan

• are not enrolled in Medicare

• are not in the TRICARE or TRICARE for Life military benefits program

• You have not received Veterans Administration (VA) benefits within the past three months

• are not claimed as a dependent on another person’s tax return

• are not covered by a “general purpose’ health care flexible spending account (FSA) (This includes your spouse’s FSA!)

2018 HSA Contributions Vantage Radiology will make a contribution of $1,400 to your Health Savings Account if enrolled (distributed monthly). You may also make contributions to your Health Savings Account through payroll deductions. The IRS has established the following maximum HSA contributions per tax year:

Annual Employer Contribution $1,400 / Employee

2018 Maximum Annual Employee Contribution (includes Employer Contribution)

$3,450 / Employee Only $6,900 / Family Enrollment

IMPORTANT: All contributions to your HSA are done on a post-tax basis. Please speak to your tax advisor about tax advantages related to this type of account.

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Dental Plan – The Guardian

Vantage Radiology is pleased to offer new comprehensive Dental Benefits plan design to eligible employees and their dependents through The Guardian with a few plan enhancements. International Dental Travel Assistance While traveling internationally the Guardian offers International Dental Travel Assistance. You may get a referral to a local dentist for immediate dental care through the International Dental Travel Assistance Program which is available 24/7 in over 200 countries. (coverage will be out-of-network). Dental Maximum Rollover Guardian offers a dental Maximum Rollover feature (MRA). You may now roll over a portion of your un-used annual maximum to use next plan year. If you use preferred providers exclusively during the benefit year, the Guardian will increase the amount credited to the MRA. See the Guardian benefit summary for additional information. Dental Network Access Plan (NAP) The Guardian has a Dental Network Access Plan (NAP). This mean that benefits are paid at the same coinsurance percentage in-network and out-of-network benefits. You retain the complete freedom of choice however your plan year maximum will stretch further if you go to a Preferred Provider who offers discounts on their usual fees. To find a provider visit www.guardiananytime.com.

Benefits Guardian

Calendar Year Maximum $1,500

Calendar Year Deductible

Individual $50

Family Maximum $150

Preventive & Diagnostic Care 100%, Deductible waived

Basic Restorative Care 80%

Major Restorative Care 50%

Rollover Amount $350

TMJ

Benefits 50%

Annual Maximum $1,000

Lifetime Maximum $5,000

Group Life and AD&D Benefits

Vantage Radiology and Diagnostic Services provides Group Life and AD&D insurance to all benefit eligible employees at no additional cost. Please be sure to select a beneficiary.

Unum

Employee Life Benefit 1 X salary up to $50,000

AD&D

Accidental Death Benefit In the event of an accidental death, the benefit may double. Please see your booklet for further details.

Dismemberment In the event of an accidental dismemberment, a benefit is provided up to a scheduled amount corresponding to the loss. Please see your booklet for further details.

BENEFIT REDUCTION Benefits begin to reduce at age 65. Please refer to your booklet for further details.

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Voluntary Life and AD&D Benefits

Vantage Radiology and Diagnostic Services offers Voluntary Life and AD&D insurance to all benefit eligible employees at the employee’s cost. Please see the Unum Benefit Summary in your packet for rate information.

Employee Unum

Benefit Amount $10,000 increments up to 5x annual earnings to a maximum of $500,000.

Guarantee Issue Amount $70,000

Spouse

Benefit Amount 100% of employee benefit amount in increments of $5,000, to a maximum of $500,000.

Guarantee Issue Amount $25,000

Child(ren)

Benefit Amount 100% of employee amount in increments of $2,000, to a maximum of $10,000.

Guarantee Issue Amount Full Amount

BENEFIT REDUCTION

Benefits begin to reduce at age 65. Please refer to your booklet for further details.

BENEFICIARY DESIGNATION

If you are married and living in a community property state, your insurance carrier may require that you designate your spouse (or in some cases a registered domestic partner) for at least 50% of the benefit unless you have a waiver notice on file from your spouse. Consult your legal or tax advisor for further guidance on this issue.

Voluntary Short Term Disability Benefits

Vantage Radiology and Diagnostic Services offers Voluntary Short Term Disability coverage to all benefit eligible employees. This benefit is 100% voluntary. An Evidence of Insurability form will be required for all late enrollees.

Please review the Unum Benefit Summary in your packet for rate information.

Benefits Unum

Benefits Begins After a 14-day waiting period from the date of your disability condition

Weekly Benefit 40%, 50% or 60% of salary based on your election

Maximum Benefit $2,000 per week

Maximum Benefit Duration Up to 11 weeks

In the event of a disability claim, payments received under this plan would not be considered taxable income.

Group Long Term Disability Benefits

Vantage Radiology and Diagnostic Services provides Group Long Term Disability insurance to all benefit eligible employees. This benefit is 100% paid for by Vantage Radiology. Please review the Unum Benefit Summary in your packet for additional information.

In the event of a disability claim, payments would be considered taxable income.

Benefits Unum

Benefits Begin After a 90-day elimination (waiting) period of continuous disability from the day your

disabling condition occurs

Monthly Benefit 66 2/3% of your covered pre-disability monthly earnings

Maximum Benefit Up to $6,000 per month

Benefit Duration To age 65

Definition of Disability Own Occupation and 20% earnings loss

Pre-Existing Condition Limitation

A pre-existing condition is a condition, regardless of cause, for which medical advice, diagnosis, care or treatment was recommended or received within the 3 months prior to your enrollment date. The plan will not pay benefits for any pre-existing conditions that result in disability during your first 12 consecutive months of coverage.

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Group Long Term Care (LTC)

Employees have the option to purchase a long term care policy for you and for your spouse and family through Unum.

• Benefit Amount: Up to $6,000 per month total benefit

• Lifetime Benefit period can be purchased up to $9,000 through a full medical underwriting

Please see Human Resources for more information.

Employee Assistance Program (EAP)

Unum There are times when we all need a little help. No matter what the issue, Work-life Balance EAP services are available to you 24/7 with confidential support, guidance and resources. All employees and immediate household members may access our EAP. Please be assured that the services provided to you through our EAP are completely confidential. You can access an array of benefits through the 24 hour hotline (1-800-854-1446) or the website at www.lifebalance.net. User ID and password are both lifebalance. These benefits include

• In-person help with short-term issues

• Phone access to legal counsel

• Work/life services for assistance with: childcare, eldercare, adoption, relationships and financial issues

Contact Information

Benefit Resource Center

The Benefit Resource Center is designed to provide you with a responsive, consistent, hands-on approach to benefit inquiries. Benefit Specialists are available to research and solve elevated claims, unresolved eligibility problems, and any other benefit issues with which you might need assistance. The Benefit Specialists are experienced professionals and their primary responsibility is to assist you. The Specialists in the Benefit Resource Center are available Monday through Friday 7:00 AM to 6:00 PM (Pacific Time). If you need assistance outside of regular business hours, please leave a message and one of the Benefit Specialists will promptly return your call or e-mail message by the end of the following business day. Phone: (866) 4ourBRC (468-7272) Email: BRCWest@usi.com Fax: (877) 678-5840

If you have any further questions concerning your benefits, please contact:

www.regence.com 888-367-2111

Unum Life/AD&D:

Group #386611 002

Voluntary Life/AD&D: Group #131970

Voluntary STD: Group #R0345553

Username/password: lifebalance

800-854-1446

Long Term Disability: Group #386611 001

www.lifebalance.net Unum Employee Assistance Program

Health Equity HSA Administrator www.healthequity.com 866-346-5800

Medical: Group #10001017

Vision: Group #10001017

Carrier Plan Website Phone Number

Regence BlueShield

Vision Service Plan (VSP) www.vsp.com 844-299-3041

Unum

www.unum.com 877-225-2712

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Refer to the table below for the l monthly employee contributions (Medical/Vision & Dental) as of September 1, 2018:

Regence HDHP

Your Monthly Cost Regence PPO

Your Monthly Cost

Regence Classic UW Medicine

Your Monthly Cost

Regence Classic Multicare

Your Monthly Cost

Employee Only $0 $35 $0 $0

Employee & Spouse/DP $657.30 $895.60 $761.70 $772.20

Employee & Child(ren) $505.10 $696.20 $585.30 $593.30

EE, Spouse/DP & Child(ren) $1,162.40 $1,556.80 $1,347.00 $1,365.50

Regence Dental

Your Monthly Cost

Employee Only $0

Employee & Spouse/DP $45.86

Employee & Child(ren) $63.23

EE, Spouse/DP & Child(ren) $109.09

Monthly Premiums

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Confidentiality Disclosure

These materials are produced by USI for the sole use of its clients, prospective clients, and their representatives. Certain information contained in these materials are considered proprietary information created by USI and/or their licensed and appointed insurance carriers. Such information and any insurance designs furnished by USI are considered “Confidential Material.” Such information shall not be used in any way, directly or indirectly, detrimental to USI and clients and/or potential clients and any of their representatives will keep that information confidential. IRS Circular 230 Disclosure: USI does not provide tax advice. Accordingly, any discussion of U.S. tax matters contained herein (including any attachments) is not intended or written to be used, and cannot be used, in connection with the promotion, marketing or recommendation by anyone unaffiliated with USI of any of the matters addressed herein or for the purpose of avoiding U.S. tax-related penalties. Also, the information contained in this benefit summary should not be construed as medical or legal advice.

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Important Legal Notices Affecting Your Health Plan Coverage THE WOMEN’S HEALTH CANCER RIGHTS ACT OF 1998 (WHCRA)

IF YOU HAVE HAD OR ARE GOING TO HAVE A MASTECTOMY, YOU MAY BE ENTITLED TO CERTAIN BENEFITS UNDER THE WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998 (WHCRA). FOR INDIVIDUALS RECEIVING MASTECTOMY-RELATED BENEFITS, COVERAGE WILL BE PROVIDED IN A MANNER DETERMINED IN CONSULTATION WITH THE ATTENDING PHYSICIAN AND THE PATIENT, FOR:

▪ All stages of reconstruction of the breast on which the mastectomy was performed; ▪ Surgery and reconstruction of the other breast to produce a symmetrical appearance; ▪ Prostheses; and ▪ Treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. Therefore, the following deductibles and coinsurance apply:

NEWBORNS ACT DISCLOSURE - FEDERAL Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

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 60 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.

Benefit Description HDHP w/ HSA 3.0 PPO Plan Regence Classic Multicare / UW Medicine

Coinsurance 80/60/60% 90/70/70% 80/60%

Calendar Year Deductible $1,500 / $3,000 agg. $1,000 / $3,000 $1,000 / $3,000

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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. 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 $149 per day (up to a $1,496 cap per request), 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.

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CONTACT INFORMATION

CONTACT INFORMATION

Questions regarding any of this information can be directed to: Beth Williams

533 SW 335th St STE C Federal Way, WA 98033

253-661-1700

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

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2018. Contact your State for more information on eligibility –

ALABAMA – Medicaid FLORIDA – Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447

Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268

ALASKA – Medicaid GEORGIA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: http://dch.georgia.gov/medicaid Click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507

ARKANSAS – Medicaid INDIANA – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1-800-403-0864

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COLORADO – Health First Colorado (Colorado’s Medicaid Program) &

Child Health Plan Plus (CHP+) IOWA – Medicaid

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711

Website: http://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp Phone: 1-888-346-9562

KANSAS – Medicaid NEW HAMPSHIRE – Medicaid

Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512

Website: https://dhhs.nh.gov/ombp/nhhpp Phone: 603-271-5218 Hotline: NH Medicaid Service Center at 1-888-901-4999

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

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

LOUISIANA – Medicaid NEW YORK – Medicaid Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711

Website: https://dma.ncdhhs.gov/ Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP Website: http://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/medical-assistance.jsp Phone: 1-800-657-3739

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

MISSOURI – Medicaid OREGON – Medicaid Website: https://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

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To see if any other states have added a premium assistance program since January 31, 2018, or for more information on special enrollment rights, contact either:

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

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

MONTANA – Medicaid PENNSYLVANIA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

Website: http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htm Phone: 1-800-692-7462

NEBRASKA – Medicaid RHODE ISLAND – Medicaid Website: http://www.ACCESSNebraska.ne.gov Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-1178

Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347

NEVADA – Medicaid SOUTH CAROLINA – Medicaid

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

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

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid

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

Website: http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program Phone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid WEST VIRGINIA – Medicaid

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

Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP

Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002

VERMONT– Medicaid WYOMING – Medicaid

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

Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531

VIRGINIA – Medicaid and CHIP

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